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Rheumatoid arthritis

Also listed as: Arthritis - rheumatoid

• Signs and Symptoms
• Causes
• Risk Factors
• Diagnosis
• Treatment Approach
• Other Considerations
• Supporting Research

Rheumatoid arthritis (RA) is a long-term (chronic) disease that causes inflammation of the joints and surrounding tissues. It can also affect other organs. 

RA destroys the protective tissue (cartilage) surrounding the joints. Healthy cartilage allows bones to glide smoothly over one another, and absorbs the shock of physical movement. With RA, the cartilage breaks down and wears away. As a result, the bones rub together. Patients with this disease have joint swelling, pain, and stiffness.

RA usually affects joints on both sides of the body equally. Wrists, fingers, knees, feet, and ankles are the most commonly affected.

Signs and Symptoms

RA usually develops slowly over time, with the following symptoms:

• Morning stiffness -- waking up with stiff joints (often the wrists and base of the fingers; ankles, balls of the feet, elbows, or knees)
• Joint pain with warmth, swelling, tenderness, and stiffness of the joint after inactivity
• Limited range of motion in the affected joints
• Fatigue
• Low grade fever (when joints are acutely inflamed)
• Small, round, firm bumps (called nodules) under the skin; you can feel these, but they are generally painless

JRA, also known as Still's disease, is usually preceded by a high fever and shaking chills. A pink skin rash may also be present.

Causes

The cause of RA is unknown. It is considered an autoimmune disease. The body's immune system normally fights off foreign substances, like viruses. But in an autoimmune disease, the immune system confuses healthy tissue for foreign substances. As a result, the body attacks itself.

RA can occur at any age. It usually occurs in people between 25 and 55. Women are affected more often than men.

The course and the severity of the illness can vary considerably. Infection, genes, and hormones may contribute to the disease.

RA usually affects joints on both sides of the body equally. Wrists, fingers, knees, feet, and ankles are the most commonly affected.

Risk Factors

• Age. Although the disease can occur at any age, RA generally starts in young adulthood usually between ages 25 and 55. JRA affects 70,000 to 75,000 children in the United States.
• Female. Women are affected two and a half times more often than men, and have a greater chance of having a severe case.
• Family history. Having relatives with this type of arthritis increases your risk of getting it yourself.
• Cigarette smoking. It appears that heavy smoking over a long period of time increases your risk of getting RA.
• Coffee intake. This is controversial. One Finnish study reported a direct association between coffee consumption and an increased risk for RA, but the study did not account for other factors such as the way coffee is prepared in Finland (typically without filters). A study in the U.S. of 121,701 women found little evidence of an association between coffee or decaf coffee and the risk of RA. Further investigation is needed.
• Medication. Interferon-alpha, a drug used to treat hepatitis, autoimmune diseases, and other diseases has triggered RA in rare cases.

Other risk factors include:

• History of blood transfusions
• Obesity

Diagnosis

RA can be difficult to diagnose because it resembles many other conditions, and symptoms develop so gradually they can go unnoticed. Even after RA has been diagnosed, it is extremely important to determine how the disease is progressing in order to treat it appropriately.

Your doctor will take your medical history and perform a physical exam. Blood tests, x-rays, and aspiration (the removal of fluid from the joint) may also be needed.

Treatment Approach

RA usually requires lifelong treatment, including various medications, physical therapy, education, and possibly surgery. Treatment is aimed at relieving symptoms and preserving joint function.

Regular visits to your healthcare provider will be necessary to monitor the progress of the disease and side effects of drugs you may be taking. This might also entail regular blood and urine tests.

Frequently, the disease can be controlled with a combination of treatments. Treatment may vary depending on the severity of the symptoms. Surgery may be needed, if medications fail.

For the past 10 years, studies have shown that early, aggressive treatment for RA can delay the onset of joint destruction. In addition to rest, strengthening exercises, and anti-inflammatory agents, the current standard of care is to start therapy with disease-modifying anti-rheumatic drugs (DMARDs) -- these are drugs that actually alter the course of the disease rather than just relieve symptoms. Studies show that certain dietary supplements, particularly omega-3 fatty acids, show promise in helping to relieve symptoms. Other symptom-relieving measures might include bathing in sulfur baths or warm pools, applying capsaicin to the skin for pain, and having electrical stimulation to increase muscle strength.

Lifestyle

Range of motion exercises and individualized exercise programs prescribed by a physical therapist can help to maintain joint motion and strength and delay the loss of joint function.

Joint protection techniques, such as heat and cold treatments and splints or orthotic (straightening) devices to support and align joints, may be very helpful.

Medications

The following drugs are used to treat RA:

• Disease-modifying anti-rheumatoid drugs (DMARDs) methotrexate is used most often.
• Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) -- NSAIDS are commonly used to relieve joint pain and inflammation. Although NSAIDs work well, long-term use can cause stomach problems, such as ulcers and bleeding, and possible heart problems. In April 2005, the FDA asked drug manufacturers of NSAIDs to include a warning label on their product that alerts users of an increased risk for cardiovascular events and gastrointestinal bleeding.
• Cyclo-oxgenase-2 (COX-2) inhibitors -- COX-2 inhibitors block an inflammation-promoting enzyme called COX-2. This class of drugs was initially believed to work as well as traditional NSAIDs, but with fewer stomach problems. However, numerous reports of heart attacks and stroke have prompted the FDA to re-evaluate the risks and benefits of the COX-2s. Rofecoxib (Vioxx) and valdecoxib (Bextra) have been withdrawn from the U.S. market following reports of heart attacks in patients taking the drugs. Celecoxib (Celebrex) was still available at the time of this report, but labeled with strong warnings and a recommendation that it be prescribed at the lowest possible dose for the shortest duration possible. Patients should ask their doctor whether the drug is appropriate and safe for them.
• Corticosteroids -- decrease inflammation and control pain. They are taken by mouth or injected through an IV. Use of corticosteroids for RA is usually limited to a short course at the lowest effective  dose.
• Immune suppressants -- used for serious cases of RA when all other medications have failed. These include azathioprine and cyclophosphamide.
• Tumor necrosis factor (TNF) modifiers -- such as etanerceptand infliximab. Both are FDA-approved for moderate to severe cases of RA. These drugs block TNFs (inflammatory proteins). They are injected into an IV.

Surgery and Other Procedures

Occasionally, surgery may be required to treat severely affected joints. The most successful surgeries are those on the knees and hips. Removal of the synovium (called synovectomy) is a common surgical procedure.

A later alternative is total joint replacement with a prosthesis (an artificial joint). Surgeries may relieve pain, correct deformities, and modestly improve joint function. In extreme cases, total knee or hip replacement can mean the difference between being completely dependent on others and having an independent life at home.

Nutrition and Dietary Supplements

Diet

It is important to eat a nutritious diet full of whole foods including protein, which is needed to heal. Foods rich in B vitamins, vitamin E, zinc, and selenium may be particularly important. Although several types of diets may be effective for RA, no one diet has been found to work for everyone.

There are reports of people with RA who experienced an improvement in their symptoms when they switched from a typical Western diet (high in animal protein and simple sugars) to a vegan diet with lots of uncooked berries, fruits, vegetables, nuts, roots, seeds, and sprouts. Vegan diets contain no animal products and obtain protein from vegetable sources.

Elimination/provocation diets (also called elimination/re-challenging diets), are designed to detect allergens by systematically taking certain foods out of the diet and reintroducing them one at a time. Such diets should be strictly supervised by a qualified physician and/or dietitian. If this process is followed, you should keep careful track of your symptoms in a food diary to see if the dietary changes impact your symptoms.

Supplements

Since supplements may have side effects or interact with medications, they should be taken only under the supervision of your doctor.

Bromelain

Bromelain (Ananas comosus), found in pineapples, is a mixture of enzymes with anti-inflammatory properties. Preliminary studies suggest that bromelain may help reduce the pain associated with RA. In fact, studies of people with osteoarthritis (OA) suggest that bromelain supplements may be as effective as some commonly used NSAID medications (such as ibuprofen and diclofenac) for reducing pain associated with this and other types of arthritis. People should not take bromelain for more than 8 to 10 days in a row. People often take quercetin and bromelain together.

Copper

Animal studies suggest that oral copper supplements reduce the development and progression of arthritis. Many people with RA apply copper solutions to their skin or wear copper bracelets in hopes of relieving pain and inflammation. Although reports of success with these methods are mixed, one early study did show that the copper bracelets worked better than placebo bracelets. Sweat can interfere with how well the topical copper solutions and bracelets work.

Manganese

People with RA tend to have low levels of MnSOD (an antioxidant that helps protect the joints from damage during inflammation). Researchers believe that manganese increases MnSOD activity. Manganese is often combined with glucosamine and/or chondroitin, two substances that may help treat OA.

Omega-3 Fatty Acids

Extensive research indicates that omega-3 fatty acids reduce inflammation and help prevent arthritis. Omega-3s are essential fatty acids, meaning that the body requires them but must obtain them from food. Several articles reviewing the research on omega-3 fatty acids have found that omega-3 supplements reduce tenderness in joints, decrease morning stiffness, and reduce the amount of medication people need for RA.

Further, an animal study suggests that treatment with omega-3 fatty acids may reduce the risk of ulcers from NSAIDs. More research is needed to determine whether this particular effect applies to people.

Good sources for omega-3 fatty acids include fish oils (from cold water, oily fish) and plant oils (for example, rapeseed (canola) oil, soybeans, soybean oil, pumpkin seeds, pumpkin seed oil, flaxseeds, flaxseed oil, walnuts, and walnut oil).

Another potential source of omega-3 fatty acids is the New Zealand green lipped mussel ( Perna canaliculus ), used for centuries by the Maori people for good health. In a trial involving 28 people with RA, nearly 70% of those who received P. canaliculus extracts experienced the following:

• Decreased joint stiffness and pain
• Increased grip strength
• Enhanced walking pace

However, 10% of participants experienced a temporary worsening of symptoms when first taking the supplement. Use lipid extracts of P. canaliculus rather than powder since there is less chance of an allergic reaction. People who are allergic to seafood should avoid P. canaliculus .

Omega-6 Fatty Acids

Some preliminary information indicates that gamma-linolenic acid (GLA), an omega-6 fatty acid, from evening primrose oil (EPO), borage oil, or black currant seed oil, may diminish joint pain, swelling, and morning stiffness. GLA may also reduce the amount of pain medication needed. Talk to your doctor about whether using GLA is safe for you. During the first three months of use, pay attention to whether or not your symptoms improve. Some researchers theorize that borage oil may not be safe to use with NSAIDs (such as ibuprofen). This theory needs to be tested.

At the same time that this particular omega-6 fatty acid (namely, GLA) may be helpful. People with RA should avoid other omega-6 fatty acids (linoleic acid, found in vegetable oils and arachidonic acid, found in meat) because they promote inflammation.

Quercetin

Quercetin is a flavonoid as well as an antioxidant found in many fruits, fresh berries, and vegetables. Laboratory and animal studies suggest that quercetin has anti-inflammatory properties. Test tube studies show that quercetin inhibits the type of inflammation that can occur in the joints of those with arthritis. Bromelain can enhance the effects of quercetin.

Selenium

The body naturally contains small amounts of the essential mineral selenium. It is also an antioxidant, and is found in fish, shellfish, Brewer's yeast, wheat germ, garlic, whole grains, sunflower seeds, and Brazil nuts. Low blood levels of selenium may be associated with increased risk of RA. It is not known whether supplementation with selenium alone is beneficial. However, some experts believe that the combination of selenium and vitamin E can relieve symptoms of RA.

Sulfur

Sulfur is a naturally occurring mineral found primarily near hot springs and volcanic craters. It is available in two supplement forms -- dimethyl sulfoxide (DMSO) and methylsulfonylmethane (MSM). Sulfur-containing mud baths (often called balneotherapy) is one of the oldest forms of therapy to relieve pain for people with arthritis. This tradition is supported by scientific studies. Soaks in the Dead Sea, with or without mud packs, may be particularly beneficial. The benefits that you can experience from sulfur baths if you have arthritis include:

• Improved strength
• Less morning stiffness
• Decreased inflammation and swelling
• Diminished pain

You can purchase mud packs and Dead Sea salts over the counter. These are not as effective as a spa treatment or the Dead Sea itself, but they may help you feel better. More studies are needed to determine whether topical application of DMSO is effective for reducing pain.

Vitamin B5 (Pantothenic Acid)

Although vitamin B5 has not been widely used for RA, some researchers report that blood levels of vitamin B5 are lower in people with RA than those without this condition. A study conducted in 1980 concluded that 2,000 mg/day of calcium pantothenate (a form of vitamin B5) improved symptoms of RA including morning stiffness and pain. Further studies are needed to confirm these findings, but there may be some benefit to ensuring adequate vitamin B5 in your diet. Vitamin B5 is found in a wide variety of foods, such as fresh meat and vegetables, and whole grains. Processed and frozen foods contain lower amounts of this vitamin.

Vitamin B6 (Pyridoxine)

Low levels of vitamin B6 have been associated with RA. This may be due to low dietary intake of vitamin B6. In addition, methotrexate and penicillamine, drugs sometimes prescribed for RA, can reduce the levels of vitamin B6 in people taking either of these medications.

Vitamin B Complex

Eating a balanced diet, including a complete vitamin B complex, is a good practice. It is not known if taking extra vitamin B5 or B6 is helpful for arthritis.

Vitamin B9 (Folic Acid)

Methotrexate, commonly prescribed for RA, increases your body's need for folic acid. Taking a folic acid supplement decreases the side effects from the drug without reducing its effectiveness.

Vitamin D

Vitamin D is needed to maintain healthy cartilage. Vitamin D has been shown to prevent the breakdown of cartilage in people with OA. It is possible that adequate amounts of vitamin D may also be useful for those with RA.

Vitamin D is found in cod liver oil, fatty fish, eggs, and fortified milk, and cereal. If you follow a vegan diet, don't get enough exposure to the sun, or are obese or older, you may be prone to having low levels of vitamin D, and may need to take a supplement.

Others

Additional nutrients that may prove beneficial as part of the treatment for RA include:

• Creatine
• Melatonin
• Antioxidants in general, vitamins C and E in particular
• Vitamin B2 (Riboflavin)
• Lipase
• Herbs

The use of herbs is a time-honored approach to strengthening the body and treating disease. However, herbs contain active substances that can trigger side effects and interact with other herbs, supplements, or medications. For these reasons, herbs should be taken with care and only under the supervision of a practitioner knowledgeable in the field of herbal medicine.

The following have been used to treat RA:

• Burdock (Arctium lappa and other Arcticum spp)
• Goldenrod (Solidago virgaurea)
• Horsetail (Equisetum arvense)
• Lavender (Lavendula augustifolia) -- used topically
• Pau d'Arco (Tabebuia avellanedae)
• Stinging nettle (Urtica dioica)
• Turmeric (Curcuma longa)
• Wild yam (Dioscorea villosa)

A qualified herbal specialist may recommend a single herb or a combination of substances. If you are considering taking herbs for RA, it is important to work closely with a knowledgeable practitioner and follow their instructions carefully.

Other herbs that an herbalist may consider include:

Black cohosh (Cimicifuga racemosa)

Preliminary studies suggest that black cohosh may help reduce inflammation associated with the two main types of arthritis, OA and RA. In a review of scientific studies, researchers concluded that a combination of black cohosh, willow bark (Salix spp.), sarsaparilla (Smilax spp.), guaiacum (Guaiacum officinale) resin, and poplar bark (Populus tremuloides) may help relieve symptoms of OA. More research is needed to determine whether this combination would be helpful for RA.

Capsaicin (Capsicum frutescens)

Capsaicin is the main component in hot chili peppers (also known as cayenne). Researchers believe that when applied to the skin, it may deplete stores of a substance that contributes to inflammation and pain in arthritis. Pain reduction generally begins three to seven days after initially applying the capsaicin cream to the skin, but may be most pronounced after about four weeks of use. Wash hands well with vinegar after use and avoid touching the eyes.

Cat's claw (Uncaria tomentosa)

In a study of 40 people with RA who were taking the drugs sulfazaline or hydroxychloroquine, treatment with an extract from cat's claw for 24 weeks resulted in reduced joint pain and swelling.

Devil's claw (Harpagophytum procumbens)

Devil's claw has been evaluated for the treatment of OA. With more research it may prove to be beneficial for RA as well. For people with osteoarthritis, devil's claw appears to decrease pain, improve joint function, and reduce the amount of medications needed.

Feverfew (Tanacetum parthenium)

Although many laboratory tests demonstrate anti-inflammatory properties of feverfew, and many professional herbalists recommend feverfew for the treatment of arthritis, a study conducted in 1989 concluded that feverfew was no more effective than placebo in improving symptoms of RA. Some experts argue that this study was poorly designed, since some patients continued using NSAIDs during the study period, which can interfere with feverfew and reduce its effectiveness. (NSAIDs, such as ibuprofen, are commonly prescribed or recommended for arthritis.) Until further studies are conducted, the safety and effectiveness of feverfew for people with RA is unclear.

Ginger (Zingiber officinale)

Ginger extract has long been used in traditional medical practices (such as Ayurvedic and Chinese) to decrease inflammation. There have been case reports of the benefit of ginger for RA in the medical literature. In one case, a man with RA consumed fresh ginger lightly cooked in meat and vegetable dishes every day and after three months was completely free of pain and swelling. More research is needed before scientists can recommend ginger for relief of RA symptoms.

Willow bark (Salix spp.)

This herb has been used traditionally for arthritis because it can decrease pain and reduce inflammation. In fact, aspirin was originally synthesized from salicylic acid, one of the ingredients in willow bark.

Acupuncture

There is little to no scientific evidence supporting the use of acupuncture for RA. However, some practitioners will consider acupuncture to treat this joint condition. Acupuncturists treat people with RA based on an individualized assessment of the excesses and deficiencies of qi, or energy, located in various meridians. A qi deficiency is usually detected in the spleen and/or kidney meridians.

Acupuncturists may use moxibustion (a technique in which the herb mugwort (Artemesia vulgaris) is burned over specific acupuncture points) to strengthen the entire energy system. Qualified acupuncturists may also provide lifestyle, dietary, and herbal advice to people with RA. Practitioners may apply local treatment to the painful areas and related sore points, either with a needle or moxibustion. However, given the current lack of evidence, acupuncture should be used as a supportive treatment with conventional medical therapy.

Chiropractic

Chiropractors do not treat red, swollen joints, and high velocity chiropractic manipulation is considered inappropriate in areas of the body affected by this condition. However, some chiropractors report that spinal manipulation may decrease pain and enhance joint mobility when used in between flare ups for people with RA.

Massage and Physical Therapy

Exercise

It is important to maintain a balance between rest (which will reduce inflammation) and exercise (which will relieve stiffness and weakness). Studies suggest that as little as three hours of physical therapy over six weeks will help you people who have RA, and these benefits are sustained.

The goal of exercise is the following:

• To maintain a wide range of motion
• To increase strength, endurance, and mobility
• Improve general health
• Promote well-being

While traditional guidelines have restricted RA patients to only gentle exercise, research suggests that more intense exercise may not only be safe, but may actually produce greater muscle strength and overall functioning. Signs from your body are the best guides for how long or hard you should exercise.

• If you feel sharp pains while exercising, stop immediately.
• If lesser aches and pains continue for more than two hours afterwards, then try a lighter exercise program for awhile.
• Using large joints instead of small ones for ordinary tasks can help relieve pressure. For example, use your hip to close doors or the palm of your hand to push buttons.

Balneotherapy (Hydrotherapy or spa therapy)

Balneotherapy is one of the oldest forms of therapy for pain relief for people with arthritis. The term "balneo" comes from the Latin word for bath (balneum) and refers to bathing in thermal or mineral waters. For example, sulfur-containing mud baths have been shown to relieve symptoms of arthritis. The goals of balneotherapy for arthritis include:

• Improving range of joint motion
• Increasing muscle strength
• Eliminating muscle spasm
• Enhancing functional mobility
• Easing pain
• Exercising and swimming in a heated pool may also be beneficial.

Mechanical Aids

A variety of mechanical devices, called orthoses, are available for people with RA to help support and protect joints. Made from lightweight metal leather, elastic, foam, and plastic, orthoses allow some movement within the affected joint and do not restrict nearby joints. For example, splints or braces help align joints and properly distribute weight. Shock-absorbing soles in shoes can help in daily activities and during exercise. These mechanical aids are used most frequently to treat arthritic hands, wrists, knees, ankles, and feet. A physical or occupational therapist should custom-fit orthoses.

Compression gloves are another potentially helpful aid. Two studies on the overnight use of compression gloves (close-fitting nylon-spandex gloves) concluded that the gloves reduced pain and stiffness in people with RA in the fingers.

Other possibilities for symptom relief include:

• Transcutaneous nerve stimulation (TENS) -- small studies show that at 70Hz, TENS, a technique used by many physical therapists, may provide short-term pain relief for people with RA.
• Magnetic devices -- devices employing static magnetic fields may help reduce pain
• Heat and cold applications -- some people find these applications comforting; may reduce pain

Homeopathy

Recent trials evaluating the use of homeopathy in the treatment of RA found that the remedies were no more effective than placebo in reducing symptoms. These studies contradict an older trial that showed beneficial effects with homeopathic treatment. Despite the lack of definitive evidence, professional homeopaths might recommend one of the following treatments for RA based on their knowledge and clinical experience, as well as successful trials for homeopathy to treat OA. Before prescribing a remedy, homeopaths take into account an individual's constitutional type. In homeopathic terms, a person's constitution is his or her physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.

Potential remedies include:

• A topical homeopathic gel containing comfrey (Symphytum officinale), poison ivy (Rhus toxicodendron), and marsh-tea (Ledum palustre)
• A combination homeopathic preparation containing R. toxicodendron, Arnica Montana (arnica), Solanum dulcamara (climbing nightshade), Sanguinarra Canadensis (bloodroot), and Sulphur
• A liquid homeopathic preparation containing R. toxicodendron, Causticum (potassium hydrate), and Lac vaccinum (cow's milk).

Mind/Body Medicine

Chronic pain and disability can make daily functioning difficult. A holistic approach to your care may positively affect both your lifestyle and how you feel overall. Many people report that relaxation techniques, such as guided imagery and meditation, are an important part of general care and help alleviate pain and other symptoms of RA.

Ayurveda

Yoga

This ancient Indian practice is well known for its physical, psychological, emotional, and spiritual benefits and is often recommended to relieve musculoskeletal symptoms. In one small study, men and women with RA had improved grip strength in their hands after practicing yoga for only 15 days. Women in this study showed greater improvements than men. Certain yoga "asanas" (postures) strengthen the quadriceps and emphasize stretching. People with arthritis should begin asanas slowly and they should be performed only after a warm up. Yoga is best performed under the careful guidance of a reputable instructor.

Herbal Remedies

A recent trial comparing Ayurvedic herbal remedies with placebo, or “dummy treatment” found that participants who consumed the Ayurvedic herbs experienced significant improvement (with only mild side effects) compared to those in the placebo group. An Ayurvedic combination containing the following herbs significantly reduced pain and disability in people with RA:

• Winter cherry (Withania somnifera)
• Boswellia (Boswellia serrata)
• Turmeric (Curcuma longa)

Potential side effects from these herbs include nausea, dermatitis, and stomach pain.

Traditional Chinese Medicine

Tai Chi

This gentle exercise program practiced in China for centuries has been shown to produce a number of benefits, including the following:

• Improved fitness
• Increased muscular strength
• Enhanced flexibility
• Reduced percentage of body fat
• Diminished risk of falls in the elderly

In a trial of people ranging in age from 49 to 81 with OA of the knee or hip, those who practiced Tai Chi twice a week for three months showed significant improvement compared to those in the control group in the following areas:

• Overall sense of quality of life
• Diminished feelings of stress/tension
• Increased satisfaction with general health
• Decreased fatigue
• Easier self management of arthritis symptoms

These benefits are likely to apply to individuals with RA as well. A review of the literature found that Tai Chi benefits lower extremity range of motion for people with RA.

Other Considerations

Pregnancy

Borage seed oil, and possibly other sources of gamma-linolenic acid (GLA), should not be used during pregnancy because they may be harmful to the fetus and induce early labor. Pregnant or breastfeeding women should also not take goldenrod.

Warnings and Precautions

Omega-6 fatty acid supplements should not be used if you have a seizure disorder because there have been reports of these supplements inducing seizures.

Stinging nettle may enhance the effect of NSAIDs. Although the combination of stinging nettle and NSAIDs may be beneficial for the treatment of arthritic conditions, you should consult your doctor before adding this herb to an existing medication regimen.

Prognosis and Complications

RA is associated with many complications.

• Joint deformities
• Cervical spine problems (can be life-threatening)
• Painless, hard, round or oval masses called nodules that appear under the skin
• Pleuritis (inflammation of the lungs)
• Anemia
• Rheumatoid vasculitis (inflammation of the blood vessels)
• Pericarditis (inflammation of the outer lining of the heart)
• Myocarditis (inflammation of the heart muscle)
• Congestive heart failure
• Eye inflammation

The course of the disease varies between individuals. People with a certain antibody in the blood (rheumatoid factor) or nodules seem to have more severe disease. People who develop RA at younger ages also tend to have faster disease progression.

Remission is most likely to occur in the first year and decreases over time. About 20% of people will experience remission and be able to care for themselves 10 to 15 years after diagnosis.

Although complications may shorten the life expectancy of people with RA, treatment is constantly improving and the occurrence of severe disability and life-threatening complications appears to be decreasing.

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• Review Date: 10/26/2005
• Reviewed By: A.D.A.M. editorial, previously reviewed by: Shiva Barton, ND, Wellspace, Cambridge, MA; Gary Guebert, DC, DACBR, (Chiropractic section October 2001) Login Chiropractic College, Maryland Heights, MO; Joseph Trainor, DC, (Chiropractic section October 2001) Integrative Therapeutics, Inc., Natick, MA; Marcellus Walker, MD, LAc, (Acupuncture section October 2001) St. Vincent's Catholic Medical Center, New York, NY; David Winston, Herbalist, Herbalist and Alchemist, Inc., Washington, NJ; Leonard Wisneski, MD, FACP, George Washington University, Rockville, MD; Ira Zunin, MD, MPH, MBA, (Acupuncture section October 2001) President and Chairman, Hawaii State Consortium for Integrative Medicine, Honolulu, HI.

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