The earliest indicator of RA is usually finger swelling and stiffness. — Photos: Dr CHOW SOOK KHUAN
Inflammation is a part of the process where the immune system defends the body from harmful pathogens such as bacteria and viruses.
It presents itself as pain, swelling, redness, heat and loss of function.
However, in rheumatoid arthritis (RA) – a chronic and progressive autoimmune disease – the immune system doesn’t work properly and attacks the lining of the joints instead, causing pain and inflammation.
Left untreated, RA can cause joint deformities, physical disability and poor quality of life.
It can also affect many other parts of the body, such as the lungs, heart, skin, nerves, muscles, blood vessels and kidneys.
In Malaysia, it is estimated that five in 1,000 persons are afflicted with this condition, with a three-to-one ratio of women to men.
Yet, there is low disease awareness and screening for RA, as statistics show that only 20% of adults seek help from their primary care doctors for musculoskeletal problems yearly.
This delay in diagnosis can lead to increased levels of pain and disability, as well as increased healthcare costs, over the duration of the disease.
Don’t delay treatment
According to consultant rheumatologist Dr Chow Sook Khuan, RA can develop at any age, from toddlers to the elderly.
“It used to affect those between 30 and 60 years, but from recent observations, we are noticing that there seems to be a higher incidence among those above 60, although there is no explanation for this.
“Women are more prone to it after menopause, and as many are on hormone replacement pills, we don’t know if this plays a role in developing RA,” she says.
RA is symmetrical, which means symptoms appear in the same spot on both sides of the body, often in the joints of the feet and hands.
In contrast, osteoarthritis – the wearing away of cartilage due to wear and tear – begins in an isolated joint, often in the knee, fingers, hands, spine and hips.
While both sides may also hurt in osteoarthritis, one side is usually more painful.
Dr Chow explains: “If you have RA and your weight-bearing joint (e.g. knee) is damaged because you haven’t treated it fast enough, you may get a more serious secondary osteoarthritis.
“Or you can have both RA and osteoarthritis.
“Osteoarthritis can also cause deformity in the finger joints, but it doesn’t affect the joint function so you can still lead a normal life.”Among the first signs of RA are early morning stiffness in the finger joints, which can occur with or without pain.
It can last for more than 30 minutes, sometimes up to a day.
The patient is unable to even pick up a toothbrush because she can’t grip.
Or she isn’t able to raise her arms up because the shoulder joints are stiff.
“Osteoarthritis can also give you morning stiffness, but it doesn’t last as long and can be overcome by exercise.
“With RA, exercise cannot overcome stiffness because patients may not even be able to extend their fingers,” says Dr Chow.
Other symptoms include fever, weight loss and fatigue.
When the symptoms don’t go away, and include swelling and tenderness, it’s time to head to the doctor’s office for a consultation.
Don’t leave it until your joints are so damaged, you need to undergo joint replacement surgery.
In the current era, patients don’t need surgery unless they don’t follow treatment protocols or delay seeking treatment.
Dr Chow says: “The joint will take about three years to be totally damaged.
“We can replace hip and knee joints, but not the wrist.
“It’s also possible to replace the elbow and shoulder joints, but it is not so common.”
Rheumatoid factor
Here is an example of severe finger joint deformity from RA.
There is no one single test to diagnose RA; a combination of clinical findings and blood tests is necessary.
Dr Chow says: “We cannot diagnose based solely on a blood test.
“It’s very common for patients to come to us when they find their rheumatoid factor (RF) is positive during a routine blood test – they think they’re going to get RA.”
RF is the protein made by your immune system that can attack healthy tissue in the body.
If your blood cells have high amounts of this protein, you are RF positive; a negative result means you have a normal amount of RF in your blood.
High levels of RF are most often related to autoimmune diseases, such as RA and Sjogren syndrome.
However, there are healthy people with high RF, while some people with autoimmune diseases, as well as tuberculosis or hepatitis carriers, have normal RF levels.
Science hasn’t been able to pinpoint why.
“They may be RF positive, but if they have no joint complaints, we don’t treat them.
“Ongoing studies are inconclusive as to whether or not we should treat those with extremely high RF numbers, but without symptoms, with DMARDs [disease-modifying anti-rheumatic drugs], to prevent them from getting RA.
“So we don’t advocate giving drugs,” Dr Chow says.
Instead, this group of patients are asked to take the anti-cyclic citrullinated peptide (anti-CCP) antibodies test, along with, or after, the RF test.
She explains: “The anti-CCP is more specific for RA and has a very strong predictive value.
“If the numbers are sky high and the patient still has no symptoms, we monitor them every six months.
“If symptoms appear, we ask them to come back and consult us quickly.
“Now, we also have new tools such as the bedside ultrasound machines to look into the joints.
“If the results are not clear, then we do an MRI [magnetic resonance imaging] to confirm the diagnosis.”
Controlling inflammation
Left untreated or a delay in starting treatment can lead to severe joint deformity such as this one on both feet.
In the past, patients with RA had a shorter lifespan due to complications that arose from being bedridden.
“Without proper treatment to control inflammation, the immune system might start damaging the blood vessels and make them thicker (from the swelling).
“The arteries harden and patients die of an early heart attack,” says Dr Chow.
With new advances in medicine, RA has become a treatable disease and patients can enjoy a good quality of life.
Treatment for RA may involve one or more of the following:
- Non-steroidal anti-inflammatory drugs (NSAIDs) for symptomatic relief, i.e. reducing pain and inflammation.
- Short-term use of corticosteroids to help decrease inflammation, provide pain relief and slow down joint damage.
- DMARDs to suppress the overall immune system and slow down disease progression.
It takes roughly two to four months to see results.
- Biologics if the above treatments don’t work by six months’ time, and also, depending on the patient’s profile and financial ability.
These medications block specific parts of the immune system, such as the proteins that promote inflammation.
Biologics are more complex and harder to make than conventional DMARDs, and therefore, cost much more.
They are administered via injections or intravenously.
- Janus kinase (JAK) inhibitors (i.e. small molecule drugs) that send messages to specific cells to stop inflammation from inside the cell.
They come in pill form.
The main difference between biologics and JAK inhibitors is that while small molecule drugs are chemically derived, biologics are extracted from living organisms.
Generally, Dr Chow says all patients are initially started off on conventional DMARDs, with methotrexate being the key drug.
“Around 50% of patients respond to this and can achieve remission or low disease activity, but others need more advanced treatment, i.e. biologics or small molecule drugs.
“Small molecule drugs are similarly priced to biologics or could be cheaper, but because they’re oral drugs, patients have to pay out of pocket.
“Biologics can be dripped so some patients can get insurance support,” she says.
Individuals with RA may experience periods of flares when symptoms appear or get worse, and periods of remission when symptoms improve or disappear.
During an RA flare-up, the chronic inflammation can lower the production of red blood cells in the bone marrow, causing the patient to become anaemic.
Unfortunately, the majority of RA patients will have to be on drugs for the rest of their lives.
Dr Chow adds: “Even if the patient recovers well, e.g. the inflammatory markers are well-controlled and there is no deformity, they still cannot stop the drugs.
“Once you stop, the disease will come back and we’ll have to start treatment all over again.
“Our goal is to make you recover fully within six months, if you seek treatment early before any joint damage occurs.”
