This is Episode Seven of “Autoimmune Disease: Pieces of the Picture.” Dr. Beth Jonas describes rheumatoid arthritis, how it is diagnosed and treated, and lifestyle changes that can help patients. Dr. Jonas is an Associate Professor of Medicine in the Division of Rheumatology, Allergy, and Immunology, and directs the UNC Rheumatology Fellowship Training Program. She is a rheumatologist with the UNC Thurston Arthritis Research Center.
“What I tell my patients is that I really want them to be as active as they can be but without really hurting their joints. Some amount of low level activity every day is very important to keep the joints supple and healthy.”
– Beth Jonas, MD
Ron Falk, MD: Hello, and welcome to the Chair’s Corner from the Department of Medicine at the University of North Carolina. This is our series where we are exploring topics related to autoimmune diseases, to help patients and their loved ones understand and manage their condition. Today we will talk about rheumatoid arthritis.
Our expert today is Dr. Beth Jonas, who is an Associate Professor of Medicine in our Division of Rheumatology, Allergy, and Immunology. Dr. Jonas specializes in the care of patients with rheumatoid arthritis and other related conditions, and she also directs the UNC Rheumatology Fellowship Training Program. Welcome, Dr. Jonas.
Beth Jonas, MD: Thank you.
Rheumatoid arthritis & how it’s different from osteoarthritis
Falk: What is rheumatoid arthritis?
Jonas: Rheumatoid arthritis is a chronic condition which is characterized by inflammation of the joints, most commonly involving the small joints of the hands and feet, but almost any joint can be involved.
Falk: So if one of my joints starts to hurt, how do you separate out osteoarthritis from rheumatoid arthritis?
Jonas: We generally think about rheumatoid arthritis being a disease that affects multiple joints at the same time, so that’s one way that we can differentiate rheumatoid arthritis from osteoarthritis. Osteoarthritis is a similar kind of condition, but it usually involves the large weight-bearing joints, not as much the small joints of the hands and feet, although those joints can certainly be involved.
Falk: What’s the cause of rheumatoid arthritis?
Jonas: Well, nobody really knows what causes rheumatoid arthritis. We generally think about it as occurring in a genetically susceptible host (person), but also there are likely some antigenic triggers that may be important in why people develop rheumatoid arthritis, but the etiology (cause) is really very incompletely understood.
Falk: So, like other autoimmune diseases, it’s really the mixture of genetic predisposition with some exposure from something in the environment which triggers this autoimmune process that ends up hurting multiple joints.
Jonas: Well, that is the paradigm that we think about, although we really don’t know for sure.
Falk: What’s that word “rheumatism” really mean?
Jonas: Rheumatism is really an old term and probably just means joint pain or arthritis in general. Some people might equate the word rheumatism with rheumatoid arthritis, but they are really not the same thing. Rheumatism is just a very general term.
How rheumatoid arthritis is diagnosed
Falk: So if somebody presents to you then, in clinic, and has multiple joints that are bothering them, how do you end up proving that that person has rheumatoid arthritis?
Jonas: Making a diagnosis of rheumatoid arthritis really relies on a few things. Number one is the history: which joints are involved, how long have they been involved, are there symptoms and signs of inflammation in the joints? Those are the things that we’re looking for.
Falk: By inflammation, what does that look like?
Jonas: Swelling, warmth, redness, loss of range of motion in a joint, are all things that may indicate that there’s inflammation.
Falk: Help me understand the words “range of motion.”
Jonas: Each of our joints has a normal range of motion, which is how much you can bend and straighten that joint, so when we are evaluating patients in the clinic, we are looking to see whether the joint moves in its normal range of motion. If there’s fluid in the joint, or if there’s swelling around the joint, the range of motion may be limited.
Falk: Is that because of pain, or because the joint doesn’t move that well anymore?
Jonas: It’s sometimes related to pain, but more often than not, in rheumatoid arthritis it’s because there is swelling of the tissues in and around the joint that restricts the range of motion.
Falk: There are history questions, and you do a physical exam, and what are you looking for there?
Jonas: We’re looking for swelling of a joint, tenderness of a joint, and we’re looking at the pattern of the joints that are involved. Typically, as I mentioned, patients with rheumatoid arthritis will have involvement of multiple small joints in a symmetric pattern. Someone with rheumatoid arthritis may have inflammation, tenderness, swelling of multiple joints in their hands and feet. The other thing that we’re looking for are laboratory tests. There are some serologic studies that may indicate a higher risk for rheumatoid arthritis and those are antibodies called rheumatoid factor and antibodies to CCP.
Falk: The first question I guess, when you’re seeing one of these patients, is do they have evidence of inflammation? From blood tests, one you’re suggesting is rheumatoid factor which can be positive in patients with rheumatoid arthritis but also can be found in other sorts of inflamed patients.
Jonas: Right. Rheumatoid factor is found to be positive in about 50% of patients with very early rheumatoid arthritis, and in patients who are negative for rheumatoid factor about half of them will become positive somewhere along the course of their illness. You don’t have to have a rheumatoid factor in your blood to have rheumatoid arthritis. The flip side is true in that some people will have a positive rheumatoid factor but not have rheumatoid arthritis, so the test alone is not going to make the diagnosis.
Falk: But it’s another peg in the board for figuring out what the person has.
Falk: What is a more recent test, there are antibodies to what are known as citrullinated proteins, this anti-CCP antibody test. How good of a test is that?
Jonas: It’s probably not any more sensitive than a rheumatoid factor for patients with early disease, but it is, we think, a little more specific than a rheumatoid factor, so that is to say, if you’re CCP antibody is positive, it’s more likely than not that you do have rheumatoid arthritis. The other thing about a CCP antibody is if the titer is high, that tends to be associated with more aggressive disease, so it can help us prognostically if we’re seeing a patient with RA who has a high CCP antibody.
Falk: So if the antibody to CCP is negative, that does not exclude rheumatoid arthritis.
Falk: If the antibody test is positive, it is helpful, part of the diagnostic picture, but it doesn’t prove that you have rheumatoid arthritis, and then if you have a lot of this antibody—the measurement in your blood, the titer, is very high, it may suggest that if you have rheumatoid arthritis, you have a more aggressive disease. Am I getting that right?
Jonas: That is correct.
Falk: There’s no definitive blood test in other words that proves if you do or do not have this disease.
Jonas: That’s correct. It’s really a combination of your history, the pattern of the joint involvement, the laboratory tests, and then sometimes we’ll use x-rays or other tests that would support the diagnosis, but the blood test alone is not going to make a diagnosis.
Flare-ups of disease
Falk: Is this a relapsing and remitting disease like so many other autoimmune diseases, or does it come and stay and never go away?
Jonas: This is a chronic disease, so it comes and it stays, but it may have times of exacerbations, so periods of time where the arthritis is more severe, and other times when it’s less so.
Falk: What makes the disease process get better and what makes it get worse?
Jonas: We really don’t know for sure. Many patients will say that if they overuse their joints, they may have a flare, or if they’re under a particular amount of stress during a period of time that their joints might flare. If they don’t get adequate sleep, they may have a flare, but for each patient it’s very different. Sometimes people flare and get better for no apparent reason.
Falk: Does weather play a role in how someone feels, if their joints are going to feel better or worse?
Jonas: This is an area of some controversy in rheumatology. Many patients will describe that when the weather is cold and rainy, that their joints feels worse, that they feel achy and more sore. I certainly can say that I’ve observe this in my patients, although I will say that there’s not a lot of hard data that supports this in the literature.
The importance of movement & a healthy lifestyle
Falk: Overworking a joint can make it feel worse, but exercise is probably very good for patients. How do you balance out the question of how much to exercise and how much to rest? When is it a good idea to chill and when is it a good idea to push on?
Jonas: This comes up all the time, and I think it’s very important. Back in the day, we used to tell patients who had very active arthritis to really rest a lot. It turns out that that might not have been the best advice. In fact we used to splint joints that were very active, and we found out that actually makes things worse. We generally try not to splint anything and try to keep things moving as comfortably and gently as we can during periods of a flare, and try to keep patients moving.
Generally if you have a joint that’s highly inflamed, it’s best not to stress that joint, but moving through a normal, gentle range of motion can be very helpful to get that joint under better control. What I tell my patients is that I really want them to be as active as they can be but without really hurting their joints. Some amount of low level activity every day is very important to keep the joints supple and healthy and moving as well as they can be.
Falk: What other lifestyle modifications should patients do to help?
Jonas: We talked about exercise, the other thing I that think is important is really getting enough sleep. Resting adequately each day is very important to maintaining your energy and also managing your pain. Keeping your weight in a healthy range is really important – you don’t want to have too much weight on a joint that may be affected. Stress management is also really important, because patients will say if they have unusual stressors, their joint pain gets worse. All these kinds of lifestyle modifications we recommend for all of our patients.
Falk: If a patient of yours is smoking, you want them to stop smoking for their general health. What do you tell them about the consequences of smoking on their rheumatoid arthritis?
Jonas: As you mentioned there are a lot of good reasons to stop smoking, but smoking actually is a risk factor for the development of rheumatoid arthritis. So I tell my patients that, “Your smoking may have contributed to you getting rheumatoid arthritis.” The other thing that we know about patients with rheumatoid arthritis who smoke tend to not respond as well to medications while they’re smoking, and we definitely advise them to stop for that reason.
Treatment options for rheumatoid arthritis
Falk: What’s the advantage for someone diagnosed early with rheumatoid arthritis, versus waiting for the disease to move along?
Jonas: We really want to make this diagnosis early. The reason is, is that we have so many good therapies now that are going to prevent the disease from progressing. Once the disease has set in, there’s a risk for damage to the joints. Once a joint is damaged, it’s really irreversible, so the time to act is early. We like to think about therapy for patients with rheumatoid arthritis really at the first visit, and even in patients who don’t have particularly aggressive disease, we’re always thinking about ways to control inflammation and prevent joint damage.
Falk: And those drugs that are called “DMARD.” What’s a DMARD?
Jonas: A DMARD is a disease-modifying antirheumatic drug. These are a group of medicines that have been shown to prevent the disease from affecting the synovium, the tissue that lines the joint, as well as the underlying bone, and can prevent erosion of bone, which is one of the hallmarks of severe disease.
Falk: There are drugs that are disease-modifying agents. They almost come in two flavors, there are the more recent drugs that are biological forms of therapy that are usually infusions or injections that affect rheumatoid arthritis. The mainstay of treatment is a drug called methotrexate. Can you spend some time talking about that?
Jonas: Methotrexate is a drug that we have been using for the treatment of rheumatoid arthritis for more than thirty years. It’s taken by mouth once a week and really has made a huge difference in what we can do for patients with rheumatoid arthritis. For most patients, this may be the first DMARD medication that they take. Most people tolerate this medicine quite well, and a good percentage of patients get an excellent response to methotrexate. There are of course some patients in whom the medication does not adequately treat their disease, and in those patients we often consider multiple agents together, combinations of DMARDs, or the use of biologic therapy. Those are the medicines that are injectable, or by infusion.
Falk: There are some patients who take methotrexate and they really can’t tolerate it. Would you jump to one of these biological therapies more rapidly then?
Jonas: In some cases we would do that. Some patients will have some nausea, or hair loss, or oral ulcers that preclude the use of methotrexate. Occasionally we see patients who have underlying liver disease, and those patients can’t take methotrexate. Those might be situations where we might go to a biologic DMARD, but there are also other oral agents like hydroxychloroquine or sulfasalazine, or leflunomide, and a number of other oral disease-modifying therapies that we might use in lieu of methotrexate in those cases.
Falk: The real revolution that came about is based on the understanding that there are very specific chemicals that exist in the body and in the joints that can be blocked by these injectables, the anti-tumor necrosis family—TNF family of drugs. They’ve really changed a lot of the landscape of therapy.
Jonas: Yes, this has been probably one of the most amazing things during the course of my career. These drugs became available about 20 years ago and I think they have just revolutionized how we treat patients with rheumatoid arthritis, and also really have changed the future for all of those patients. It was not uncommon 20 years ago to see patients who came to our clinic in a wheelchair. These days, it’s very unusual to see that. The medications have really made a huge difference and have changed the future for our patients.
Falk: Patients can get by with perhaps limited joint destruction – they can do very well for very long periods of time.
Jonas: Sometimes I’ll see people in my clinic who have been on these medicines since the outset of their disease, and I can’t even tell that they have rheumatoid arthritis. That’s not true for everybody, but it’s certainly a possibility for some patients.
Falk: There are other biological forms of therapy as well, that are different than TNF blockers that seem to help in some patients too, the future is pretty bright for all kinds of therapy for this disease.
Jonas: That’s absolutely true. We have many drugs that we call non-TNF biologics, which we’ve saved for patients who haven’t responded to TNF inhibitors, or in whom they can’t take TNF inhibitors. There’s a fairly big pipeline of new drugs coming on the market to treat rheumatoid arthritis.
Pregnancy & medications
Falk: If a young woman who is afflicted with rheumatoid arthritis wants to become pregnant, what are the issues there? Is it safe? Is it something they should be worried about? What do you suggest to your patients?
Jonas: We see a lot of women in the childbearing age who have rheumatoid arthritis. The most important thing is really to work closely with your doctor, to talk about your plans for pregnancy. Most women with rheumatoid arthritis can have a successful pregnancy and do well, but it requires that we manage the medicines very carefully. For example, methotrexate is a medicine that we really cannot use during pregnancy, so if you’re on methotrexate, that medication is going to need to be stopped and in most cases we’ll have to add something else on to replace that so that the patient can maintain good control of their disease. So it really requires some careful planning around medications.
Staying in touch with your doctor
Falk: When one has a chronic disease where one does well for a while and then flares, it’s really important to have close communication of the patient and provider. Is that true for rheumatoid arthritis as well?
Jonas: Absolutely. I think it’s very important that there is a close collaboration between the patient and the physician, and also regular follow-up to make sure that whatever medication you’ve chosen is actually working, and that you haven’t developed any toxicity, and that you can anticipate the problems that may come along in the future. Having that close collaboration with your physician is critically important.
Falk: An organized approach to being able to get a hold of your doctor in a reasonable period of time if you’re having symptoms, and regular check-ups are a good idea as well.
Jonas: Absolutely. Most of the medications that we have need to be monitored, so we have regular visits to monitor the medications and monitor the disease to make sure they’re under control.
Falk: Where do you tell patients to go online or to find helpful information? What sources of information would you trust out there?
Jonas: I think there are 2 excellent places to go for information. One of them is the Arthritis Foundation, which is www.arthritis.org and the other is the American College of Rheumatology which is www.rheumatology.org and both of these web sites have specific areas of information for patients to learn more about their disease.
Falk: Dr. Jonas, thank you so much for spending time here today.
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