Dr Rachel Byng-Maddick, Consultant Rheumatologist, explains how to diagnose and treat rheumatoid arthritis.

Early diagnosis and treatment

Rheumatoid arthritis (RA) is an inflammatory disease with a progressive course affecting the synovium of joints and extra-articular structures resulting in pain, disability and increased mortality. It affects 0.8-1% of the UK population. Persistent inflammation leads to erosive joint damage and functional impairment in the vast majority of people. Many studies have shown that early, aggressive treatment can prevent joint destruction and prevent significant disability and morbidity. If RA is left untreated, it may also have significant effects on the heart, lungs, eyes and other organs.

Early diagnosis of RA, can be made following symptoms of joint pains, stiffness and swelling. X-rays of hands and feet are useful to look for erosive changes in the smaller joints. Ultrasound of affected joints can also be used to look for synovitis and erosion. Larger joints are sometimes imaged by MRI, to assess for synovial inflammation and joint effusion. Blood tests are also helpful in the diagnosis of RA. Although many patients have a raised systemic inflammatory response (high C-Reactive Protein or Erythrocyte Sedimentation Rate) and positive antibodies (Rheumatoid factor and anti-CCP antibody), if these tests are normal this does not exclude a diagnosis of RA and patients should be assessed by an experienced Rheumatologist.

Initial treatment includes disease modifying drugs such as methotrexate, sulphasalazine or hydroxychloroquine. As these drugs are often slow to work, steroids may be used to control disease activity quickly in the short term. If inflammation cannot be achieved with these drugs, biologic therapies which target specific immune pathways known to play a role in the pathogenesis of RA are used. These include anti-TNF therapy (Adalimumab, Etanercept, Infliximab, Golimumab or Certolizumab), B cell depletion therapy (Rituximab), IL-6 inhibitors (Tocilizumab, Sarilumab), T cell co-receptor blockade (Abatacept) and more recently small molecule inhibitors of JAK have also been introduced (Baricitinib and Tofacitinib).

Achieving remission

Remission is defined as significant improvement of RA symptoms, such that patients do not experience prolonged joint stiffness, swelling or persistent pain (due to their RA). Spontaneous remission in RA is rare, and usually only occurs with medication. If treatment is stopped, the symptoms are likely to recur as the inflammation may become active again.

Doctors use a “treat to target” approach for managing RA, which involves closely monitoring disease activity and using treatment to reduce measured inflammation by the disease activity score, aiming for the lowest possible score. Achieving remission (or at least low disease activity) is important in RA, as this reduction in inflammation will prevent on-going joint damage and reduces extra-articular manifestations of disease including, increased cardiovascular risk. Tight control of disease activity and early aggressive treatment is associated with higher rates of sustained remission, with a possibility of drug-free remission. Ultrasound is often used to exclude on-going subclinical synovitis.

Other factors which may influence sustained remission include the disease duration and severity, gender (remission is more common in men) and age. A review of several studies reported in the journal, Current Rheumatology Reports, found that less than 15 % of people with RA are able to sustain a drug-free remission.

Psychological support for rheumatoid arthritis sufferers

Living with a long-term condition such as RA is associated with poorer psychological well-being. A survey carried out by the National Rheumatoid Arthritis Society (NRAS) last year found that of the patients with RA surveyed, 50% had clinical anxiety and 69% had clinical depression, but were not formally diagnosed with a mental health condition, despite meeting the diagnostic criteria. https://www.nras.org.uk/publications/emotional-health-well-being-matters

Therefore significant numbers of people who were suffering with mental health illness were not receiving treatment which in turn may have affected their overall physical health. Research has shown that those suffering with mental health problems such as anxiety and depression are less able to manage their disease, which can lead to poorer clinical and psychological outcomes.

The survey also found that a significant number of people with RA did not know how to access psychological support or were uncomfortable asking for this type of help. In this vein, people with RA did not believe that health professionals had enough time to help them with their emotional problems. It has been shown that if emotional and psychological well-being is acknowledged by healthcare professionals, patients are more likely to discuss their problems.

As well as pain and disability leading to more psychological distress, the symptoms experienced by people with RA may also lead to job losses and unemployment. It may have a significant impact on personal relationships, including those integral to family life, such as being a parent, managing a household or maintaining intimate relationships and upholding friendships.

It is important for healthcare professionals to recognise that people with RA may suffer with mental health problems as a consequence of their illness, and should encourage a discussion about the person’s emotional well-being. This assures patients that this aspect of their lives is as important as their physical health and validates what they are feeling, therefore enabling an open dialogue about these issues.

Exercise and prevention against loss of function

Having RA may lead to reduced or poor mobility, chronic pain, anxiety, depression and fatigue. Physical exercise can help to reduce joint pain, improve overall cardiovascular fitness and health, as well as improving emotional and mental well-being. Moderate, regular activity and stretching, can help to build muscle strength and increase flexibility of affected joints.

Low-impact exercise is generally recommended for people with all types of arthritis, such as swimming or cycling. Although some people with RA may find exercise painful initially, even simple activities such as walking or yoga may help to reduce inflammation. The best type of exercise is that which the patient enjoys, so that they continue to do it!

Exercise should be regarded as an integral part of the treatment programme for people with RA. A physiotherapist will be able to help design a safe, effective daily workout routine that helps to keep joints flexible and strong. This will also give confidence to patients about what exercises are appropriate, particularly with respect to minimising strain on affected joints, whilst improving overall body strength.

Diet and supplements

There is no scientific evidence to suggest that eating particular foods or excluding certain foods will have a significant impact on RA.

Although changing dietary intake will not induce remission, some people find that acidic foods, such as tomatoes, potatoes, peppers and aubergine can worsen their symptoms. If avoidance of particular food does help one individual, it is important to ensure that these foods are replaced with equally nutritious food. On the whole, eating healthily with fruit, vegetables, whole grains, healthy fats and calcium is good for overall health and arthritis.

The most important aspects of diet and in people with arthritis are 1) weight and 2) intake of sufficient vitamins and minerals. Being overweight may increase strain on joints, worsening pains particularly in the back, hips, knees, ankles and feet. Reducing obesity will also improve cardiovascular risk as well as emotional and mental well-being. A balanced and varied diet should contain all of the vitamins, minerals, antioxidants and other nutrients needed. Omega-3 fatty acids, found in oily fish, walnuts, soy, canola oil, flax seeds and pumpkins seeds may have weak anti-inflammatory properties.

In addition, turmeric, which contains curcumin, has been shown to have anti-inflammatory properties. There is no scientific evidence to show that it significantly improves or impacts on RA disease activity, but it has minimal-to-no side-effects, and therefore can be added in conjunction to prescribed medication.

In order to keep bones healthy, it is important to ensure there is adequate calcium intake in the diet, particularly in postmenopausal women who are at a higher risk of osteoporosis. The best sources of calcium are milk, yoghurt, cheese, calcium-enriched milk (e.g. made from soya, rice or oats), or tinned sardines (where bones are also ingested).

Vitamin D is also required to maintain strong and healthy bones, but is also recognised to boost the immune system and may have some anti-cancer effects. From June to August in the UK, getting an average of 15 minutes a day of sunlight on bare skin (for example bare arms, legs and face) should be enough for most people to get their recommended daily amount of vitamin D.

Stopping standard therapy or immunosuppression is not recommended, in exchange for altered diet or dietary supplements.

Key messages for rheumatoid arthritis:

• Symptoms of joint pain, prolonged joint stiffness (> 30 minutes) or joint swelling should be investigated by a rheumatologist for a diagnosis of rheumatoid arthritis

• Early diagnosis is key to staying active and independent

• Early, aggressive treatment helps to prevent long-term damage and disability

• Treating psychological aspects of disease is equally as important as treating physical symptoms

• Regular exercise and stretching helps to improve joint health

• A healthy well balanced diet should include all of the nutrients required for a healthy body and mind.

About the author

Dr Rachel Byng-Maddick is a Consultant Rheumatologist, practising at Westminster Bridge Consulting Rooms at St Thomas’ Hospital and the Royal Brompton Hospital at 77 Wimpole Street. She specialises in diagnosing and treating inflammatory arthritis and general rheumatological conditions. For further information please contact pa@byng-maddick.com or 0207 993 8499.

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