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Our office is located at
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near Hospital Pharmacy.
Tan Tock Seng Hospital,
11 Jalan Tan Tock Seng,
Singapore 308433
Tel: 6357 8037
Fax: 6357 8039
Send Comments to:
info@rass.org.sg
weihowekoh@gmail.com
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Introduction
Rheumatoid arthritis is a relatively common disease in Singapore. It is one of many
different types of arthritis, each with its own particular characteristics. With proper
treatment, rheumatoid arthritis can be controlled and severe deformities of the joints
may be prevented. When first diagnosed with the disease, some patients with rheumatoid
arthritis may feel depressed, anxious or frustrated. Misconceptions about the disease
and the desire for a rapid cure may lead the patient to seek unproven therapy,
resulting in delay in appropriate treatment and dire consequences.This booklet is
written for people who have rheumatoid arthritis, and their family. It aims to explain
some of the facts about rheumatoid arthritis and help you understand the disease so that
you can take a positive role in keeping it under control.
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What is Rheumatoid Arthritis?
Rheumatoid arthritis is an inflammatory disease characterised by pain, swelling and
stiffness in the joints. The disease causes inflammation in the lining of the joints
("arth" means joint, "itis" means inflammation). Inflammation is the body’s reaction
to injury.
In an inflamed area, the flow of blood increases, resulting in heat and redness;
fluid and cells leak into the tissue, causing swelling and pain. Most inflammatory
reactions are short-lasting responses to injury but in rheumatoid arthritis the
inflammation is persistent and abnormal. Fluid may accumulate in the joint as a result
of the inflammation and this contributes to the joint swelling. If the inflammation
continues uncontrolled for a long time, it may cause damage to the joints or tendons.
This inflammation distinguishes rheumatoid arthritis from other more common forms of
arthritis like osteoarthritis.
Apart from the joints, the disease can also affect other parts of the body like the
eyes, lungs, nervous system and the skin. In its mild form, it may cause no more
than minor discomfort and does not lead to serious joint deformity. In its severe
form, rheumatoid arthritis can give rise to painful and badly damaged joints. The
disease is thus different from patient to patient. It is a chronic disease and there
may be periods of remission (no symptoms) between periods of active disease.
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Who gets it and how common is it?
It can occur at any age but most commonly, it appears between the ages of 25 and 50.
A similar form of arthritis affects children. Both sexes may be affected although it
is three times more common in women than in men. As other types of arthritis may
sometimes mimic rheumatoid arthritis, it is difficult to be sure how common it is. In
the USA, approximately one percent of the population have rheumatoid arthritis. The
figure in Singapore is not yet known.
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What causes Rheumatoid Arthritis?
It is not yet known what causes rheumatoid arthritis. It is thought that the
inflammation in the joint is due to a disorder of the body’s immune system and that
a triggering agent causes the disease only in those with a genetic or inherited
susceptibility. The result is an immune reaction to the body’s own cells and tissue
especially in the joints leading to inflammation in the joints. The persistent inflammation
causes damage to the joints.The "triggering agent" may well be a virus or bacteria but
it has yet to be identified. The disease is however not contagious.There is no scientific
evidence that rheumatoid arthritis is caused by changes in weather, lack of vitamins
or excess dietary intake of certain food stuff.
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How is Rheumatoid Arthritis diagnosed?
The diagnosis of rheumatoid arthritis is based on the overall finding of the
characteristic symptoms the patient experiences and signs of arthritis on examination,
together with the help of laboratory tests and X’rays. The pattern of joint
involvement is one useful way of differentiating rheumatoid arthritis from
other types of arthritis. For example, the wrists and many of the joints of the
hands may be affected but usually not the joints closest to the finger nails
(except for the thumb). In contrast, another common type of arthritis called
osteoarthritis affects the joints closest to the fingernails more often than other
joints of the hands. Rheumatoid arthritis may also involve other joints like the
elbows, shoulders, neck, jaw, hips, knees, ankles, and the feet. Apart from the neck,
rheumatoid arthritis usually does not affect the spine.
Another type of arthritis which predominantly affects the spine but can also involve the
joints of the limbs, is called spondyloarthropathy.
Spondyloarthropathy more often afflicts young male adults. The joints tend to be
symmetrically affected in rheumatoid arthritis, meaning that if the knuckles of
the left hand are inflammed, it is likely that those on the right will be similarly
affected. Rheumatoid arthritis tends to persist for more than a few weeks to months.
Some other forms of arthritis like those associated with a viral infection come in
shorter spells and often resolve completely. The presence of lumps or nodules under
the skin and along tendons is another feature of rheumatoid arthritis which is not
usually found in other types of arthritis.
A blood test which identifies the presence of a substance called the rheumatoid
factor, which is present in about 70% of cases, helps in the diagnosis. However
the presence of rheumatoid factor in the absence of other characteristic features of
the arthritis does not allow the diagnosis of rheumatoid arthritis to be made because
it may occur in other conditions and even in normal people. The activity of the
disease may be assessed with the help of some blood tests such as the "erythrocyte
sedimentation rate" or ESR. Anaemia or low red blood cell counts may be present
especially when the disease is active.
X’rays are usually normal early in the disease They may later show typical
pattern of joint damage or "erosions" of the bones. Serial X’ray may help to
assess the degree of joint damage and the response to treatment.
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Is Rheumatoid Arthritis Inherited?
The disease is not passed directly from parents to children. A tendency or
susceptibility to develop the disease may be inherited but the presence of
other yet unknown factors are also important for it to occur. Rarely, there are
some families where the arthritis affects more than one member.
How does Rheumatoid Arthritis affect the patient?
About 10% of patients have a single attack of arthritis and a long lasting
remission after that. However, in the majority of patients with the disease,
the arthritis will persist for a long time if left untreated. The course of the
disease varies from person to person. There will be some whose disease will be mild
with periods of exacerbation (worsening of the arthritis called "flares"). In others,
the disease may be continuously active and progress relentlessly.
When the disease starts, the patient may feel generally unwell with fatigue, loss of
appetite and weight, and develop joint stiffness and aches. The stiffness in the muscles
and joints often occur in the morning and it may be a few hours before it gets better.
The inflammed joints will become swollen, warm, tender to touch and difficult to move.
If the inflammation in the joints is prolonged, the joint may be damaged and the muscles
around the joints may become weak and wasted. The joints may become deformed and
occasionally the tendons may rupture causing the fingers to "drop" and unable to move.
The disease may strike the patient suddenly and severely. Those afflicted with
the disease may find that they are unable to perform activities of daily living that
they used to take for granted, like dressing, bathing and doing simple household chores.
Depression, denial, frustration and anxiety are sometimes experienced by patients who
will benefit from counselling and education about their disease.
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How do you treat Rheumatoid Arthritis?
Understanding the disease will make it easier to cope with it. It is useful to learn
more about the disease by talking to your doctor, physiotherapist, other patients and
by joining a support group.No single standard treatment is suitable for all patients.
Therapy is tailored to the severity of the disease and involves a combination of
medication, rest, physiotherapy and knowing how to protect the joints.
REST is one of the best way to treat the inflammed joint and reduce fatigue. Splints
may be used to restrict movement to rest the joint and prevent joint deformity.
However too much rest may allow the joint to stiffen and the surrounding muscles to
be weak. Therefore, once the inflammation has subsided, mobilisation of the joint and
physiotherapy may be required.
MEDICATION is often required to control the disease. Many patients are afraid about
taking drugs because of the possible side effects. Whilst the drugs may have occasional
side effects, for most patients the benefits of the drugs far weigh the potential risks
and they provide a great relief to many sufferers. There are two major groups of drugs
used to treat rheumatoid arthritis; one group is the "anti-inflammatory" agents and the
other is the so-called "disease-modifying" agents which induces remission of the disease
over a long period of time.
Anti-inflammatory drugs have more immediate effect and reduces the pain, swelling
and stiffness associated with the arthritis within hours and days. They are called
non-steroidal anti-inflammatory drugs or NSAID and there are many different types
available with varying dosing intervals. Some examples of NSAIDs are aspirin,
indomethacin, diclofenac, naproxen, ibuprofen, mefenamic acid and piroxicam. NSAIDs
may cause gastric upset which may be reduced by taking them after food or with another
drug to relieve the abdominal symptoms. Different patients respond to different NSAIDs,
and it may require some time to find the best one that suits them.
A new group of anti-inflammatory drugs called the "COX-2 inhibitors" or Coxibs, have
been recently developed. This class of drugs differs from the "conventional NSAIDs"
by selectively inhibiting an enzyme involved in the inflammatory process,called the
cyclo-oxygenase 2 or COX 2 enzyme. The Coxibs are associated with fewer serious
gastrointestinal side effects such as bleeding stomach ulcers compared to the
"conventional NSAIDs". Examples of Coxibs include Celecoxib, Rofecoxib and the
newer Etoricoxib and Valdecoxib.
Disease-modifying drugs are used to control the arthritis and hopefully prevent the
disease from progressing. In contrast to NSAIDs, these drugs tend to act more slowly
and may take months to produce maximal benefit. There are possible side effects which
may require regular monitoring of blood and urine test. There are many drugs in this
group such as methotrexate, gold, sulphasalazine, hydroxychloroquine, chloroquine and
penicillamine. Some patients respond so well to the drugs that the disease seems to
disappear and they do not require the NSAID. However the arthritis may flare if the drug
is stopped and patients are usually required to take it on a long term basis.
Another drug, leflunomide, has been developed recently to treat rheumatoid arthritis.
This drug has been found to be as effective as methotrexate and sulphasalazine.
Leflunomide may be used as an alternative treatment for patients who do not respond
to or are intolerant of methotrexate or sulphasalazine.
Corticosteroids have strong anti-inflammatory properties but should be used only sparingly
and in very severe disease. When used in the appropriate conditions, steroids can be
of great benefit. However, it may have many side effects especially when used in large
doses and for long period of time. Injection of steroids into the joints is occasionally
used to help control the arthritis in one or two troublesome joints.
Advances in the understanding of the pathogenesis of rheumatoid arthritis have
resulted in the development of biological therapies which are targeted at various
sites in the inflammatory process. Recently, two biological agents which inhibits a
key element of the immune process called tumour necrosis factor or TNF, have been
available in Singapore for the treatment of rheumatoid arthritis. The two TNF
inhibitors, infliximab and etanercept, have shown significant benefit in the
controlling the arthritis even in patients whose disease have been resistant to
conventional treatments. However, the biological agents have to been given by
injection and are relatively expensive.
HEAT AND COLD treatment is a simple and effective therapy for relieving joint pain and
muscle spasm. Hot pads, a hot shower, paraffin wax and cold compress may be used.
EXERCISE AND PHYSIOTHERAPY are also important in the overall treatment of the disease.
It is important that the muscles are kept strong and that the joints maintain as full a
range of movement as possible when the inflammation in the joints is sufficiently
controlled.
DIET has no special effect on arthritis. A well-balanced and healthy diet is beneficial.
It is logical that you should diet if you are overweight in order to reduce the stress
on the joints in your lower limbs.
SURGERY may be recommended for patients with severe disease to correct or prevent
joint deformity. In the badly damaged joints like the hips and the knees, joint
replacement may provide the patient pain relief, increased mobility and a better
quality of life. Lupus is an unpredictable disease but in most cases, it can be
successfully treated. Once an effective treatment program has been started, it is
important for the patient to keep to it faithfully and to inform the doctor of any
change in symptoms so that the medications can be modified.
The treatment program for lupus includes medications, getting enough rest when the
disease is active and avoiding sun exposure.
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Is there a cure?
No, there is no cure yet for this disease at present. However there are effective
treatment which can control the disease. The aims of therapy are to relieve pain,
reduce joint inflammation, halt the progression of joint damage and improve the patient’s
function and well-being.
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What about pregnancy?
If your disease is well controlled, there is no reason to avoid pregnancy.
However, please consult your doctor before you plan to get pregnant
because he or she will have to assess your disease and decide if you need to
stop taking certain medication that may affect your pregnancy.
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What is the future outlook?
It is important to continue the fight against the disease. This disease has a spectrum
of severity ranging from mild to very severe. Only a small minority of patients will
develop crippling deformities. Many patients, with proper treatment and self care, can
cope well with the disease and can look forward to a full and productive life. Continuing
research on this disease will allow us to understand it more and enable us to better treat
the disease. New therapies like biological agents (eg. monoclonal antibodies) are being
evaluated. Thus the outlook for patients with this disease is bright.
If you like further information please write to the Rheumatoid Arthritis Society
(Singapore),
PO Box ie Towner Post Office PO Box 1578 Singapore 913240
Tel: 6357 8037
Fax: 6357 8039
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