In RA, the body’s immune system doesn’t act the way it should, and inflammation flares out of control. Pharmacists have an important role to play in raising awareness of rheumatoid arthritis and its treatment to patients. 

CAUSES  

RA is an autoimmune disease that results in pain and swelling of the joints. The usual function of the body’s immune system is to fight off infections to keep a patient healthy, however in the case of an autoimmune disease, a patient’s immune system starts attacking their healthy tissues. “In RA, the immune system targets the lining of the joints, causing inflammation and joint damage,” explained Arthritis Australia. “RA usually affects smaller joints, such as the joints in the hands and feet. However, larger joints such as the hips and knees can also be affected.”¹ 

The exact cause of RA is still unclear, however nongenetic factors may be contributors, according to the National Institutes of Health (NIH), who explained that these factors may trigger the condition in patients who are at risk, although the mechanism is unclear. Potential triggers include: 

• Changes in sex hormones, particularly in women 
• Occupational exposure to certain kinds of dust or fibres and viral or bacterial infections 
• Long-term smoking is a well-established risk factor for developing rheumatoid arthritis² 

SYMPTOMS  

Stiffness for a prolonged period, especially in the morning, is a sign that a patient may have RA, as this is not common in other conditions, warned the American College of Rheumatology (ACR). “This stiffness may last 1-2 hours but will generally improve with movement of the joints.” According to the ACR, other symptoms may include: 

• Loss of appetite and energy 
• Low fevers 
• Dry eyes and mouth from a related condition, Sjogren’s syndrome 
• Firm lumps known as rheumatoid nodules, which grow beneath the skin in places such as the elbow and hands³ 

DIAGNOSIS  

“RA is diagnosed by examining blood test results, examining the joints and organs, and reviewing x-ray or ultrasound images,” the ACR explained. “There is no single test to diagnose RA. Blood tests are run to look for antibodies in the blood that can been seen in RA. Sometimes these antibodies are found in patients without RA – this is called a false positive result. Blood tests are also run to look for high levels of inflammation. The symptoms of RA can be very mild making the diagnosis more difficult. Some viral infections can cause symptoms that can be mistaken for RA.”⁴ 

“Patients commonly present with pain and stiffness in multiples joints or just one location,” explained doctors Rindfleisch and Muller in Diagnosis and Management of Rheumatoid Arthritis (published in Am Fam Physician. 15 Sept 2005). “In most patients, symptoms emerge over weeks to months, starting with one joint and often accompanied by prodromal symptoms of anorexia, weakness, or fatigue. Joints most commonly affected are those with the highest ratio of synovium to articular cartilage. The wrists are nearly always involved, as are the proximal interphalangeal and metacarpophalangeal joints. The distal interphalangeal joints and sacroiliac joints tend not to be affected. Rheumatoid joints typically are boggy, tender to the touch, and warm, but they usually are not erythematous.⁵ 

TREATMENT  

“The goal of pharmacotherapy is to reduce the pain, swelling, and stiffness of the joints, preserve joint function, slow destructive joint changes, prevent systemic complications and improve the patient’s ability to perform his/her daily activities,” Brand et al. explained in A Quick and Painless Reminder: The Pharmacotherapy of Rheumatoid Arthritis in Primary Practice (published in South African Family Practice. Vol.60 No.2 2018). “The three main groups of drugs used for the treatment of RA are the non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids and disease-modifying antirheumatic drugs (DMARDs).⁶ 

• Methotrexate is an anchor drug for treatment of RA, because it is more effective, more tolerated and causes less adverse effects than other disease modifying anti-rheumatic drugs (DMARDs), according to Professor Santram Lodhi in Current treatment for Rheumatoid Arthritis (published in in Asian Journal of Pharmacy and Pharmacology 2015; 1(2):45).⁷ 
• Corticosteroids are often used acutely when the diagnosis of rheumatoid arthritis has been made. Systemic steroids are often utilised (oral prednisolone, intramuscular or intravenous methylprednisolone). Intra-articular steroids can be used for particularly swollen or painful joints. Steroids have powerful anti-inflammatory effects and are usually offered in the short term when patients first present with symptoms.⁸ 
• “In patients with RA, Non-steroidal anti-inflammatory drugs (NSAIDs) are now used primarily for controlling pain,” said Prof Lodhi. “They are not believed to have disease modifying properties, such as the prevention of joint destruction. They are used by approximately half of patients with RA, sometimes regularly but often on an as-needed basis.”⁷ 

NONPHARMACOLOGICAL MANAGEMENT  

In Diagnosis and management of rheumatoid arthritis (published in Prescriber June 2017) Gerald Tracey described the various nonpharmacological approaches to treating rheumatoid arthritis that exist, with the aim being to complement drug-based therapies. These include: 

• Exercise 
• Sleep  
• Diet 
• Weight loss  
• Management of co-morbidities (e.g., cardiovascular risk, glycaemic control) 
• Smoking cessation⁸ 

REFERENCES:  

1. Arthritis Australia. (2007). ‘Rheumatoid Arthritis.’ Available from: https://www.melbournearthritis.com.au/pdf/rheumatoid-arthritis.pdf 
2. Genetics Home Reference. ‘Rheumatoid Arthritis.’ Available from: https://ghr.nlm.nih.gov/condition/rheumatoid-arthritis#genes 
3. American College of Rheumatology. (2019). ‘Patient Fact Sheet: Rheumatoid Arthritis.’ Available from: https://www.rheumatology.org/Portals/0/Files/Rheumatoid-Arthritis-Fact-Sheet.pdf 
4. American College of Rheumatology. ‘Rheumatoid Arthritis.’ Available from: https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Rheumatoid-Arthritis 
5. Rindfleisch, A & Muller, D. (2005). ‘Diagnosis and Management of Rheumatoid Arthritis.’ Available from: https://www.aafp.org/pubs/afp/issues/2005/0915/p1037.html 
6. Brand et al. (2018). ‘A Quick and Painless Reminder: The Pharmacotherapy of Rheumatoid Arthritis in Primary Practice.’ Available from: https://www.ajol.info/index.php/safp/article/view/170787 
7. Lodhi, S. (2016). ‘Current treatment for Rheumatoid Arthritis.’ Available from: https://www.researchgate.net/publication/291354605_Current_treatment_for_Rheumatoid_Arthritis 
8. Tracey, G. (2017). ‘Diagnosis and management of rheumatoid arthritis.’ Available from: https://onlinelibrary.wiley.com/doi/pdf/10.1002/psb.1580