Rheumatoid arthritis

Rheumatoid arthritis belongs to the autoimmune conditions, the illnesses in which the body's defences, meant for fighting infection, attack the delicate lining of the joints by mistake. That attack is the inflammation, and it is what makes the joints hurt and swell and, given time, harms them. Wear and tear plays no part in it.

What triggers it is still not fully understood. The best explanation is an inherited tendency that something in a person's surroundings then brings out; nobody has pinned down a single cause.

A few things make it likelier:

• Relatives who have rheumatoid arthritis or a different autoimmune illness
• Smoking, which raises the odds of developing it and, once it has started, can leave it more stubborn to treat
• Being a woman: women develop it roughly two to three times as often as men, and it often starts somewhere between 40 and 60

The condition often creeps in rather than arriving overnight, and the way it spreads through the joints can itself be a pointer. The usual signs are:

• Several joints that hurt and swell, often the small joints of the hands and feet, and frequently in pairs, left and right
• Stiffness on waking that takes longer than half an hour to wear off
• Joints that are warm to the touch, tender or puffy
• Tiredness, and a feeling of being run down in yourself

The symptoms can come and go, and they may be put down to ordinary aches; that is partly why it pays to have a specialist look at what is really going on.

Three strands make the diagnosis: what you tell the doctor, what the examination shows and what the tests reveal. Blood tests can reveal inflammation and some of the antibodies that often go with the condition, but none of them settles the question alone. Once the joints have stayed inflamed for a while, the standard work-up includes X-rays of the hands and feet, which record how the joints look at the outset.

Ultrasound comes into its own here. It can show inflamed joint linings and tendons that a hands-on examination can miss, at times before any swelling can be seen. Point-of-care ultrasound is part of the consultation with Dr Borukhson, so this look inside the joints can often happen at the same appointment and the answer arrives with less waiting. Its role is in making the diagnosis: after treatment begins, how active the condition is gets judged from how you feel, what the examination finds and what the blood tests show, not from routine repeat scans. You can find out about the scan itself on the ultrasound clinic page.

The aims are to quieten the inflammation, relieve the symptoms and keep the joints from harm. Your treatment is shaped around you and talked through in full, and one principle runs through it: effective treatment started early, ideally inside three months of the symptoms first becoming persistent, gives the best results in the long run.

The backbone is a group of medicines called disease-modifying anti-rheumatic drugs (DMARDs), which calm the misdirected immune response and guard the joints rather than only dulling the pain. Methotrexate is usually tried first; sulfasalazine, hydroxychloroquine and leflunomide are among the others, and where the response falls short, a biologic or a targeted drug is usually added, or used in its place. A specialist oversees all of them. Most DMARDs come with regular blood tests, methotrexate calls for careful planning around a pregnancy, and a biologic needs screening first, because infections can become likelier on it. Methotrexate damps down the immune system, so it can make an infection likelier, as a biologic can.

A new DMARD can take two to three months to start working, and a short course of a steroid such as prednisolone often bridges that gap; a short course is also used to settle a flare. In established rheumatoid arthritis steroids are sometimes continued for longer, though only once their long-term effects have been talked through with you and the other medicines have been offered. Your plan is looked at again from time to time. A joint that stays stubbornly inflamed can sometimes be settled with an ultrasound-guided injection. The details of your own treatment are always decided with you.

This is a condition you live with for the long term, but once treatment holds the inflammation down, plenty of people stay active and well, and low disease activity, or none at all (remission), is a fair aim.

Alongside your medicines, a few habits make a real contribution:

• Stay active. Steady movement that is kind to the joints keeps you strong and supple; our guide to arthritis and exercise goes into it.
• Give up smoking, which helps the treatment work and does your heart and lungs good.
• Eat sensibly and keep your weight healthy, as diet and arthritis explains.
• Ration your energy in a flare and rest when the tiredness is bad.

Turning up for your blood tests and reviews lets the plan be adjusted as your needs shift.

Over the years, rheumatoid arthritis makes heart attacks and strokes somewhat more likely, the more so while it is active, as with other kinds of inflammatory arthritis. Keeping the inflammation under good control is among the best ways to lower the risk, and the straightforward checks to ask for are listed in the guide on inflammation and your heart.

Most of what rheumatoid arthritis brings can wait for your regular reviews. For the few things that cannot wait, the lists below run from the most pressing down, and the paragraph after them covers what your team or GP should see within days.

Treat any of these as a 999 or A&E emergency: call 999 and do not drive yourself to A&E.

• Severe illness with suspected sepsis: a high fever with shaking, confusion, rapid breathing, or feeling dramatically worse over hours
• With a fever or feeling unwell, a rash that does not fade when you press it, a stiff neck with eyes that cannot bear bright light, or skin, lips or tongue turning blue, grey, pale or blotchy, since these can be signs of meningitis or sepsis; on black or brown skin the rash and the change of colour may be easier to see on the palms of the hands or the soles of the feet
• Chest pain that is crushing, tight or like a pressure, that spreads to an arm, the jaw, the neck, the stomach or the back, that comes with breathlessness, sweating, feeling sick or feeling light-headed, or that came on suddenly and does not go away
• Breathlessness that is severe, with gasping, choking or no breath to get words out; or coughing up blood
• Palpitations happening now that do not stop, or that come with chest pain, breathlessness, feeling faint or fainting, since a heart whose muscle or rhythm is affected has to be checked at once
• New unsteadiness or trouble walking, wetting or soiling yourself without warning, or clumsiness or weakness in the hands that has come on suddenly, since rheumatoid arthritis can loosen the joints at the top of the neck until they press on the spinal cord
• Sudden weakness or numbness on one side, a drooping face or difficulty speaking, a sudden severe headache, sudden confusion or a seizure, or sudden loss of vision, any of which can be a stroke, even if it stops after a short time, and rheumatoid arthritis makes a stroke somewhat likelier
• An eye that suddenly and completely loses its sight
• Sudden severe pain in the abdomen or back, since the pancreas can react to prednisolone
• Lips, mouth, throat or tongue that suddenly swell, a throat that feels tight, very fast breathing or a struggle to breathe or to swallow, skin, tongue or lips turning blue, grey or pale (on black or brown skin this may be easier to see on the palms of the hands or the soles of the feet), becoming suddenly very confused, drowsy or dizzy, or fainting and not being able to be woken, since this can be a severe allergic reaction, anaphylaxis, which can follow a dose of any medicine
• Vomiting blood, or bleeding from the back passage that is heavy or will not stop, most of all with faintness, confusion or pain in the abdomen, or vomit that is black or dark brown, since a stomach ulcer on prednisolone can bleed
• Thoughts of harming yourself or ending your life, which steroids can bring on

Any of these needs an assessment that is urgent, on the same day, from your GP, your rheumatology team or NHS 111:

• A fever, or feeling generally unwell, on immunosuppressant, biologic or steroid treatment, since an infection has to be treated early; a sore throat that lingers belongs here too, since treatment of this kind can let an infection turn serious, and some of these medicines blunt its usual warning signs
• A joint that is hot and swollen, with a fever or feeling unwell, since an infected joint has to be ruled out at once, at A&E or through NHS 111
• A joint that has become hot and very swollen suddenly, or is worsening quickly, even without a fever, since an infected joint does not always announce itself with one; a joint that will take no weight at all, or that cannot be moved, is a 999 or A&E emergency, whether or not there is a fever
• New chest pain, new palpitations, or breathlessness that is new or getting worse, since rheumatoid arthritis can inflame the heart and the lungs; palpitations happening now that do not stop, or that come with chest pain, breathlessness, feeling faint or fainting, belong to the first list; a dry cough that will not clear needs the same-day call too, since methotrexate can, rarely, inflame the lungs
• Pins and needles, numbness, heaviness or weakness that has crept on in an arm, a leg or a hand, with pain in the neck, since the loosened joints at the top of the neck can press on a nerve or on the spinal cord
• A new red, painful eye, or sight that has blurred, dimmed or changed, which needs an eye casualty or urgent eye clinic the same day, as does an eye that light hurts, since rheumatoid arthritis can reach the eye and inflame it; on hydroxychloroquine, a change in sight is also one to report to the team that prescribes it
• A marked change in mood or behaviour, confusion, or seeing or hearing things that are not there, on steroid treatment, since prednisolone can do this, the more so the higher the dose; confusion that comes on suddenly is a 999 or A&E emergency, as the first list says
• Unusual thirst or hunger, passing urine more often, or feeling sleepy or confused, on steroids, or swelling of the arms or legs, bruising or bleeding that is not normal, black or dark red stools, severe stomach pain, severe back pain, a severe upset stomach, being sick, or very bad dizziness or passing out, since each can be a steroid effect that needs checking without delay; pain in the abdomen or back that comes on suddenly and severely is a 999 or A&E emergency, as the first list says
• Contact with measles, chickenpox or shingles, since these infections can be severe on steroids and a medicine to protect you may be needed
• Being near someone with measles, chickenpox or shingles, while you take a medicine that weakens the immune system, since measles and chickenpox can be dangerous when the immune system is weakened, and you can catch chickenpox from someone with shingles if you have never had chickenpox; NHS 111 can tell you what to do that day

If a flare leaves several joints hot, swollen and sore and they are not calming down, ring your rheumatology team or GP and be seen within days rather than at the next routine visit, though any joint that is suddenly hot and very swollen, or getting worse fast, belongs to the same-day list above. Tingling or numbness in a hand that has come on gradually, which in rheumatoid arthritis can come from a nerve pinched at the wrist, is one to mention to your GP or team; numbness that has become constant, or a grip that is weakening, should be seen by your GP or team within days. With neck pain, tingling or numbness of this kind is for the same-day list, and a hand that suddenly goes weak or numb is a stroke sign, in the first list. If you hope to have a baby, tell your team well beforehand, since some medicines must be switched first, as the guide on arthritis, autoimmune conditions and pregnancy explains. If you cannot tell how urgent something is, asking is never a mistake.

Recognising rheumatoid arthritis early, and treating it early, gives the joints, and everything you use them for, the best chance of being protected. Joints that keep hurting or swelling, or stiffness that lingers for a long time each morning, merit an opinion within days, from your GP or from a specialist you book directly, mild as they may seem.

If I might have rheumatoid arthritis, how soon should I see a specialist?

Soon: a rheumatologist should see you even when the symptoms are mild or keep coming and going. The joints fare best over the years when the inflammation is damped down early. Joints that stay painful or swollen, or stiffness on waking that lasts beyond half an hour, are reasons to be seen within days, by your GP or by a specialist you book directly, rather than to watch and wait.

What should I expect when I first come?

Dr Borukhson listens to your account, examines your joints carefully and arranges blood tests that measure inflammation and look for the antibodies that often go with the condition. Point-of-care ultrasound is part of the consultation with Dr Borukhson, and it can show an inflamed joint lining or tendon that the eye and the fingers may miss, so the picture is clearer from the start.

Can a blood test prove that I have rheumatoid arthritis?

Not by itself. The blood can show inflammation and certain antibodies, yet no one result decides it, and every result is read alongside your symptoms and the examination. Ultrasound adds to this, since it can show inflammation inside a joint that an examination may not pick up.

Will I need checks while I am on treatment?

Yes. Most of the medicines that alter the course of the condition, methotrexate among them, come with blood tests at regular intervals, and before a biologic is started you are screened, since it can raise the chance of infection. If you may become pregnant, the medicines are arranged with that in mind. Your follow-up visits are where the plan can be changed to match how you are doing.

Will I always need treatment?

Rheumatoid arthritis lasts, so most people stay on treatment for the long run to keep the inflammation quiet and the joints safe. That does not make the plan fixed: it is looked at again at each review and can be altered as your health and your life change, and how long you stay on any one medicine is decided together with you.