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Rheumatoid Arthritis is an autoimmune disease, meaning the immune system does not fulfil its function of attacking foreign bodies. Instead, tissue is wrongly seen as foreign thus creating an inflammatory response, generally around a joint. This causes inflammation and damage, along with weakening of ligaments and tendons, resulting in deformities (Metex 2012). 1% of the population are affected with Rheumatoid Arthritis; it can occur at any age, but in the majority of cases symptoms will begin between the ages of forty and sixty, with life expectancy being reduced by up to eighteen years (Luqmani et al 2008). Symptoms usually develop gradually, acute onset is rare. Small joints such as fingers and toes become inflamed first, and then other joints, including the knees and ankles. Symmetry of the body often occurs in affected joints with muscle stiffness also being prevalent; especially after long periods of sitting or lying down. In 25% of chronic cases Rheumatoid nodules develop, they are firm, subcutaneous nodules forming over pressure points like the metacarpophalangeal joint (WebMD), frequently being associated with serious extra-articular manifestations, such as the lungs and kidneys. Rheumatoid Arthritis can cause systematic symptoms, such as fever and a loss of appetite (WebMD); common symptoms, meaning misdiagnosis is common.
The main pathological irregularity in this disease is synovitis; as inflammatory cells infiltrate the synovial membrane it proliferates. Chronically inflamed tissue extends from the joint margins, eroding the articular cartilage; continuous erosion of bone and cartilage with accompanying use of ligaments and joint capsules leads to joint deformity (Apley and Solomon 2001).
Rheumatoid Arthritis is not a curable disease; however there are many treatments available to manage the condition and make sufferers more comfortable, with treatment depending on how long the patient has had the condition, or the location affected, thus treatments vary depending on the patient. Early diagnosis of the condition is vital, as hasty detection means more time to find the most effective therapy for the patient. Both drug and non-drug treatments are available. The use of physiotherapy improves muscular strength and the range of movement in the joint; occupational therapy shows patients how to protect their joints during daily activities; and podiatry provides advice on appropriate insoles to improve the mechanism of deformed feet (Apley and Solomon 2001). The main aims of drug treatments are to alleviate symptoms, and to slow down the development of the condition.
In order to treat the symptomatic complaints of Rheumatoid Arthritis Non-steroidal anti-inflammatory drugs (NSAID's) are often prescribed, they have no effect on the activity of the disease or its progression, but they can reduce inflammation, control pain, and relieve stiffness. There are two types of NSAID's, the 'traditional' ones such as ibuprofen or diclofenac; and COX-2 inhibitors. When pain is detected, damaged tissues release prostaglandins - similar to hormones - they send a message to the brain that an inflammatory response is required, resulting in swelling and tenderness. NSAID's stop the prostaglandins by blocking the COX-1 and COX-2 enzymes, subsequently reducing inflammation and minimizing pain and stiffness. Despite being responsible for the inflammatory response, prostaglandins have other purposes, like protecting the stomach lining and kidneys. Therefore by ultimately blocking all prostaglandins, the use of NSAID's can cause stomach ulcers, due to the stomach lining being broken down and therefore becoming susceptible to damage from acids. The likelihood of this, along with other side effects varies according to the strength of the NSAID. It appears that the more an NSAID blocks the COX-1 enzyme, the more prone the patient will be to stomach ulcers and bleeding. While the risks are dangerous, only 1 in 2-3,000 patients are likely to suffer bleeding. This is why if an NSAID is prescribed, it will be combined with other drugs, like proton pump inhibitors to reduce the amount of acid in the stomach. An example of combination therapy is Arthrotec, an NSAID that combines Diclofenac with the active ingredient misoprostol in order to prevent stomach irritation (WebMD). A newer form of prescription NSAID, COX-2 specific therapies are now available, they have the same efficacy as the 'traditional' drugs, but a much more desirable side-effect profile with regards to the gastrointestinal tract. Although preferable, COX-2 must not be used in patients with cardiovascular risk factors.
Disease-modifying anti-rheumatic drugs (DMARD's) are capable of suppressing disease activity and slowing down erosive joint damage by blocking the effects of chemicals produced by antibodies that attack the tissues, thus causing damage to tendons, cartilage ligaments and bones. The sooner a patient begins the treatment, the more efficacious they will be; especially as DMARD's take up to six weeks to take effect. The most commonly used DMARD is methotrexate as it appears to work the best, it is also low in cost and can be used in children. Although, it still comes with side effects, which can include gastrointestinal upset, and sometimes hepatic and haematological disorders; meaning regular blood work and monitoring of the patient is required. Studies have, however, shown that taking a weekly 5mg dose of folic acid can reduce the side effects of methotrexate. The majority of patients on methotrexate tolerate the drug well and half of those who begin treatment will still be taking it after five years. (WebMD) Patients who do fail to respond to DMARD's can try a new type of treatment; biological therapy, which include TNF-alpha inhibitors that work by using anti-cytokine therapy; Tumour necrosis factor (TNF) and interleukin-1 (IL-1) are considered to be master cytokines in chronic, destructive Rheumatoid Arthritis. The body naturally produces the protein TNF-alpha to mobilise white blood cells in order to fight pathogens; the inflammatory response. In a patient without Rheumatoid Arthritis the TNF-alpha would then be removed, but in affected patients it isn't, causing a large build up and therefore unnecessary inflammation, leading to tissue damage (cgi.cnn). Although they reduce symptoms of the disease, there is a risk of reactivation of latent infection such as hepatitis B and Tuberculosis, therefore pre-treatment screening and vigorous monitoring during treatment is crucial.
To conclude, Rheumatoid Arthritis is a life changing autoimmune disease that cannot be cured, however there are a variety of treatments available to make the condition easier to manage, drug related and non-drug related. The two drug treatments discussed; NSAID's and DMARD's both concentrate on improving different elements of the condition. NSAID's focus purely on improving the symptoms of Rheumatoid Arthritis, such as inflammation of joints and relief of stiffness; and DMARD's concentrate on supressing disease activity, therefore slowing down erosive joint damage. Indisputably all prescriptions have the potential to improve patient's lives dramatically, but due to potentially fatal side effects patients must be monitored during treatment.