Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease that typically presents as a symmetric inflammatory polyarthritis (synovitis) primarily affecting the hands and feet. Any joint lined by a synovial membrane may be involved; however, extraarticular involvement of various organs can be significant. RA is theorized to develop when a genetically susceptible individual experiences an external trigger (e.g., cigarette smoking, infection, trauma) that precipitates an autoimmune reaction.
Rheumatology is a rapidly advancing, but relatively young, subspecialty. An understanding of the pathophysiology, treatment, and classification of RA is still emerging. Here are five things to know about RA.
1. A healthier lifestyle is associated with a reduced risk of developing RA.
Large epidemiologic studies have identified several factors that increase the incidence of RA; these include an unhealthy diet, smoking, adiposity, low educational level, and low socioeconomic status. A patient’s response to antirheumatic medications can be affected by certain lifestyle habits, which can be associated with worse treatment outcomes; such habits include smoking, insufficient physical activity, and obesity, among others. Although methodologic problems may impede making firm conclusions regarding a causal role for these factors in the disease course and risk of developing RA, current evidence is sufficient to recommend quitting smoking, adopting a healthy diet, preventing obesity, and maintaining a high level of physical activity to support the effectiveness of current antirheumatic drugs.
In the Nurses’ Health Study, biennial questionnaires were used to collect lifestyle and medical information to determine which modifiable risk factors are associated with the risk for RA in women. Patient medical records were used to confirm incident RA and serostatus. The healthy lifestyle index score (HLIS), which includes five modifiable risk factors (smoking, alcohol consumption, body mass index, physical activity, and diet), was used to assess risk. Cox regression, which was adjusted for confounders, was used to model associations between HLIS and the incidence of RA. The study concluded that a healthier lifestyle was associated with a lower risk of developing RA, and a significant number of RA cases may be preventable if patients adopted four or more healthy lifestyle factors.
The Mediterranean diet is one current popular dietary option that appears to have promising evidence in many disease processes, including RA.
2. In pregnant women with RA, the course of the disease can change throughout pregnancy.
The course of RA often changes during pregnancy. About half of pregnant women with RA have low disease activity, and 20%-40% achieve remission by the third trimester; however, nearly 20% have worse or moderate to high disease activity during pregnancy that may require further therapeutic intervention. Postpartum flares of RA also may occur, with studies reporting rates of 39%-90%.
No specific guidelines address obstetric monitoring in patients with RA. Because few data suggest a significantly increased risk for preterm birth, preeclampsia, or fetal growth restriction, no special obstetric monitoring is indicated beyond what is performed for usual obstetric care.
Medications considered to be low risk in pregnancy include low-dose corticosteroids, antimalarial agents, sulfasalazine, and azathioprine. Certain tumor necrosis factor inhibitors are also thought to be relatively safe.
3. A well-designed exercise program can be beneficial in RA.
Regular physical activity has replaced bed rest as the recommended response to the stiffness and pain associated with RA. However, many patients who have RA do not really believe this. Lack of conviction and motivation appear to be the major factors that deter nearly half of patients with RA from moving about enough to help their situation. There is ample evidence about the benefits of physical activity in RA, but little research into why few patients with RA take advantage of it. The extreme physical inactivity of patients with RA becomes a vicious cycle in terms of health and disease progression. Thus, encouraging physical activity is an essential part of the overall treatment of RA.