From telegraph.co.uk
The autoimmune disorder can be debilitating, but lifestyle changes and up-to-date treatments offer hope for millions
Rheumatoid arthritis is chronic, long-lasting and incurable, but a recent trial has raised hopes that it could be preventable.
The trial focussed on a pre-existing arthritis drug, abatacept, usually a second or third line treatment for those with fully established Rheumatoid arthritis (RA). This time though, it was given to patients who had not yet developed the disease, but were assessed as high-risk. After a year, just 6 per cent had developed RA compared with 29 per cent who were taking a placebo. It offers hope to millions.
RA is the most common form of autoimmune inflammatory arthritis, and it happens when the immune system misfires, attacking our own bodies at the joints, resulting in hot, red, painful inflammation. Abatacept dials down the T cells involved in our immune system’s inflammatory response (a response that’s helpful when tackling a pathogen, but not when it’s attacking healthy tissue.) The next stage, say researchers, is to assess who would benefit most from receiving the drug.
So who is at risk of RA, what are the signs and what current treatment paths are available?
Signs and Symptoms: how does RA feel?
“Rheumatoid arthritis might sneak up on you with occasional pain in the joints of your hands or feet, or in some cases, you might wake up one morning in such stiffness and pain, you can’t move parts of you,” says Dr Wendy Holden, a consultant rheumatologist at Arthritis Action.
Essentially, RA is swelling, stiffness, warmth, redness and pain at the joints, which is almost always worse in the morning and after long periods of resting. (This early morning stiffness and pain can last for two or three hours.) “It’s most common in the joints of the hands and feet, but you can get it in the other joints in between – the shoulders, elbows, knees and ankles,” says Dr Holden. “Swelling is key. You can see it. Your fingers might look swollen. Your shoes can feel tighter. In the worst, untreated cases, it can make hands look like boxing gloves. It can also make you very tired, lethargic and off your food.”
Who is most likely to develop RA?
“The peak age of onset is 46 to 70,” says Dr Benjamin Ellis, a consultant rheumatologist and senior clinical advisor for Versus Arthritis. “You’re more at risk if a parent or sibling has it, and it is more common in women.” (Women are two to three times more likely to develop RA.) If you are overweight or a smoker, you’re also more likely to get RA. There is some evidence that eating a lot of red meat and not consuming enough Vitamin C can also raise your risk.
What causes RA?
To be blunt, we don’t know, although it’s believed to be a combination of genetic and environmental factors. “RA happens when the immune system goes wrong and starts attacking the joint. No one knows the trigger, although there are a lot of theories,” says Dr Holden. “Stress is thought to be one trigger. Another theory is that it is triggered by some infection in susceptible people.” Gum disease has been highlighted as one suspect. Another is the Epstein Barr virus. In truth, there isn’t solid evidence for any one single trigger.
How is RA diagnosed?
Ideally, as quickly as possible. Swift diagnosis and treatment make a huge difference to long-term prognosis. “All the time that you’re not treating RA, the immune system is attacking the joints, eating holes in the cartilage that coats the joints and once it’s gone, you can never get it back – we don’t have the technologies to do that yet,” says Dr Ellis.
“The National Institute for Health and Care Excellence (NICE) guidelines say that GPs should refer anyone with suspected RA to a rheumatology team within three working days and that treatment should start no more than six weeks from the time of referral.”
Diagnosis can be straightforward, says Dr Holden. “Often, the symptoms and the swelling are so distinctive, you know as soon as a patient walks in the door. Blood tests can also give a good indication, if they reveal certain inflammatory markers and antibodies produced by the immune system known as anti-CCP. We can also look for inflammation and damage inside the joints through X-Rays, ultrasound or, less commonly, MRI scans.”
How serious is RA?
“At its worst, and when left untreated, it can be absolutely devastating, and not compatible with normal life,” says Dr Holden. Pain and flare-ups can stop you from being able to work. Untreated RA can lead to permanent damage in the bone and cartilage, ruptured tendons and joint deformities. Having RA also increases your risk of cardiovascular disease and certain cancers including lung and prostate, although reasons are unclear and could be down to common risk factors such as smoking and being overweight.
Inflammation in your lungs can lead to conditions such as pleurisy, pulmonary fibrosis or chronic obstructive pulmonary disease (COPD). Depression is a frequent comorbidity to RA with prevalence two to three times higher than in the general population.
The treatment options
“The main treatment aim is to control and rebalance the immune system,” says Dr Ellis. The last few decades have seen huge progress in our ability to do this. Conventional Disease Modification Anti-Rheumatic Drugs (cDMARDs), such as low dose methotrexate, are usually the first step, given in tablet form. They work simultaneously across many different pathways to control the immune system.
If trying two cDMARDs has not been effective, the next step is to take biological DMARDS (bDMARDs), a more precise tool.
“These have transformed the lives of hundreds of thousands of people globally when conventional medicine hasn’t worked,” says Dr Ellis. “Their genius is that they use a trick of the immune system to control the immune system itself.”
These bDMARDs involve artificial antibodies created in a lab that are administered by injection. In the most common of these, known as anti-TNF therapies, the antibodies lock on to a cytokine called TNF, the “chemical messengers” in our bodies that cause joints to become inflamed. The presence of these antibodies on the cytokines signals to the immune system to clear them up. Most patients self-inject these antibodies at home using a pre-filled device a bit like an EpiPen – it could be once a week, once every fortnight, monthly or even less frequently.
“Initially, biologics were very costly, and NICE only allowed them for people with the most severe disease,” says Dr Ellis. “As costs have fallen, people with moderate disease have been able to access them too.”
Later breakthroughs are JAK inhibitors that work by blocking the signalling system in the white blood cells in order to stop them from continuing the immune system attack.
“A huge frustration is that the only way to know which treatment will work best for any given person is to try one for a bit, then if that doesn’t work try another for a bit, and so on,” says Dr Ellis. “Maybe in the future, perhaps before I retire, we’ll have a blood test, or a test of fluid taken off the joint or a biopsy, that can tell you which treatment you’d respond to. Then we could go straight for the treatment that would work best for you.”
In addition to medicines to control RA’s progression, a doctor may prescribe pain medicines such as paracetamol, ibuprofen or steroids delivered through tablet or injection.
How can I manage my arthritis?
“Take your medication on schedule,” says Dr Holden. “Once your immune system is under control, the aim will be to carefully reduce the medication with the support of your doctor and see how low you can go. In some cases, you might be able to stop taking it.”
Exercise is also important. “Inflammation causes loss of muscle so wastage is part of the condition,” says Dr Holden. “Exercise can reduce that risk, make your muscles strong, keep joints mobile and help improve fatigue and pain. It’s also good for your mental health.”
Maintain a healthy weight and eat a Mediterranean diet with a range of different coloured fruit and vegetables to increase the antioxidants that can reduce inflammation. “Avoid ultra-processed food and sugars and not too much red meat,” says Dr Holden.
Eating oily fish is beneficial – its long-chain omega-3 polyunsaturated fatty acids can reduce inflammation and disease activity in RA. “There is probably much more to uncover about diet and RA,” says Dr Holden. “The role of the gut microbiota in maintaining the immune system and inflammatory response is an exciting area of research although we’re not there yet.” Lastly, don’t smoke! It causes whole-body inflammation, one of the main triggers for arthritis, and also substantially reduces the effectiveness of certain RA medications.
What is the best treatment for RA?
You might be doing all the right things and still get flare-ups – so managing your response and finding a way to live your life fully is key. Trials of CBT for people with RA found that it significantly improved fatigue, mental health and sleep patterns. The programme involved people keeping a daily diary of thoughts and feelings, and learning ways to plan and prioritise their days, building in regular rest breaks, noting and managing stress triggers and breaking unhelpful thinking patterns.
Pain is complicated. It’s the body’s response to threat – and if we are tired, unsupported, lonely, sleep-deprived, that threat is greater and our pain response is worse. “This is why tackling sleep problems and stress, and finding support can ease physical symptoms,” says Dr Holden.
“You can feel very out of control when you’re diagnosed with RA, so learn as much as you can about the condition,” Dr Holden continues. “Be assertive and get help if you need it.”
Find the ways of easing symptoms that work for you – for example, hot or cold therapy through heat pads or ice packs, hydrotherapy, physiotherapy, splints for hands, cushioned insoles from a podiatrist, an array of household gadgets and adaptations can all to make every-day life easier.
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