At it's most basic, the average person would describe rheumatoid arthritis (RA) as joint pain, but the disease is not purely joint disease and goes beyond that. It's a painful and destructive joint disease that can cause deformity in the hands, affect the heart, eyes and lungs, and even shorten a person's life span. Further, patients with prolonged inflammation can develop insulin-resistance, a risk factor for diabetes, according to rheumatologist and internal medicine specialist Dr. K. Neil Parker.
While Dr. Parker said arthritis is a common disease, he said since he has returned home to practice, he's seen quite a few cases of Bahamians with dramatic cases of arthritis.
The good news is that RA can be treated safely, effectively and affordably, but diagnosis must be made as early as possible, and treatment began to control the condition to ensure the best outcome for patients.
"Rheumatoid arthritis is an autoimmune disease. This is a condition where the body attacks itself. The body fails to recognize a part of itself as friendly and basically attacks it," said Dr. Parker at the most recent Doctors Hospital Distinguished Lecture Series. "That component in rheumatoid arthritis is the synovium of the joint, a particular component of the joint lining, and that causes inflammation, it causes pain and it causes the arthritis of rheumatoid arthritis."
It's a disease that affects approximately one percent of the world's population. About 0.5 percent of the population will develop rheumatoid arthritis on an annual basis, he added.
Dr. Parker said it's a disease primarily of middle-aged to elderly people, even though some young patients can get it. The peak age in females is between 40 to 60 years, with males tending to be a bit older. He said there's a slight female predominance, and twice as many females as males have it.
The slight female predominance in RA is thought to be related to the hormonal axis (hypothalamic pituitary adrenal axis). He said the disease is also associated with tragic or serious life events which can also have a hormonal component to them.

Impact of Rheumatoid arthritis
"Beyond it being a joint disease, it's a disease that increases the risk of coronary artery disease, or atherosclerosis, which drives not only coronary artery disease, but strokes. It also increases the need for surgeries -- it's a disease that causes disability, loss of productivity. It can really affect quality of life, and can actually shorten your life as well and increase your mortality."
The rheumatologist and internal medicine specialist said rheumatoid arthritis can be familial, but that it's not 100 percent a genetic disease.
"There is interplay like most conditions between the genes and the environment -- evidenced by the fact that if you have identical twins, if one twin has it, there is a 15 to 30 percent chance that the other twin will develop it; if you have non-identical twins, there is about a five percent chance that the other twin will develop it. The best-established gene that's associated with rheumatoid arthritis is the HLA-DRB1 gene and that really increases the risk of rheumatoid arthritis in individuals who have it."
The best-established environmental risk factor for rheumatoid arthritis is smoking, according to the doctor. When you smoke, it causes an activation of an enzyme in the lungs that produces proteins which the body makes the antibodies to.
"Smoking will increase your risk factor about two-fold. And if you have the genetic predisposition, combine that with smoking, and your risk for rheumatoid arthritis goes up to about 40-fold compared to the general population."
The risk improves after you stop smoking, but he said it takes about 10 years for a person's risk of rheumatoid arthritis to go down to approach that of the non-smoking population.
In addition to smoking there are some viruses that are associated with rheumatoid arthritis, but he noted that there is no definitive proof, or the mechanism isn't well established.
"It is believed that certain infections, if you get them, while your body responds to them it produces antibodies that cross react with your joints, and can trigger rheumatoid arthritis. We call that molecular mimicry. And there is also an association of gum disease with rheumatoid arthritis -- so all of this 'feeds' into the fact that there is interplay between your genetic risks and the environment."
Dr. Parker said in the rheumatology world there is excitement surrounding the makeup of bugs in the stomach that potentially predispose a person to autoimmune diseases like RA. It's research that he says is ongoing, but that a person basically has to have some susceptibility to have RA. And then once you get to modification of your gene from a risk factor like smoking, to bugs in your stomach, or the bugs in your gums, this leads to alteration of the genes.
"The body begins to produce antibodies against itself which leads to the arthritis, and also the other associated problems that go along with rheumatoid arthritis like the vascular disease, potential metabolic syndrome; increased inflammation can produce insulin resistance which drives diabetes as well," he said.
A person's immune system (innate and adaptive) allows a person to fight off infections and to stay healthy. He said the immune system is involved in RA, and that the cells develop the propensity to attack the joints, and begin to develop proteins that further the attack.
One of the most significant markers of RA is erosion of the bones, and that, he said, occurs early in the disease, which is why it's imperative to diagnose the condition early and treat it aggressively and appropriately; he said bony erosions are driven by cells that "eat" through the lining of the bone and actually go into the marrow as well.
"We go from having a nice healthy joint, healthy cartilage and fluid -- then the rheumatoid arthritis starts, the synovium gets angry, it produces inflammation, cartilage begins to get destroyed, as the cartilage wears away, you get fibrous tissue developing in the joint, and eventually the bones fuse, and you get the fusion of the joint itself. So you go from having a nice normal joint to a totally fused and destroyed joint."

How do you know if you have rheumatoid arthritis?
Dr. Parker said RA generally has an insidious onset over weeks to months.
"You have the joint pain, you have stiffness, some patients can have fever, some patients can have fatigue and this develops and progresses over months. There are some patients that get very sick, very fast, but that tends to be the minority. And there are some patients who just develop joint pain in one or a few joints that go away -- we call that palindromic rheumatism and about half of these patients will go on to develop rheumatoid arthritis."
There are differences between RA and osteoarthritis. Regular osteoarthritis, the doctor said, is a wear and tear disease. In addition to the significant inflammation in rheumatoid arthritis, RA affects a different subset of joints.
"Rheumatoid arthritis tends to be a symmetrical disease within the joint and outside the joint. In addition to the pain, a significant proponent of rheumatoid arthritis is stiffness. This stiffness you can get with regular osteoarthritis, but with rheumatoid arthritis, the stiffness tends to last for an hour or more. Patients usually take a long time to get going. If they sit down, if they stop moving, the joint becomes stiff, and it takes a long time for the joint to loosen up. As they get going the stiffness resolves. You can also experience pain in the feet, in addition to the wrist and hands, and the ball of the foot. Early in the disease the neck stiffness has to do with ligamental inflammation. Rheumatoid arthritis tends to affect the upper neck, but not the lower back."
Dr. Parker said RA is not just a joint disease, but a whole body disease. He said patients can develop rheumatoid nodules to pressure points at the elbows and fingers that tend to be firm and tender. He said the lungs and eyes can also get involved, and patients can get secondary Sjojgren's syndrome, and a lot of patients will end up with dry eyes and dry mouth if the joint is not treated, and end up with extensive joint damage.
"In addition to the joint damage, you can get deformities. There are certain classical deformities -- swan neck deformity, boutonniere deformity, and also deviation of the fingers to the outside of the hand away from the thumb. They tend not to be reversible when they occur, however treatment would prevent those things from happening."
Extra-articular manifestation, he said, can be seen in about half of the patients with RA. Patients also can be anemic and have enlarged lymph nodes. He said RA is also associated with increased risk of lymphoma, not necessarily being related to the treatment, but some of the treatments can increase risk for cancer as well. Specific syndromes patients can see are enlarged spleens, and low white cell counts.
Up to 30 percent of patients with lung disease can have RA. They can have interstitial disease, or fibrosis of the lungs, as well as involvement of the pleura.
"Lung involvement is the third leading cause of death in patients with rheumatoid arthritis, behind infection and cardiovascular disease. In addition to involvement in the lungs, you can get involvement or inflammation in the lining of the heart and that would present with chest pain when you breathe in. You can also get accelerated atherosclerosis with rheumatoid arthritis. Patients can also present with pain in the eye, blurred vision, redness in the eye --rheumatoid arthritis can affect multiple layers in the eye, giving you various different presentations."

Testing, diagnosis and treatment
Diagnosing RA, or any inflammatory arthritis, Dr. Parker said can be difficult to distinguish from gout as a result, and an important component of diagnosing the condition is to actually remove fluid and send it to the lab for analysis.
But he advised that making a diagnosis is important because diagnosing the condition and treating it early prevents the damage.
"It's a clinical diagnosis, so there are a number of factors you want to take into consideration -- the number of joints, and the size of the joints is important in determining if you have rheumatoid arthritis. Larger joints tend not to be as specific. The more joints you have and the more small joints [in your hands and fingers] you have, the more likely it is you have rheumatoid arthritis. The antibodies, while not being necessary, significantly increase your risk of having rheumatoid arthritis. If you have inflammatory markers in your blood, whether they're positive or negative, that increases your risk of having rheumatoid arthritis."
If you have symptoms for more than six weeks, he said that's considered chronic arthritis, which again increases the risk.
The 2010 American College of Rheumatology and the European League Against Rheumatism's classification for rheumatoid arthritis lists 10 components that comprise arthritis. To have a RA diagnosis, the doctor said a patient would have to score at least six or more out of the 10 of the components to be clinically diagnosed with RA.
Dr. Parker said treatment could be thought of as two components -- treatment of the pain, and stopping the condition. They utilize disease-modifying anti-rheumatoid drugs to stop or arrest the progress of the disease.
"You want to employ the drugs within the first three to six months of diagnosis to give yourself the best chance of arresting the destruction of the joint. A number of patients will not be able to be controlled with simple oral medications and there are multiple biologic medications that can be used to treat the rheumatoid arthritis. So it really becomes a matter of what the patient responds to, and escalating the care overtime. Generally, patients are assessed every three months after they're stable to determine the effectiveness of the treatment."
To determine if treatment is effective, Dr. Parker said they have a number of disease activity scores that incorporate the patient's perception of pain -- the number of tender joints they have, the number of swollen joints, and their blood work in terms of markers of information to determine whether or not the patient's disease is controlled.
In addition to early and aggressive treatment, he said they treat to remission or low disease activity.
"When treating patients for rheumatoid arthritis, we use a joint count as well as the patient's assessment of how painful they are, along with their markers for inflammation. We actually calculate a score. When treating patients for rheumatoid arthritis we generally count the shoulders, the elbows, the joints and hands and the number of tender and swollen joints they have in addition to their blood work and how they feel and calculate a literal score, and use them from visit to visit to track how the patient is progressing."
If a person scores less than 2.6 they are considered to be in remission. And Dr. Parker said ideally, that's where they want to get a patient, but if not, low disease activity of 2.6 to 3.2 is acceptable.
For a patient to be considered in clinical remission at least five of the following -- morning stiffness of not more than 15 minutes, no fatigue, no joint pain, no joint tenderness or pain on motion, no soft tissue swelling in joints or tendon sheaths -- must be present for at least two consecutive months.
He said medical professionals could determine if a patient is at risk for aggressive disease if the following are present -- younger age of onset, the more joints involved, poor functional status, whether they have extra-articular features, whether they have rheumatoid nodules, whether or not their antibodies are positive, and if they have co-morbid cardiovascular disease. If they have the indicators, he said an aggressive course and intensive treatment is needed.

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