Rheumatoid Arthritis (RA)

Overview

• Rheumatoid arthritis (RA) is the most common persistent inflammatory arthritis, occurring throughout the world and in all ethnic groups.
• The prevalence is lowest in black Africans and Chinese, and highest in Pima Indians.
• The clinical course is prolonged, with intermittent exacerbations and remissions.
• Patients with RA have an increased mortality when compared with age matched controls, primarily due to an increased risk of cardiovascular disease.
• This is most marked in those with severe disease, with a reduction in expected lifespan by 8–15 years.
• Around 40% of RA patients are registered as disabled within 3 years of onset, and around 80% are moderately to severely disabled within 20 years.
• Functional capacity decreases most rapidly at the beginning of disease and the functional status of patients within their first year of RA is often predictive of long term outcome.
• Factors that associate with a poorer prognosis are disability at presentation, female gender, involvement of MTP joints, radiographic damage at presentation, smoking and a positive RF (Rheumatoid Factor).

Other Factors:

• In former years, around 25% of patients required a large joint replacement but rates are now falling, probably reflecting more aggressive and effective medical therapy. [1]
• Rheumatoid arthritis is a chronic inflammatory disorder that can affect more than just your joints. In some people, the condition can damage a wide variety of body systems, including the skin, eyes, lungs, heart and blood vessels.
• An autoimmune disorder, rheumatoid arthritis occurs when your immune system mistakenly attacks your own body’s tissues.
• Unlike the wear-and-tear damage of osteoarthritis, rheumatoid arthritis affects the lining of your joints, causing a painful swelling that can eventually result in bone erosion and joint deformity.
• The joint damage that RA causes usually happens on both sides of your body.
• So if a joint is affected in one of your arms or legs, the same joint in the other arm or leg will probably be affected, too. [2]

Indian epidemiology then other

Causes of Rheumatoid Arthritis (RA)

• Nobody knows what causes the immune system to malfunction.
• Some people appear to have genetic factors that make it more likely.
• One theory is that bacteria or a virus triggers RA in people who have this genetic feature.
• In RA, the immune system’s antibodies attack the synovium, which is the smooth lining of a joint. When this happens, pain and inflammation result.
• Inflammation causes the synovium to thicken.
• Eventually, if left untreated, it can invade and destroy cartilage the connective tissue that cushions the ends of the bones.
• The tendons and ligaments that hold the joint together can also weaken and stretch.
• The joint eventually loses its shape and configuration.
• The damage can be severe. [3]

Risk factors:

Factors that may increase your risk of rheumatoid arthritis include:

Sex i.e.:

• Women are more likely than men to develop rheumatoid arthritis.

Age i.e.:

• Rheumatoid arthritis can occur at any age, but it most commonly begins in middle age.

Family history i.e.:

•  If a member of your family has rheumatoid arthritis, you may have an increased risk of the disease.

Smoking i.e.:

• Cigarette smoking increases your risk of developing rheumatoid arthritis, particularly if you have a genetic predisposition for developing the disease.
• Smoking also appears to be associated with greater disease severity.

Environmental exposures i.e.:

• Although poorly understood, some exposures such as asbestos or silica may increase the risk of developing rheumatoid arthritis.
• Emergency workers exposed to dust from the collapse of the World Trade Center are at higher risk of autoimmune diseases such as rheumatoid arthritis.

Obesity i.e.:

•  People especially women age 55 and younger who are higher-weight person appear to be at a somewhat higher risk of developing rheumatoid arthritis. [2]

AAA

Risk factors are things that make you more likely to develop a disease in the first place.

Pathogenesis refers to the development of a disease. It’s the story of how a disease gets started and progresses.

This is the entire journey of a disease, encompassing the cause but going beyond it.

Pathophysiology, on the other hand, focuses on the functional changes that occur in the body due to the disease. It explains how the disease disrupts normal physiological processes and how this disruption leads to the signs and symptoms we see.

Imagine a car accident. Pathogenesis would be like understanding how the accident happened – what caused it, the sequence of events (e.g., one car ran a red light, then hit another car). Pathophysiology would be like understanding the damage caused by the accident – the bent fenders, deployed airbags, and any injuries to the passengers.

In simpler terms, pathogenesis is about the "why" of a disease, while pathophysiology is about the "how" of the disease’s effects.

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Sign and Symptoms of Rheumatoid Arthritis (RA)

Rheumatoid Arthritis

Joints:

• Joint pain
• Joint swelling, warmth and redness
• Stiffness, especially first thing in the morning or after sitting still for a long time. [2]

Rheumatoid Arthritis In Hands

Extra-articular manifestations of rheumatoid disease:

Systemic e.g.:

• Fever
• Weight loss
• Fatigue
• Susceptibility to infection

Musculo-skeletal e.g.:

• Muscle-wasting
• Tenosynovitis
• Bursitis
• Osteoporosis

Hematological e.g.:

• Anemia
• Thrombocytosis
• Eosinophilia

Lymphatic e.g.:

• Felty’s syndrome
• Splenomegaly

Nodules e.g.:

• Sinuses
• Fistula

Ocula e.g.:

• Episcleritis
• Scleritis
• Scleromalacia
• Keratoconjunctivitis sicca

Vasculitis e.g.:

• Digital arteritis
• Ulcers
• Pyoderma gangrenosum
• Mononeuritis multiplex
• Visceral arteritis

Cardiac e.g.:

• Pericarditis
• Myocarditis
• Endocarditis
• Conduction defects
• Coronary vasculitis
• Granulomatous aortitis

Pulmonary e.g.:

• Nodules
• Pleural effusions
• Fibrosing alveolitis
• Bronchiolitis
• Caplan’s syndrome

Neurological e.g.:

• Cervical cord compression
• Compression neuropathies
• Peripheral neuropathy
• Mononeuritis multiplex

Amyloidosis [1]

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Diagnosis of Rheumatoid Arthritis (RA)

To establish diagnosis:

• Clinical criteria
• ESR
• CRP
• Ultrasound
• MRI
• Rheumatoid factor
• Anti-citrullinated peptide antibodies

Monitor disease activity and drug efficacy:

• Pain (visual analogue scale)
• Early morning stiffness (minutes)
• Joint tenderness
• Joint swelling
• DAS28 score
• ESR and CRP
• Ultrasound

To monitor disease damage:

• X-rays
• Functional assessment

To monitor drug safety:

• Urinalysis
• Full blood count
• Urea
• Creatinine
• Liver function tests [1]

Erythrocyte sedimentation rate (ESR or sed rate):

• This test assesses levels of inflammation in the body.
• It measures how fast red blood cells in a test tube separate from blood serum over a set period.
• If the red blood cells settle quickly as sediment, inflammation levels are high.
• This test is not specific for RA and is a useful test for other inflammatory conditions or infections.

C-reactive protein (CRP):

• The liver produces CRP.
• A higher CRP level suggests that there is inflammation in the body.
• This test is not specific for RA and CRP can occur in other inflammatory conditions or infection.

Anemia:

• Many people with RA also have anemia.
• Anemia happens when there are too few red blood cells in the blood.
• Red blood cells carry oxygen to the tissues and organs of the body.

Rheumatoid factor:

• If an antibody known as rheumatoid factor is present in the blood, it can indicate that RA is present.
• However, not everyone with RA tests positive for this factor. [3]

Complications are what happen after you have a disease. They are the negative consequences of the disease process.

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Treatment of Rheumatoid Arthritis (RA)

There is no cure for rheumatoid arthritis.

But clinical studies indicate that remission of symptoms is more likely when treatment begins early with medications known as disease-modifying antirheumatic drugs (DMARDs).

Medications:

The types of medications recommended by your doctor will depend on the severity of your symptoms and how long you’ve had rheumatoid arthritis.

NSAIDs i.e.:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) can relieve pain and reduce inflammation.
• Over the counter NSAIDs include ibuprofen (Advil, Motrin IB) and naproxen sodium (Aleve).
• Stronger NSAIDs are available by prescription.
• Side effects may include stomach irritation, heart problems and kidney damage.

Steroids i.e.:

• Corticosteroid medications, such as prednisone, reduce inflammation and pain and slow joint damage.
• Side effects may include thinning of bones, weight gain and diabetes.
• Doctors often prescribe a corticosteroid to relieve acute symptoms, with the goal of gradually tapering off the medication.

Disease-modifying antirheumatic drugs (DMARDs) i.e.:

• These drugs can slow the progression of rheumatoid arthritis also save the joints and other tissues from permanent damage.
• Common DMARDs include methotrexate (Trexall, Otrexup, others), leflunomide (Arava), hydroxychloroquine (Plaquenil) and sulfasalazine (Azulfidine).
• Side effects vary but may include liver damage, bone marrow suppression and severe lung infections.

Biologic agents i.e.:

•  Also known as biologic response modifiers, this newer class of DMARDs includes abatacept (Orencia), adalimumab (Humira), anakinra (Kineret), baricitinib (Olumiant), certolizumab (Cimzia), etanercept (Enbrel), golimumab (Simponi), infliximab (Remicade), rituximab (Rituxan), sarilumab (Kevzara), tocilizumab (Actemra) and tofacitinib (Xeljanz).

These drugs can target parts of the immune system that trigger inflammation that causes joint and tissue damage.

These types of drugs also increase the risk of infections.

In people with rheumatoid arthritis, higher doses of tofacitinib can increase the risk of blood clots in the lungs.

Biologic DMARDs are usually most effective when paired with a nonbiologic DMARD, such as methotrexate.

Occupational Therapy:

• Your doctor may send you to a physical or occupational therapist who can teach you exercises to help keep your joints flexible.
• The therapist may also suggest new ways to do daily tasks, which will be easier on your joints.
• For example, you may want to pick up an object using your forearms.
• Assistive devices can make it easier to avoid stressing your painful joints.
• For instance, a kitchen knife equipped with a hand grip helps protect your finger and wrist joints.
• Certain tools, such as buttonhooks, can make it easier to get dressed.

Surgery:

If medications fail to prevent or slow joint damage, you may consider surgery to repair damaged joints.

Surgery may help restore your ability to use your joint.

It can also reduce pain and improve function.

Rheumatoid arthritis surgery may involve one or more of the following procedures:

Synovectomy i.e.:

• Surgery to remove the inflamed lining of the joint (synovium) can be performed on knees, elbows, wrists, fingers and hips.

Tendon repair i.e.:

•  Inflammation and joint damage may cause tendons around your joint to loosen or rupture.
• Your surgeon may be able to repair the tendons around your joint.

Joint fusion i.e.:

•  Surgically fusing a joint may be recommended to stabilize or realign a joint and for pain relief when a joint replacement isn’t an option.

Total joint replacement i.e.:

• During joint replacement surgery, your surgeon removes the damaged parts of your joint and inserts a prosthesis made of metal and plastic.
• Surgery carries a risk of bleeding, infection and pain. [2]

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Homeopathic Treatment of Rheumatoid Arthritis (RA)

Arnica:

• Useful for chronic arthritis with a feeling of bruising also soreness.
• The painful parts feel worse especially from being moved or touched.

Bryonia:

• Helpful for stiffness also inflammation with tearing or throbbing pain, made worse by motion.
• The condition may have developed gradually, additionally it is worse in cold dry weather.
• Discomfort is aggravated specifically by being touched or bumped, or from any movement.
• Besides this, Relief can be had from pressure and from rest.
• Lastly, The person may want to stay completely still and not be interfered with.

Calcarea carbonica:

• Generally, Helpful for deeply aching arthritis involving node formation around the joints.
• Inflammation and soreness are worse especially from cold and dampness, and problems may be focused on the knees and hands.
• Common symptoms are: weakness in the muscles, easy fatigue from exertion, additionally a feeling of chilliness or sluggishness.
• The person who benefits from Calcarea is often solid and responsible, but tends to become extremely anxious and overwhelmed when ill or overworked.

Aurum metallicum:

• This remedy is often prescribed for wandering pains in the muscles and joints that are better from motion and warmth, and worse at night.
• The person may experience deep pain in the limbs when trying to sleep.
• Also may feel discomfort that may wake the person up.
• People who need this remedy have a tendency to feel depressed.

Causticum:

• Useful when deformities develop in the joints, in a person with a tendon problems, muscle weakness, and contractures.
• The hands and fingers may be most affected.
• Stiffness and pain are worse from being cold, and relief may come with warmth.
• The person often feels best in rainy weather and worse when the days are clear and dry.

Calcarea fluorica:

• Helpful when arthritic pains improve with heat and motion.
• Joints become enlarged and hard, and nodes or deformities develop.
• Arthritis after chronic injury to joints also responds to Calcarea fluorica.

Dulcamara:

• Indicated if arthritis flares up during cold damp weather.
• The person gets chilled and wet.
• They are often stout, with a tendency toward back pain, chronic stiffness in the muscles, and allergies.

Kali bichromicum:

• This is useful when arthritic pains alternate with asthma or stomach symptoms.
• Pains may suddenly come also go, or shift around.
• Discomfort and inflammation are aggravated by heat and worse when the weather is warm.

Kali carbonicum:

• Arthritis with great stiffness and stitching pains, worse especially in the early morning hours and worse from cold and dampness, may respond to Kali carbonicum.
• The joints may be becoming either thickened or deformed.

Kalmia latiflora:

• Basically, Useful for intense arthritic pain that flares up suddenly.
• The problems start in higher joints also extend to lower ones.
• Pain and inflammation may begin in the elbows, after that spreading downward to the wrists and hands.
• Discomfort is worse especially from motion and often worse at night.

Ledum palustre:

• Arthritis that starts in lower joints also extends to higher ones are candidate for this remedy.
• Furthermore, Pain and inflammation often begin in the toes and spread upward to the ankles and knees in RA.
• The joints may also make cracking sounds.
• Ledum is strongly indicated when swelling is significant and relieved by cold applications.

Pulsatilla:

• Applicable when rheumatoid arthritis pain is changeable in quality, or when the flare-ups move from place to place.
• The symptoms (and the person) feel worse from warmth, and better from fresh air and cold applications.
• Can benefit people who are emotional and affectionate, sometimes having teary moods.

Rhododendron:

• Strongly indicated if swelling and soreness flare up before a storm, continuing until the weather clears.
• Cold and dampness aggravate the symptoms.
• Discomfort is often worse toward early morning, or after staying still too long.

Rhus toxicodendron:

• Useful for rheumatoid arthritis, with pain and stiffness that is worse in the morning and worse on first motion, but better from continued movement.
• Hot baths or showers, and warm applications improve the stiffness and relieve the pain of RA.
• The condition is worse in cold, wet weather.
• The person may feel extremely restless, unable to find a comfortable position, and need to keep moving constantly.
• Continued motion also helps to relieve anxiety.

Ruta graveolens:

• Arthritis with a feeling of great stiffness and lameness, worse specifically from cold and damp and worse from exertion, may be helped by Ruta graveolens.
• Tendons and capsules of the joints can be either deeply affected or damaged by RA.
• The arthritis may have developed after overuse, from repeated wear also tear.  [4]

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1. Davidson’s Principles and Practice of Medicine (22nd edition) Ch. 25
2. https://www.mayoclinic.org/diseases-conditions/rheumatoid-arthritis/symptoms-causes/syc-20353648
3. https://www.medicalnewstoday.com/articles/323361.php
4. https://www.wellinghomeopathy.com/treatment-of-rheumatoid-arthritis/#Homeopathic_treatment_for_Rheumatoid_Arthritis

Frequently Asked Questions

What is Rheumatoid Arthritis ?

Rheumatoid arthritis is a long-term, progressive, also disabling autoimmune disease. Additionally, It causes inflammation, swelling, and pain in and around the joints and other body organs.

Homeopathic Medicines used by Homeopathic Doctors in treatment of Rheumatoid Arthritis ?

• Arnica
• Bryonia
• Calcarea carb
• Aurum metallicum
• Causticum
• Calcarea fluorica
• Dulcamara
• Pulsatilla

What causes Rheumatoid Arthritis ?

• Genetic factors
• Either Bacteria or a virus
• Antibodies attack the synovium
• Inflammation causes the synovium to thicken
• The joint eventually loses its shape also configuration
• The damage can be severe
• Women are more likely than men
• Family history

What are the symptoms of Rheumatoid Arthritis ?

• Joint pain
• Joint swelling, warmth also redness
• Stiffness
• Fever
• Weight loss
• Fatigue
• Susceptibility to infection