Rheumatoid and osteoarthritis - why does it hurt and can it be stopped?

Arthritis is a general term that implies acute or chronic inflammation of a joint, often accompanied by pain and structural changes. Though most of us think of old age and repetitive work as the causes of arthritis, the reality is much more complicated. Arthritis isn’t just one disease; it’s a complex disorder that can comprise more than 100 distinct conditions and can affect people at any stage of life.

Osteoarthritis

Osteoarthritis is sometimes called degenerative joint disease, but osteoarthritis most of the time because many sufferers experience little or no inflammation of the joints themselves. This is the most common form of arthritis in the United States, affecting an estimated 21 million adults. Osteoarthritis occurs when cartilage in the joints wears down over time or after trauma. Thus, it rarely affects children or younger adults. This disease can affect any joint in the body, though it commonly affects the load-bearing joints in the hips, knees, hands, and spine. Osteoarthritis typically affects one joint, though in some cases, such as with finger arthritis, several joints may be affected. Two of the most common joints in the hand to be affected are the carp metacarpal joint at the base of the thumb and the distal interphalangeal joints (the last knuckle of the fingers). It is somewhat rare, however, for the exact same joints to be involved in both hands.

The diagnosis of osteoarthritis is supported by a history of stiffness that is worse in the morning or after activity, as well as pain in the joints. Physical examination often reveals crepitus, a grinding sensation with movement of the joint, as well as decreased range of motion as the osteoarthritis progresses. It is rare for joints affected by osteoarthritis to be red and warm, markedly swollen, or tender to light touch. X-rays are often normal or show mild narrowing of the affected joints initially. As osteoarthritis progresses however, asymmetric joint space narrowing worsens, and the bones surrounding the affected joint begin to show changes, as well.

Several kinds of medication can be used to manage osteoarthritis pain, but these medications are used primarily to treat the symptoms, not to modify the cause of the osteoarthritis. For mild cases, medications include Tylenol and non-steroidal anti-inflammatory medications (NSAIDs), such as ibuprofen, meloxicam, and etodolac. There are several classes of NSAIDs, and it is common for a provider to try a patient on several different types because each class works slightly differently. For mildmoderate osteoarthritis, injectable viscosupplemention is approved by the Food and Drug Administration. Usually, these medications are administered weekly for three to five weeks, although a one-time injection is being developed and should be available soon. If pain becomes severe, one can consider stronger pain medications or surgical procedures including joint replacement.

Rheumatoid arthritis

Rheumatoid arthritis (RA) is an autoimmune disease characterized primarily by inflammation of the lining, or symposium, of the joints. Autoimmune diseases are illnesses that occur when the body tissues are mistakenly attacked by the body’s own immune system. In the case of RA, the lining of the joints is attacked by an organization of cells and antibodies designed normally to “seek and destroy” invaders of the body, particularly infections. This leads to swelling of the synovial lining, causing pain, warmth, stiffness, redness, and swelling around the joint. The inflamed joint lining then thickens, and eventually, those inflamed cells release enzymes that may digest bone and cartilage, causing more pain and loss of movement. RA affects 1.3 million Americans and people of all races equally. This disease most commonly affects patients between the ages of 40 and 60, but several variants affect children, as well.

The diagnosis of RA can be supported by a history of fatigue, prolonged pain and morning stiffness of at least 30 to 60 minutes, and symmetric joint involvement in the smaller joints (like the hands of feet). It is common for the disease to “flare” or become more active at times, with affected joints becoming red, hot, and swollen. In the hands, the metacarpophalangeal joints (where the fingers meet the hand) are often affected. It is more common in this disease than in osteoarthritis for several joints to be involved at once. In addition, X-rays in rheumatoid arthritis often show different characteristics than those in osteoarthritis, but the main difference in the diagnosis of RA versus osteoarthritis is the use of blood work to help diagnose RA. Rheumatoid factor can be found in the majority of patients with RA, and more recently, doctors have begun to look for the citrulline antibody (or anti-CCP), as it is found in the blood work of most RA patients. There are no markers of osteoarthritis that can be found with any currently available blood tests.

The medications used to manage RA are different from those used in osteoarthritis. RA requires medications other than NSAIDs and corticosteroids to stop progressive damage to cartilage, bone, and adjacent soft tissues. The medications needed for ideal management of the disease are also referred to as disease-modifying anti-rheumatic drugs (DMARDs). These second-line or slow-acting medicines may take weeks to months to become effective. They are used for long periods, even years, at varying doses. If effective, DMARDs can promote remission, thereby retarding the progression of joint destruction and deformity. Because of potentially serious side effects, immunosuppressive medicines (other than methotrexate) are generally reserved for patients with an aggressive form of the disease or those with serious complications of rheumatoid inflammation, such as blood vessel inflammation. The exception is methotrexate, which is not frequently associated with serious side effects and can be carefully monitored with blood testing. Methotrexate has become a preferred medication in the management of RA as a result.

For both types of arthritis, several shared treatment options exist, including physical therapy, assistive devices, medication (by mouth and /or injected into the joint), and surgery. Strengthening the muscles surrounding and supporting the joint can help improve function and decrease discomfort. As a result, health care providers often prescribe physical therapy. Therapists can also show patients how to use canes or front-wheeled walkers effectively in most stages of arthritis to offload the joint and provide relative rest. Likewise, joint replacement surgeries are options before pain or deformity becomes severe in either osteoarthritis or RA.

Despite the similarities, osteoarthritis and rheumatoid arthritis are different diseases requiring different kinds of medications for optimal management. A health care provider may order X-rays and appropriate lab tests to help with the diagnosis, as well as to monitor the progression of each type of arthritis. But there is hope because new treatment options are being researched. To learn more about supporting research or fundraising on the local or national level, contact the local chapter of the Arthritis Foundation, or go online to research the recommendations of the American College of Rheumatology at www.rheumatology.org or American Academy of Orthopedic Surgeons at www.aaos.org .