Rheumatoid arthritis: symptoms and management

Rheumatoid arthritis is a common condition that can lead to debilitating pain if not treated. In his latest article, leading consultant Dr Robert Marshall explains this condition in detail.

What are the key early warning signs and symptoms of rheumatoid arthritis?

The cardinal sign of rheumatoid arthritis is swelling in the joints. It usually affects the joints of the hand or the feet but others can be affected. Without obvious swelling, it is sometimes difficult to recognise rheumatoid arthritis.

However, there are several other symptoms that are characteristic of inflammatory conditions. This can include:

• Early morning stiffness – this tends to improve with movement and exercise, but often it can take 30 minutes or more before the body has warmed up. Stiffness also tends to worsen when at rest. Sometimes people might wake in the middle of the night with pain.
• Fluctuating symptoms – some people may suffer from a very painful, swollen hand for a few days before the pain moves to different joints.
• Strong family history – this can greatly increase the risk of developing rheumatoid arthritis.

What are the current best practices to treat rheumatoid arthritis? Are there any new or evolving treatments?

There is a lot of focus on early recognition of rheumatoid arthritis. If they have symptoms, they should go see their GPs as soon as possible. GPs are also encouraged to refer their patients to rheumatologists as soon as possible, so a diagnosis can be made and treatment can begin. There is evidence that starting treatment earlier can lead to better outcomes for the patient.

We often adopt a “treat to target” approach. This means we will set a target of a certain disease activity score. We will keep monitoring the patient, and if the disease is still active at each review, we may increase the doses of medication or include different medications to try and get it under control.

What lifestyle modifications can be made to manage symptoms and improve quality of life?

There are a number of different ways that you can manage symptoms. These include:

• Stop smoking – Not only can smoking contribute to causing rheumatoid arthritis, but we also know that people who continue to smoke once diagnosed not only suffer from worse symptoms, but medications can also be less effective.  
• Sensible alcohol limits –certain arthritis medications can affect the liver, so it is important not to drink too much alcohol.
• Keeping a healthy weight – This can be difficult as having arthritis makes it harder to lose weight. Not only does carrying increased weight put more pressure on the joints, it also contributes to higher inflammation levels. This is why exercise is so important to help with joint stiffness. Patients will often be referred to a physiotherapist who can give them more advice, but largely it is important to keep active without overdoing it.
• Diet – Many patients ask me what the best diet is, and although we don’t have a lot of good evidence, a healthy, balanced diet with plenty of fruit and vegetables is generally recommended. A Mediterranean-style diet with plenty of oily fish, olive oil and sundried tomatoes is often quite helpful for rheumatoid arthritis as well.  

What is the most effective treatment for rheumatoid arthritis? When should I start taking medication, and when is surgery required?

The most important thing is to have regular reviews with your rheumatologist or rheumatological nurse. Many people think they are doing reasonably well, and carry on with daily life, but the symptoms can be more active than they believe. It is important to review the symptoms every few months, ideally, face-to-face with your rheumatologist.

Nowadays, we use very specific outcome measures, such as the disease activity score. This is a composite score based on how many tender joints you have, how many swollen joints you have, how you think you’re doing generally, and a blood test to measure CRP, a marker of inflammation. We put all this together and it gives us a number that tells us how active the condition is.

Surgery is becoming a lot less common than it was, because in the last 20 years, we have gotten a lot better at controlling joint damage, and it doesn’t tend to cause as much damage as it used to. Nonetheless, if the joints have been damaged, surgery can be an option. It is important to discuss this with both your rheumatologist and orthopaedic surgeon. 

How important are patient education and self-management strategies in rheumatoid arthritis outcomes?

Unfortunately, rheumatoid arthritis is a long-term condition. Like conditions such as diabetes, it won’t go away without treatment. We do know that it is likely to fluctuate day-to-day, week-to-week and month-to-month.

It is important to keep a symptom diary to record how you are feeling, your flare-ups, how you’re sleeping, etc.

Although many advancements have been made in treating the condition, there is no magic wand that we can wave and completely take all symptoms away. There will generally be some residual symptoms.

It is important for patients to try and understand what can trigger flare-ups. Stress is often a trigger for people. Similarly, not sleeping well or infections can cause your symptoms to flare. If you do have an infection, it’s advised to stop the medications while you are unwell.

If you are fatigued or not feeling well, you may not feel like doing much, but it is very important to keep trying to get regular exercise.

There are a number of simple things that can be done if joints are painful or swollen: resting, putting less strain on the joint, and gentle stretching exercises to keep the range of movement.

Heat packs are useful if the joint is painful, but if it is very swollen and inflamed then an ice pack can be helpful.

Talking with family and friends for support is also very important. If you are at work then talk to your manager, as there are often things that can be done at work to help people struggling with arthritis. There is also legal protection for people under the Equality Act.

We also know that mental health problems such as anxiety and depression. These are common among the general population, but people who have rheumatoid arthritis are more susceptible to them. However, this can be treated with appropriate support, which ranges from treating arthritis to counselling. You can talk to your GP about getting help with these problems.

Dr Robert Marshall is a renowned consultant rheumatologist based in Bristol. You can book a consultation with Dr Marshall today via his Top Doctors profile.