Description Of Rheumatoid Arthritis Essay

Rheumatoid arthritis (RA) is an autoimmune disease whereby the immune system which normally protects the body from invading pathogens and foreign substances, attacks the joints between the bones. This occurs as the white blood cells of the immune system move into the joints and release cytokines, attacking the synovial membrane, the inner lining of the joint. Description Of Rheumatoid Arthritis Essay.

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As a result, this causes the synovium to thicken, forming an abnormal layer of tissue to grow over the surface of the inner joints. Pain, inflammation and swelling is a response to this process and if not attended to, the bone and cartilage inside the joint can be destroyed and the space between one bone and the next can become smaller, allowing the bones to rub against each other and making it more difficult to move. Joints can become irreversibly deformed, losing their firmness, stability and flexibility (Guo et al. , 2018). RA can affect most joints in the body, including that of the wrists, hands, elbows, knees, ankles and feet. The disease usually occurs symmetrically, meaning that if the right elbow is affected, the left elbow is likely affected also.

The causes of RA are unknown, although genetics and environmental factors such as trauma and exposures to chemicals are also considered to be triggers, as well as hormones. It is known that the abnormal reaction of the immune system is the main role in the inflammatory response but there is still uncertainty as to why the immune system reacts in this manner. (Thakur et al. , 2018). There is currently no cure for this chronic disease, but there are drugs such as Disease Modifying Antirheumatic Drugs (DMARDs) and Biological DMARDs (bDMARDs) that slow down the disease progression. The main aim of these drugs is to obtain the lowest level of disease action by maintaining the patient in remission, as well as reducing bone harm and improve quality of life and physical function of the patient. The use of these drugs depends upon many factors, including the stage of progression and severity of the damage. Description Of Rheumatoid Arthritis Essay.

DMARDs, or conventional drugs, are often the first line treatment for mild to moderate RA and include methotrexate, sulfasalazine, hydroxychloroquine and leflunomide (Vaz, Lisse, Rizzo & Albani, 2009). Methotrexate is often used first, as a low weekly dose and can be taken alone or in combination with one of the other conventional drugs but for active RA with significant functional impairment, triple therapy of methotrexate with sulfasalazine and Hydroxychloroquine is used. These agents should be commenced as soon as possible, as they are used to induce inflammatory remission and prevent joint damage. The response to these drugs should be within 12 weeks of use, and during that period of time, corticosteroids can also be used to aid in the reduction of the inflammation. The immunosuppressive and anti-inflammatory activities of the DMARDs often reasons for significant toxicities, hence, careful monitoring is required to identify adverse effects.

If there is minimal response to DMARDs, or higher doses are not tolerated well, bDMARDs are then considered. They may be used as monotherapy or in combination with other DMARDs such as methotrexate, and they tend to work within 2 to 6 weeks (Hazlewood et al. , 2016).Description Of Rheumatoid Arthritis Essay.  Biologics bind to Tumour Necrosis Factor (TNF) molecules and inhibit its activity, where these molecules are cytokines responsible for the inflammatory response. Etanercept, Adalimumab and Infliximab are examples of TNF inhibitors. As bDMARDs hinder with the immune system’s capability to battle infections, testing the patient for infections such as TB is critical before initiating treatment as there is an increased chance of reinfection. Drugs used in conjunction with RA medications to control the symptoms such as pain and inflammation include Paracetamol, Corticosteroids, Non-Steroidal Anti-inflammatory Drugs (NSAIDs) such as ibuprofen, as well as COX-2 Inhibitors such as Celecoxib (Schuna & Megeff, 2000).

In May 2018, Baricitinib (Olumiant), a new drug therapy was marketed for the treatment of moderate to severe RA unresponsive to monotherapy or combination therapy with the biological treatment. Baricitinib is a Janus Kinase (JAK) Inhibitor, blocking the subtypes JAK-1 and JAK-2. JAKs are enzymes inside the cells which conduct signals from cytokines that impact immune cell function (Heim, 1999). JAKs phosphorylate and activate STATs (Signal Transducers and Activators of Transcription) which regulate actions such as gene expression within the cell, at this point, Baricitinib inhibits the phosphorylation activity and hence prevents the initiation of STATs, controlling the immune reaction and hence the inflammatory process. Nevertheless, the significance of the blockage of JAK enzymes to therapeutic value is presently unknown (Furumoto et al. , 2013).

Many clinical trials have been completed and in progress to provide evidence of this drug. As it has only been recently approved, it is still in Phase 2 of trials as of September 3rd, 2018, collecting initiatory figures on whether Baricitinib works in participants who present with RA, establishing the efficacy of the drug. In the journal Clinical Rheumatology, a randomised double blinded placebo study with varying doses was conducted for patients with active RA who have not responded well to other treatments. The study was completed over a course of 6 months and patients were assessed at 3-month intervals. Description Of Rheumatoid Arthritis Essay. The results showed that 18-20% of patients showed more than 20% improvement in tender and swollen joints as well as pain and a further 37-40% showed a 50% improvement, 28-30% showed a 70% improvement and 11-12% showed a 90% improvement.

Overall, there is a solid increase in improvement in all patients trailed on Baricitinib (Kunwar, Collins & Constantinescu, 2018). Another randomised controlled trial conducted in the journal Experimental and Therapeutic Medicine, assessed the effectiveness of Baricitinib for patients with unresponsive RA, on a dose of 4mg daily for 3-6 months. The patients showed significant improvements compared to the placebo within and there were no adverse effects identified, until the latter 3 months. Overall, the study showed Baricitinib was beneficial in treating RA (Wu et al. , 2018). Rheumatoid arthritis is an autoimmune disease whereby the body’s immune system attacks the joints causing irreversible bone damage.

The causes of RA are unknown, and it is a lifelong progressive disease. There is no current cure for RA, but there are drugs available that slow down the disease progression and the improve quality of life of the patient. Baricitinib is a new drug therapy for treatment of moderate to severe RA unresponsive to current therapies. Many clinical trials have been completed and are still in progress to deliver evidence of this drug. So far, these trials have shown that the drug is beneficial in patients and there is a marked improvement in their RA.

Rheumatoid arthritis is a chronic condition that is characterized by persistent inflammation of a number of joints. Over a prolonged period of time, this inflammation results in irreversible joint damage. Although its cause is unknown, it is usually thought to be auto-immune disorder in which the immune system starts to attack the body’s own tissue. Rheumatoid Arthritis has a world-wide distribution and affects 0.5-1%, with a female preponderance, of the population( Kumar & Clarck’s, Clinical Medicine). Description Of Rheumatoid Arthritis Essay.

The disease, causes disability and mortality and can happen from childhood to late old age. The most common age onset is between 30 and 50 years.

Gender, genetics and family are the most important risk factors, others include heavy smoking, obesity and a history of blood transfusions.

Gender: This predominance of women with rheumatoid arthritis is mainly due to the fact that diminished immunity is a significant factor. There is a great risk that a woman will develop rheumatoid arthritis at the menopause because her ovaries will have to stopped producing hormones oestrogen and progesterone. Women before the menopause are affected three times more than men.

Genetics: Genes play a significant role in the development of rheumatoid arthritis, factors are estimated to account for up to 60% of disease susceptibility.

The condition is strongly related to the presence of a protein on the surface of white blood cells called HLA-DR4.

Family:

A consultant rheumatologist will be able to treat rheumatoid arthritis, they are hospital-based doctors with specialist training in arthritis and other diseases that affect the joints. They are capable to interpret tests and may suggest more, discuss treatments, prescribe drugs, or make a referral for surgery, if it is required. If the patient undergo surgery, the rheumatologist will manage the rehabilitation by referring the patient to physiotherapists a occupational therapists. Description Of Rheumatoid Arthritis Essay.

Assessment

Rheumatoid arthritis starts in different ways. Usually, it starts slowly, with intermittent pain and swelling in some joints, especially in the fingers, wrist, and feet. I almost 20 per cent of all cases, the disease start very suddenly: one day the individual is normal and the next many joints are painful, swollen, and stiff. In some people the disease starts in less typical ways. For example, it may involve only a single joint. In others, the disease comes and goes repeatedly, often over several years, before becoming persistent. Occasionally, it starts with pain stiffness around the shoulders and so mimics a condition called polymyalgia rheumatica.

There are many key symptoms that doctors look for when they are trying to identify any type of arthritis. Sometimes these symptoms are accompanied by other features, such as loss of function and a sensation of unbearable tiredness or general symptoms that affect the body as a whole.

Symptoms:

1. Pain: Pain in a joint maybe mild, moderate, or severe, and is usually chronic.
3. Inflammation: Symptom of various type of inflammatory arthritis.
5. Swelling: Either the lining of the joint swells or fluid flows into the joint. Swelling usually indicates inflammatory arthritis.
7. Stiffness: Morning stiffness that lasts for over an hour usually indicates a form of arthritis.

There are also a list of physical examinations that could be required in order to diagnose rheumatoid arthritis:

• Visual identification of the swelling, redness and structural deformity of the joints, which is a characteristic of rheumatoid arthritis. Description Of Rheumatoid Arthritis Essay.
• Palpation of the joints, which helps to distinguish which type of arthritis.
• Pain when moving the joints.

Examinations rarely helps the diagnosis, but it does help evaluate the severity and can pinpoint problems with specific joints. As the rheumatoid arthritis affects the joints causing pain, it will limit the patient’s ability to move. Household chores, writing, picking up things from the floor and personal care are examples of daily activities that may be affected by rheumatoid arthritis. In that way, people with rheumatoid arthritis need to make changes in their lifestyle, I order to protect their joints and to know how to cope with flare-ups and stress.

Investigations:

1. X-rays: They show joint damage and provide an assessment of its severity and progression. In rheumatoid arthritis, they may reveal loss of bone, which means the presence of erosions nest to the margins of joints. Also, helps the doctor decide whether joint replacement surgery is needed.
3. Imaging Techniques:
   • Computerized tomography (CT).
   • Magnetic resonance imaging (MRI).
   • Ultrasound.
   • Isotope bone scans.
   • Dual- energy X-ray absorptiometry (DEXA).

All these imaging techniques can provide a more enhanced image of bones and joints than X-rays Some, particularly MRI and ultrasound, can show inflammation and soft-tissue swelling.

Blood test is also very important to confirm the diagnosis of rheumatoid arthritis, they can reveal specific chemicals that are markers of this disease, such as auto-antibodies that react with specific proteins in the body. Description Of Rheumatoid Arthritis Essay. Blood tests also reveal the level of haemoglobin, which may indicate anaemia or infection. Also, it measures the level of enzymes to check if the liver is working properly, kidney function can be checked as well by measuring the level of waste products. C-reactive protein (CRP) levels is checked to find out any acute inflammation. Also, erythrocyte sedimentation rate(ESR), to assess the body’s response to a damaging situation, such as inflammation or infection.

Orthopaedic surgeons have a number of joint surgeries available as part of a treatment, they all aim to relieve pain or prolong the life of a joint. The main types of joint surgery available include washing out, synovectomy, realignment, fusion, and total replacement.

Diagnosis.

Diagnosing rheumatoid arthritis requires a team effort involving the patient and several types of health care professionals, such as general practitioner, internist and rheumatologist. The diagnose of rheumatoid arthritis in its early stages can be difficult, as there is no single test for the disease. In addition, symptoms differ from person to person and can be more severe in some people than in others. Also, symptoms can be similar

Science

Rheumatoid arthritis is an autoimmune disorder that the immune system attacks his or her own body tissue. However there is not a exact cause yet, there still research on many things that could cause rheumatoid arthritis. Such as genes, environment and hormones.

It can affect various systems in the body, such as: cardiovascular, immune, respiratory, nervous, integumentary, endocrine, skeletal and excretory. Also soft tissue surrounding joins, lungs, skin, heart, eyes, kidneys, spleen, lymph nodes, and blood.

The signs that is shown in rheumatoid arthritis are caused by inflamed synovial membrane of one or more joints, causing pain and swelling. When inflammation spreads to the synovial sheats that protects the tendons, there is progressive and usually irreversible damage to joints. Bony swellings appear and deformity develops as the damage joints begin to fail. Muscles weaken due to lack of use and from the effects of generalized inflammation. Description Of Rheumatoid Arthritis Essay.

Prognosis

Research on rheumatoid arthritis has massively improved the knowledge of the immune system and genetics. Studies to understand the development of the disease may help finding new therapies that would improve the disease at early stage ( inflammatory process). Although there is an increased in knowledge about the cause of rheumatoid arthritis, the prognosis still very poor. Two factors to consider before giving the prognosis are:

How early the disease was diagnosed and how old was the patient when first diagnosed.

Research studies suggest that conditions such as heart diseases, osteoporosis, stroke, and infections may be more likely. One reason may be that people with rheumatoid arthritis are not able to exercise freely. In some cases, the drugs for rheumatoid arthritis can raise blood pressure or weaken the immune system, making infections more likely. About 10 to 20% of rheumatoid arthritis patients have sudden onset of the disease, followed by many years with no symptoms. This is considered a prolonged remission. (Carol & Richard Eustice, about.com guide).

Treatment

Current research shows that in the early days of the disease, NSAIDs (Non-steroidal Anti-inflammatory drugs) may provide some relief from the symptoms. However, they do not prevent progressive joint damage. Such damage is mainly treated with DMARDs (Disease-modifying-antirheumatic-drugs). They act slowly, taking several weeks or months to feel their effect. The rheumatologist will determine how long they should be taken as different people respond to individual DMARDs in different ways. If the disease do not respond to these, the patient may be considered for a new generation of drugs called biologic agents. They can help reduce inflammation and structural damage to the joints by blocking the action of cytokines, proteins of the body’s immune system that trigger inflammation during normal immune responses.

When the joints are damaged to the point where the pain cannot be controlled with drugs or the joint can barely move, the surgery may be the only answer. Description Of Rheumatoid Arthritis Essay.The surgeon will need to weigh up the risks and benefits before making a decision about surgery. Joint replacement, in particular, requires operating theatres equipped with ultraclean airflow systems to help maintain hygiene and reduce the risk of infection. Trained nursing staff, physiotherapists and occupational therapists are part of the multidisciplinary team working towards effective post-operative recovery and rehabilitation. There are a good number of professional involved to make any adjustment to the patient’s new lifestyle; occupational therapists can help patients to achieve personal, work, domestic, educational or leisure goals. Also, help to prevent or reduce the chance of loosing abilities in the future. A rheumatologist can refer the patient to a occupational therapist, who is specialised in solving problems with rheumatoid arthritis. Therefore, the specialist you be able to advice the patient on home adaptations.

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The rheumatologist will always be involved in the patient’s care in every treatment stage, by prescribing the DMARDs, deciding about surgery, referring to a occupational therapist, physiotherapist or dietician.

Ethics

It is essential that the patient I fully aware of the treatment and if the surgery is offered as part of the treatment, the patient will have to be mentally active to understand the whole process of the joint replacement. There is no age limit as longer as the patient is understanding the procedure and the rehabilitation.

Bibliography

Books:

Websites:

http://www.hopkins-arthritis.org/arthritis-info/rheumatoid-arthritis/rheum_clin_pres.html#epid

http://www.medicinenet.com/script/main/art.asp?articlekey=60768&page=7

http://arthritis.about.com/od/rheumatoidarthritis/a/RA_prognosis.htm?p=1 . Description Of Rheumatoid Arthritis Essay.