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Rheumatoid

Arthritis

Elizabeth Bolden, RN, MSN

Elizabeth Boldon is a Nurse Education Specialist

at Mayo Clinic in Rochester, Minnesota. She

received a BSN from Allen College in Waterloo,

Iowa in 2002 and an MSN with a focus in

education from the University of Phoenix in

2008. She has bedside nursing experience in medical neurology and the

neuroscience ICU.

Abstract

Rheumatoid arthritis involves inflammation that often leads to major pain

and disability. Autoantibodies contribute to the disease process of synovial

inflammation and joint damage for those afflicted. Symptoms include pain at

the sight of inflammation as well as more generalized feelings of fatigue, loss

of appetite and low-grade fever. Therapies for rheumatoid arthritis may be

individualized but typically focus on the suppression of synovial inflammation

and joint damage. While this study focuses on the more common approaches

of diagnosis and treatment, additional areas of research and study are

highlighted related to disease etiology, progression and lifestyle choices.

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Continuing Nursing Education Course Planners

William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,

Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner

Policy Statement

This activity has been planned and implemented in accordance with the

policies of NurseCe4Less.com and the continuing nursing education

requirements of the American Nurses Credentialing Center's Commission on

Accreditation for registered nurses. It is the policy of NurseCe4Less.com to

ensure objectivity, transparency, and best practice in clinical education for

all continuing nursing education (CNE) activities.

Continuing Education Credit Designation

This educational activity is credited for 1.5 hours. Nurses may only claim

credit commensurate with the credit awarded for completion of this course

activity.

Statement of Learning Need

Nurses experienced in the evaluation of joint pain for patients affected by

rheumatoid arthritis are better able to assess signs and symptoms and carry

forward needed treatment. Since rheumatoid arthritis is a major cause of

disability nation-wide, there is ongoing need for nursing education to

recognize early signs of the disease and to provide ongoing treatment.

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Course Purpose

To enable nurses to increase their knowledge on caring for patients with

Rheumatoid Arthritis (RA).

Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses and

Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures

Elizabeth Boldon, RN, MSN, William S. Cook, PhD, Douglas Lawrence, MA,

Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Activity Review Information:

Reviewed by Susan DePasquale, MSN, FPMHNP-BC.

Release Date: 1/1/2016 Termination Date: 7/16/2018

Please take time to complete a self-assessment of knowledge, on

page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge learned

will be provided at the end of the course.

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1. Rheumatoid arthritis is an autoimmune disease

a. that is more common in men than women.

b. commonly known as “wear and tear” arthritis.

c. in which the body’s immune system mistakenly attacks the joints.

d. which affects the cartilage but not the lining of the joints.

2. True or False: There is no evidence that a specific climate can

prevent or reduce the effects of rheumatoid arthritis.

a. True.

b. False.

3. Rheumatoid factor (RF) is an antibody that

a. is present in the blood of all patients with rheumatoid arthritis.

b. if a person tests positive, he/she will develop rheumatoid arthritis

c. is present in people with rheumatoid arthritis but no other disease.

d. is present eventually in the blood of most people with rheumatoid

arthritis.

4. ______________ is a surgical procedure that involves removing the joint and fusing the bones into one immobile unit.

a. Synovectomy

b. Arthrodesis

c. PTPN22

d. Microarray

5. Osteoporosis is a condition

a. that may be avoided by patients who take corticosteroids.

b. in which bones become weakened and fragile.

c. that develops only in women who have pre-existing rheumatoid

arthritis.

d. caused by stress.

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Introduction

Rheumatoid arthritis (RA) is a chronic inflammatory disorder that typically

affects the small joints in the hands and feet. Unlike the wear-and-tear

damage of osteoarthritis, rheumatoid arthritis affects the lining of joints,

causing a painful swelling that can eventually result in bone erosion and joint

deformity.

An autoimmune disorder, rheumatoid arthritis occurs when the immune

system mistakenly attacks the body's own tissues. In addition to causing

joint problems, rheumatoid arthritis sometimes can affect other organs of

the body — such as the skin, eyes, lungs and blood vessels.1

This course will discuss Rheumatoid arthritis as a disease process, including

the symptoms, causes, risk factors, diagnosis and treatment as well as some

current research in the area of rheumatoid arthritis.

What Is Rheumatoid Arthritis?

Rheumatoid arthritis is an autoimmune disease in which the body’s immune

system – which normally protects its health by attacking foreign substances

like bacteria and viruses – mistakenly attacks the joints. This creates

inflammation that causes the tissue that lines the inside of joints (the

synovium) to thicken, resulting in swelling and pain in and around the joints.

The synovium makes a fluid that lubricates joints and helps them move

smoothly.2

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If inflammation goes unchecked, it can damage cartilage, the elastic tissue

that covers the ends of bones in a joint, as well as the bones themselves.

Over time, there is loss of cartilage, and the joint spacing between bones

can become smaller. Joints can become loose, unstable, painful, and mobility

is reduced. Joint deformity also can occur. Joint damage cannot be reversed,

and because it can occur early, doctors recommend early diagnosis and

aggressive treatment to control RA.2

Rheumatoid arthritis most commonly affects the joints of the hands, feet,

wrists, elbows, knees and ankles. The joint effect is usually symmetrical,

affecting both sides of the body. Because RA can also affect body systems,

such as the cardiovascular or respiratory systems, it is referred to as a

systemic illness and is sometimes called rheumatoid disease.2

Symptoms of Rheumatoid Arthritis

The disease onset in RA is usually insidious, with the predominant symptoms

being pain, stiffness (especially morning stiffness), and swelling of many

joints. Typically, the joints of the fingers, the thumbs, the wrists, and the

joints of the toes are sites of arthritis early in the disease. Other synovial

joints of the upper and lower limbs, such as the elbows, shoulders, ankles,

and knees, are also commonly affected.3

Morning stiffness is a common feature of those with active RA; it can be

defined as "slowness or difficulty moving the joints when getting out of bed

or after staying in one position too long, which involves both sides of the

body and gets better with movement."3 Morning stiffness lasting more than

one hour reflects a severity of joint inflammation that rarely occurs in

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diseases other than RA, although morning stiffness, or stiffness after any

prolonged period of inactivity, is also seen in virtually all inflammatory

arthritis processes.3 Along with pain, many people experience fatigue, loss of

appetite and a low-grade fever.

The symptoms and effects of rheumatoid arthritis may come and go. A

period of high disease activity (increases in inflammation and other

symptoms) is called a flare. A flare can last for days or months. Symptoms

may also subside or disappear for periods of time, called remissions. Over

time, rheumatoid arthritis can cause joints to deform and shift out of place.

Ongoing high levels of inflammation can cause problems throughout the

body. Here are some ways rheumatoid arthritis can affect organs and body

systems:2

Eyes:

Dryness, pain, redness, sensitivity to light and impaired vision

Mouth:

Dryness and gum irritation or infection

Skin:

Rheumatoid nodules, which are small lumps under the skin over bony

areas

Lungs:

Inflammation and scarring that can lead to shortness of breath

Blood Vessels:

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Inflammation of blood vessels that can lead to damage in the nerves,

skin and other organs

Blood:

Anemia, a lower than normal number of red blood cells needed to carry

adequate oxygen to body tissues, leading to feeling weakness and

exhaustion

Causes of Rheumatoid Arthritis

The cause of rheumatoid arthritis is not yet fully understood, although

medical providers do know that an abnormal response of the immune

system plays a leading role in the inflammation and joint damage that

occurs. No one knows for sure why the immune system goes awry, but there

is scientific evidence that genes, hormones and environmental factors are

involved.2

Research has shown that people with a specific genetic marker called the

HLA shared epitope have a five-fold greater chance of developing

rheumatoid arthritis than do people without the marker. The HLA genetic site

controls immune responses. Other genes connected to rheumatoid arthritis

include STAT4, a gene that plays important roles in the regulation and

activation of the immune system; TRAF1 and C5, two genes relevant to

chronic inflammation; and, PTPN22, a gene associated with both the

development and progression of rheumatoid arthritis. Yet not all people with

these genes develop RA, and not all people with the condition have these

genes.2

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Researchers continue to investigate other factors that may play a role. These

factors include infectious agents such as bacteria or viruses, which may

trigger development of the disease in a person whose genes make them

more susceptible to it; female hormones (seventy percent of people with RA

are women); obesity; and, the body’s response to stressful events such as

physical or emotional trauma. Research also has indicated that

environmental factors may play a role in one's risk for rheumatoid arthritis.

Some include exposure to cigarette smoke, air pollution, insecticides and

occupational exposures to mineral oil and silica.2

Even though all the answers are not known, one thing is certain: rheumatoid

arthritis develops as a result of an interaction of many factors. Researchers

are trying to understand these factors and how they work together.

Risk Factors for Rheumatoid Arthritis

Factors that may increase the risk of rheumatoid arthritis include:1

Sex:

Women are more likely to develop rheumatoid arthritis.

Age:

Rheumatoid arthritis can occur at any age, but it most commonly begins

between the ages of 40 and 60.

Family history:

If a member of a person’s family has rheumatoid arthritis, they may have

an increased risk of the disease.

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Diagnosis Of Rheumatoid Arthritis

Rheumatoid arthritis can be difficult to diagnose in its early stages for

several reasons. First, 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 to those of other types

of arthritis and joint conditions, and it may take some time for other

conditions to be ruled out.

Finally, the full range of symptoms develops over time, and only a few

symptoms may be present in the early stages. As a result, medical providers

use a variety of the following tools to diagnose the disease and to rule out

other conditions:4

Medical History

The medical provider begins by asking the patient to describe the symptoms,

and when and how the condition started, as well as how the symptoms have

changed over time. The provider will also ask about any other medical

problems the patient and close family members have and about any

medications the patient is taking. Accurate answers to these questions can

help the provider make a diagnosis and understand the impact the disease

has on the patient’s life.

Good communication between patient and their medical provider is

especially important. For example, the patient’s description of pain, stiffness,

and joint function and how these change over time is critical to the

provider’s initial assessment of the disease and how it changes over time.

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Physical Examination

The health provider will check the patient’s reflexes and general health,

including muscle strength. The medical provider will also examine

bothersome joints and observe the patient’s ability to walk, bend, and carry

out activities of daily living. In addition, the skin is examined for a rash and

the provider will listen to the chest for signs of inflammation in the lungs.

Laboratory Tests

A number of lab tests may be useful in confirming a diagnosis of rheumatoid

arthritis. Following are some of the more common ones:3

Rheumatoid factor (RF):

Rheumatoid factor is an antibody that is present eventually in the

blood of most people with rheumatoid arthritis. (An antibody is a

special protein made by the immune system that normally helps fight

foreign substances in the body.) Not all people with rheumatoid

arthritis test positive for rheumatoid factor, and some people test

positive for rheumatoid factor, yet never develop the disease.

Rheumatoid factor also can be positive in some other diseases;

however, a positive RF in a person who has symptoms consistent with

those of rheumatoid arthritis can be useful in confirming a diagnosis.

Furthermore, high levels of rheumatoid factor are associated with

more severe rheumatoid arthritis.

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Anti-CCP antibodies:

This blood test detects antibodies to cyclic citrullinated peptide (anti-

CCP). This test is positive in most people with rheumatoid arthritis and

can even be positive years before rheumatoid arthritis symptoms

develop. When used with the RF, this test’s results are very useful in

confirming a rheumatoid arthritis diagnosis.

Others:

Other common laboratory tests include a white blood cell count, a

blood test for anemia, which is common in rheumatoid arthritis; the

erythrocyte sedimentation rate (often called the sed rate), which

measures inflammation in the body; and C-reactive protein, another

common test for inflammation that is useful both in making a

diagnosis and monitoring disease activity and response to anti-

inflammatory therapy.

X-Rays

X-Rays are used to determine the degree of joint destruction. They are not

useful in the early stages of rheumatoid arthritis before bone damage is

evident; however, they may be used to rule out other causes of joint pain.

They may also be used later to monitor the progression of the disease.

Treatment Of Rheumatoid Arthritis

Medical providers use a variety of approaches to treat rheumatoid arthritis.

These are used in different combinations and at different times during the

course of the disease and are chosen according to the patient’s individual

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situation; however, no matter what treatment the provider and patient

choose, the goals are the same: to relieve pain, reduce inflammation, slow

down or stop joint damage, and improve the patient’s sense of well-being

and ability to function.4

Good communication between the patient and their provider is necessary for

effective treatment. Talking to the provider can help ensure that exercise

and pain management programs are provided as needed, and that drugs are

prescribed appropriately. Effective communication with providers can also

help people who are making decisions about surgery.4

Goals of Treatment

Relieve pain

Reduce inflammation

Slow down or stop joint damage

Improve a person’s sense of wellbeing and ability to function.

Current Treatment Approaches

Lifestyle

Medications

Surgery

Routine monitoring and ongoing care.

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Health Behavior Changes

Certain activities can help improve a person’s ability to function

independently and maintain a positive outlook.4

Rest and Exercise

People with rheumatoid arthritis need a good balance between rest and

exercise, with more rest when the disease is active and more exercise when

it is not. Rest helps to reduce active joint inflammation and pain and to fight

fatigue. The length of time for rest will vary from person to person, but in

general, shorter rest breaks every now and then are more helpful than long

times spent in bed.

Exercise is important for maintaining healthy and strong muscles, preserving

joint mobility, and maintaining flexibility. Exercise can also help people sleep

well, reduce pain, maintain a positive attitude, and manage weight. Exercise

programs should take into account the patient’s physical abilities,

limitations, and changing needs.

Joint Care

Some people find using a splint for a short time around a painful joint

reduces pain and swelling by supporting the joint and letting it rest. Splints

are used mostly on wrists and hands, but also on ankles and feet. A medical

provider or a physical (PT) or occupational therapist (OT) can help a person

choose a splint and make sure it fits properly. Other ways to reduce stress

on joints include self-help devices (for example, zipper pullers, long-handled

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shoe horns); devices to help with getting on and off chairs, toilet seats, and

beds; and changes in the ways that a person carries out daily activities.

Stress Reduction

People with rheumatoid arthritis face emotional challenges as well as

physical ones. The emotions they feel because of the disease — fear, anger,

and frustration — combined with any pain and physical limitations can

increase their stress level. Although there is no evidence that stress plays a

role in causing rheumatoid arthritis, it can make living with the disease

difficult at times. Stress also may affect the amount of pain a person feels.

There are a number of successful techniques for coping with stress. Regular

rest periods can help, as can relaxation, distraction, or visualization

exercises. Exercise programs, participation in support groups, and good

communication with the health care team are other ways to reduce stress.

Healthful Diet

With the exception of several specific types of oils, there is no scientific

evidence that any specific food or nutrient helps or harms people with

rheumatoid arthritis. However, an overall nutritious diet with enough — but

not an excess of — calories, protein, and calcium is important.

Some people may need to be careful about drinking alcoholic beverages

because of the medications they take for rheumatoid arthritis. Those taking

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methotrexate may need to avoid alcohol altogether because one of the most

serious long-term side effects of methotrexate is liver damage.

Climate

Some people notice that their arthritis gets worse when there is a sudden

change in the weather. However, there is no evidence that a specific climate

can prevent or reduce the effects of rheumatoid arthritis. Moving to a new

place with a different climate usually does not make a long-term difference

in a person’s rheumatoid arthritis.

Medications

Most people who have rheumatoid arthritis take medications. Many drugs

used to treat rheumatoid arthritis have potentially serious side effects.

Medical providers typically prescribe medications with the fewest side effects

first. Patients may need stronger drugs or a combination of drugs if the

disease progresses. 1

NSAIDs

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 ringing in the ears, stomach irritation,

heart problems, and liver and kidney damage.

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Steroids

Corticosteroid medications, such as prednisone, reduce inflammation and

pain and slow joint damage. Side effects may include thinning of bones,

weight gain and diabetes. Medical providers often prescribe a corticosteroid

to relieve acute symptoms, with the goal of gradually tapering off the

medication.

Disease-modifying antirheumatic drugs (DMARDs)

These drugs can slow the progression of rheumatoid arthritis and save the

joints and other tissues from permanent damage. Common DMARDs include

methotrexate (Trexall), leflunomide (Arava), hydroxychloroquine (Plaquenil)

and sulfasalazine (Azulfidine).

Side effects vary but may include liver damage, bone marrow suppression

and severe lung infections.

Biologic agents

Also known as biologic response modifiers, this newer class of DMARDs

includes abatacept (Orencia), adalimumab (Humira), anakinra (Kineret),

certolizumab (Cimzia), etanercept (Enbrel), golimumab (Simponi), infliximab

(Remicade), rituximab (Rituxan) and tocilizumab (Actemra). Tofacitinib

(Xeljanz), a new, synthetic DMARD, is also available in the U.S.

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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.

Biologic DMARDs are usually most effective when paired with a nonbiologic

DMARD, such as methotrexate.

Surgery

Several types of surgery are available to patients with severe joint damage.

The primary purpose of these procedures is to reduce pain, improve the

affected joint’s function, and improve the patient’s ability to perform daily

activities. Surgery is not for everyone, however, and the decision should be

made only after careful consideration by the patient and their provider.

Together they should discuss the patient’s overall health, the condition of

the joint or tendon that will be operated on, and the reason for, as well as

the risks and benefits of, the surgical procedure. Cost may be another

factor.4 Following are some of the more common surgeries performed for

rheumatoid arthritis:4

Joint replacement

Joint replacement involves removing all or part of a damaged joint and

replacing it with synthetic components. Joint replacement is available for a

number of different joints, but the most commonly replaced joints are the

hips and knees. Joint replacement surgery is done primarily to relieve pain

and improve or preserve function. Although joint replacement traditionally

involved a large incision and long recovery, new minimally invasive surgeries

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are making it possible to do some forms of joint replacement with smaller

incisions and a shorter, easier recovery. Artificial joints are not always

permanent and may eventually have to be replaced. This may be an

important consideration for young people.

Arthrodesis (fusion)

Arthrodesis is a surgical procedure that involves removing the joint and

fusing the bones into one immobile unit, often using bone grafts from the

person’s own pelvis. Although the procedure limits movement, it can be

useful for increasing stability and relieving pain in affected joints. The most

commonly fused joints are the ankles and wrists and joints of the fingers

and toes.

Tendon reconstruction

Rheumatoid arthritis can damage and even rupture tendons, the tissues that

attach muscle to bone. This surgery, which is used most frequently on the

hands, reconstructs the damaged tendon by attaching an intact tendon to it.

This procedure can help to restore hand function, especially if the tendon is

completely ruptured.

Synovectomy

In this surgery, the doctor actually removes the inflamed synovial tissue.

Synovectomy by itself is seldom performed now because not all of the tissue

can be removed, and it eventually grows back. Synovectomy is done as part

of reconstructive surgery, especially tendon reconstruction.

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Routine Monitoring and Ongoing Care

Regular medical care is important to monitor the course of the disease,

determine the effectiveness and any negative effects of medications, and

change therapies as needed. Monitoring typically includes regular visits to

the medical provider. It also may include blood, urine, and other laboratory

tests and X-rays.

People with rheumatoid arthritis may want to discuss preventing

osteoporosis with their doctors as part of their long-term, ongoing care.

Osteoporosis is a condition in which bones become weakened and fragile.

Having rheumatoid arthritis increases the risk of developing osteoporosis for

both men and women, particularly if a person takes corticosteroids. Such

patients may want to discuss with their provider the potential benefits of

calcium and vitamin D supplements or other treatments for osteoporosis.4

Alternative and Complementary Therapies

Special diets, vitamin supplements, and other alternative approaches have

been suggested for treating rheumatoid arthritis.

Research shows that some of these, for example, fish oil supplements, may

help reduce arthritis inflammation. For most, however, controlled scientific

studies either have not been conducted on them or have found no definite

benefit to these therapies. As with any therapy, patients should discuss the

benefits and drawbacks with their medical providers before beginning an

alternative or new type of therapy. If the provider feels the approach has

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value and will not be harmful, it can be incorporated into a person’s

treatment plan. However, it is important not to neglect regular health care.4

Rheumatoid Arthritis Research

Over the last several decades, research has greatly increased the

understanding of the immune system, genetics, and biology. This research is

now showing results in several areas important to rheumatoid arthritis.

Scientists are thinking about rheumatoid arthritis in exciting ways that were

not possible even ten years ago.

The National Institutes of Health (NIH) funds a wide variety of medical

research at its headquarters in Bethesda, Maryland, and at universities and

medical centers across the United States. One of the NIH institutes, the

National Institute of Arthritis and Musculoskeletal and Skin Diseases

(NIAMS), is a major supporter of research and research training in

rheumatoid arthritis through grants to individual scientists, Specialized

Centers of Research, Multidisciplinary Clinical Research Centers, and

Multipurpose Arthritis and Musculoskeletal Diseases Centers.4 The following

are examples of research in rheumatoid arthritis supported by the Federal

Government through the NIAMS and other parts of NIH.

Genetics

Researchers are studying genetic factors that predispose some people to

developing rheumatoid arthritis, as well as factors connected with disease

severity. Over the past decade, NIAMS-supported research in this area has

led to several important genetic discoveries including the following:

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Variation in a gene controlling T-cell activation doubles RA risk

The variation — called a single nucleotide polymorphism (SNP) — is located

within a gene that codes for PTPN22, an enzyme known to be involved in

controlling the activation of white blood cells called T cells that play an

important role in the body’s immune system. Where the SNP is present in

one or both copies of a person’s genes for this enzyme, T cells and other

immune cells respond too vigorously, causing increased inflammation and

tissue damage. Scientists say the implications of this finding go beyond a

better understanding of rheumatoid arthritis risk; it may also help explain

why different autoimmune diseases tend to run in families. Other studies

have the same SNP with type-1 diabetes and juvenile arthritis.

Genetic variation increases risk of rheumatoid arthritis and lupus

Separate research found a SNP in a large segment of the STAT4 gene

increases the risk of both rheumatoid arthritis and another autoimmune

disease, systemic lupus erythematosus (lupus). The STAT4 gene encodes a

protein that plays an important role in the regulation and activation of

certain cells of the immune system.

One variant form of the gene was present at a significantly higher frequency

in rheumatoid arthritis patient samples from the North American Rheumatoid

Arthritis Consortium (NARAC) — a consortium formed to collect, analyze,

and make available clinical and genetic data on 1,000 sibling pairs with

rheumatoid arthritis — as compared with controls. Scientists replicated that

result in two independent collections of rheumatoid arthritis cases and

controls.

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Twin study shows genetic differences in rheumatoid arthritis

Because identical twins have the exact same genes at conception, scientists

believe that changes in the genes after the genome is constructed may

account for why one of a twin pair can have rheumatoid arthritis while the

other does not. To better understand what those changes might be,

scientists have used a sophisticated technique called microarray to examine

the expression of more than 20,000 genes at a time in 11 pairs of disease-

discordant identical twins (meaning one twin had the disease, the other did

not).

The examination led to the detection of differences in expression of 827

genes. The most significantly overexpressed gene was laeverin, an enzyme

that breaks down certain types of proteins; second was 11ß-hydroxysteroid

dehydrogenase type 2 (11ß-HSD2), important in a steroid pathway linked to

inflammation and bone erosion; and, third was cysteine-rich angiogenic

inducer 61 (Cyr61), which is known for its role in angiogenesis, the

formation of new blood vessels. The scientists say their findings are exciting

because they offer new insights into the mechanisms by which rheumatoid

arthritis is mediated.

Genetic region associated with rheumatoid arthritis risk

Using the relatively new genome-wide association approach, which makes it

possible to analyze between 300,000 and 500,000 single nucleotide

polymorphisms, researchers in the United States and Sweden identified a

region of chromosome 9 containing two genes relevant to chronic

inflammation: TRAF1 (encoding tumor necrosis factor receptor-associated

factor 1) and C5 (encoding complement component 5). Scientists say it is

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not yet known how the genes in the TRAF1-C5 region influence rheumatoid

arthritis risk, but they hope that by learning more about the genes and their

role in the disease, they may find clues to influencing treatment of the

disease.

Rare gene variants associated with rheumatoid arthritis

Another genome-wide association scan was used to determine that rare

variants of a gene that encodes the enzyme sialic acid acetylesterase (SIAE)

are associated with several autoimmune diseases, especially rheumatoid

arthritis and type 1 diabetes. This discovery suggests that SIAE plays an

important role in autoimmunity. They also highlight the promise that rare

variant analysis holds for unraveling complex, multigene diseases.

New Therapies

Researchers continue to identify molecules that appear to play a role in

rheumatoid arthritis and thus are potential targets for new treatments. The

path between identifying the molecule and developing a drug that targets it

is long and difficult. Fortunately, this path has been successfully negotiated

and new drugs have emerged that successfully reduce symptoms and

damage in rheumatoid arthrtis. Researchers continue to identify more

candidate drugs, with hopes that these will have fewer side effects or will

cure more patients.4

Tofacitinib, approved for the treatment of rheumatoid arthritis in 2012, is

from a new class of drugs developed to target Janus kinases. One member

of this family, JAK3, was discovered in the early 1990s by a National

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Institutes of Health laboratory in the National Institute of Arthritis and

Musculoskeletal and Skin Diseases (NIAMS). Subsequent studies carried out

at the National Heart, Lung, and Blood Institute (NHLBI), in collaboration

with the NIAMS, showed that genetic defects in JAK3 can cause severe

combined immunodeficiency. This discovery led to the idea that drugs

blocking Janus kinases would suppress the immune system and might be

protective against the damaging inflammation of rheumatoid arthritis and

certain other autoimmune diseases.4

Summary

In summary, rheumatoid arthritis is an autoimmune disorder that affects the

joints causing pain and possible deformity. This course has discussed

rheumatoid arthritis as a disease process, including the symptoms, causes,

risk factors, diagnosis and treatment as well as some current research in the

area of rheumatoid arthritis.

Researchers continue to investigate other factors that may play a role, such

as infectious agents (bacteria or viruses) that act as triggers in the

development of rheumatoid arthritis, the role of hormones in women,

obesity, and how stressful events of physical or emotional trauma lead to

diseases such as rheumatoid arthritis. Research focused on the role of

environmental factors is another major area that influences an improved

understanding of the effects of exposure to certain smoke, chemicals and

pollutants. While not all of the answers are known, there is clear agreement

that rheumatoid arthritis develops as a result of an interaction of many

factors. Over the last several decades, research has greatly increased the

understanding of the immune system, genetics, and biology. This research is

26


now showing results in several areas important to rheumatoid arthritis.

Scientists are thinking about rheumatoid arthritis in exciting ways that were

not possible even ten years ago.

The National Institute of Arthritis and Musculoskeletal and Skin Diseases

(NIAMS), is a major supporter of research and research training in

rheumatoid arthritis. Research in rheumatoid arthritis supported through

NIAMS researchers involve genetic factors that predispose some people to

developing rheumatoid arthritis, as well as factors connected with disease

severity that support the discovery of new treatment. New drugs have

emerged that successfully reduce the symptoms and damage that occurs in

patients with rheumatoid arthritis. Researchers continue to identify newer

candidate drugs with improved outcomes.

Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment

of Knowledge Questions after reading the article, and providing feedback in the online course evaluation.

Completing the study questions is optional and is NOT a course

requirement.

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1. Rheumatoid arthritis is an autoimmune disease

a. that is more common in men than women.

b. commonly known as “wear and tear” arthritis.

c. in which the body’s immune system mistakenly attacks the joints.

d. which affects the cartilage but not the lining of the joints.

2. True or False: There is no evidence that a specific climate can

prevent or reduce the effects of rheumatoid arthritis.

a. True.

b. False.

3. Rheumatoid factor (RF) is an antibody that

a. is present in the blood of all patients with rheumatoid arthritis.

b. if a person tests positive for it, he or she will develop the disease

rheumatoid arthritis.

c. is present in people with rheumatoid arthritis but no other disease.

d. is present eventually in the blood of most people with rheumatoid

arthritis.

4. ______________ is a surgical procedure that involves removing

the joint and fusing the bones into one immobile unit.

a. Synovectomy

b. Arthrodesis

c. PTPN22

d. Microarray

28


5. Osteoporosis is a condition

a. that may be avoided by patients who take corticosteroids.

b. in which bones become weakened and fragile.

c. that develops only in women who have pre-existing rheumatoid

arthritis.

d. caused by stress.

Correct Answers:

1. c

2. a

3. d

4. b

5. b

29


References Section

The reference section of in-text citations include published works intended as

helpful material for further reading. Unpublished works and personal

communications are not included in this section, although may appear within

the study text.

1. Rheumatoid arthritis (2014). Mayo Foundation for Medical Education

and Research. Retrieved June 22, 2015 from www.mayoclinic.org

2. Rheumatoid arthritis (2015). Arthritis Foundation. Retrieved June 28,

2015 from www.arthritis.org

3. Maini, R.N. & Venables, P.J.W. Clinical manifestations of rheumatoid

arthritis in Romain, P.L. (Ed.), UpToDate. Waltham, Mass.: and,

UpToDate. Retrieved June 28, 2015 from www.uptodate.com ; Maini,

R.N. & Venables, P.J.W. Diagnosis and differential diagnosis of

rheumatoid arthritis in Romain, P.L. (Ed.), UpToDate. Waltham, Mass.:

UpToDate. Retrieved June 28, 2015 from www.uptodate.com

4. Rheumatoid arthritis (2014). National Institutes of Health (NIH):

National Institute of Arthritis and Musculoskeletal and Skin Diseases.

Retrieved June 28, 2015 from www.niams.nih.gov

Additional Resources:

Arthritis (2015). Centers for Disease Control and Prevention. Retrieved June

21, 2015 from www.cdc.gov

http://www.mayoclinic.org/

http://www.arthritis.org/

http://www.uptodate.com/

http://www.uptodate.com/

http://www.niams.nih.gov/

http://www.cdc.gov/

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