Severity of rheumatoid arthritis
How do you know if you have severe RA? Lisa Emrich, an RA patient advocate, highlights some of the key points in this video:
If your RA is seriously impacting on your daily life, this can be thought of as severe. Doctors will use charts such as the American College of Rheumatologists Classification Criteria for Determining Progression in Rheumatoid Arthritis. These name four stages:
Stage 1 (Early): No X-ray changes apart from osteoporosis
Stage 2 (Moderate): Slight cartilage destruction on X-ray, some limitation of mobility, no change in joint shape, some muscle wasting, nodules may be present.
Stage 3 (Severe): Destruction of bone on X-ray, joint deformity, severe muscle wasting, nodules, no fusion of bones.
Stage 4 (Terminal): Bony fusion plus Stage 3.
These were developed some time ago, and are not always used. However, they can be helpful in guiding therapy and deciding who needs treatment with monoclonal antibodies.
Another proposed method uses these criteria:
Articular index (number of joints involved)
Erythrocyte sedimentation rate (inflammation marker)
And a third focuses on daily activities and how they affect you:
Class 1: Able to perform all usual activities
Class 2: Self-care and job activities possible, but limited social activities
Class 3: Self-care activities, but limited vocational and social activities
Class 4: Self-care, vocational, and social tasks limited
There are many others, including the Rome criteria, which you can find here: http://ww2.rheumatology.org/practice/clinical/bibliography/r.asp.
A clinical trial has found that a magnetic resonance scan (MRI) of the wrist in the early stages of RA can predict later progression of the disease. The scans were scored by radiologists for tendon inflammation, erosions of bone and bony swelling. At six years, the baseline scan scores were closely related to the six-year functional score rated by patients.
Several genes increase your risk of getting more severe RA. These include the tumour necrosis factor alpha (TNFa) and interleukin (IL) gene alterations, which code for the inflammatory proteins TNFa and IL. Other genes with influence include the chemokine receptor-5 (CCR5) gene – a deletion in this gene affects signalling molecules in inflammation – and protein tyrosine phosphatase non-receptor type 22 (PTPN22), which controls signalling pathways in lymph tissue.
The HLA-DRB1 shared epitope also has forms which can affect the severity of RA, with HLA-DRB1*04/04 seeming to be particularly severe. Finally, changes in the corticotropin-releasing hormone (CRH) gene involved in stress response and inflammation are also found in many families with RA.
A positive rheumatoid factor or anti-cyclic citrullinated antibody (anti-CCP) is associated with more severe joint damage and worsened RA (see the page on “Seronegative rheumatoid arthritis”).
Heavy smoking increases the severity of rheumatoid arthritis and causes greater joint damage, especially if you also have positive rheumatoid factor or a genetic mutation known as glutathione S-transferase (GST) M1. Studies have shown that those who smoke have poorer function, lower grip strength and greater associated lung disease.
The reasons for this increased risk are as yet unknown, but may be due to changes in the immune system or an increase in the production of rheumatoid factor. The severity of disease in RA appears to be directly related to the number of cigarettes smoked.
Ethnic groups are affected by risk factors in different ways. For example, the strongest gene associated with RA, HLA-DRB1, is associated with joint damage in European Caucasian and Asian populations, but not Greeks or Hispanic Americans. Mutations in the FcγRIIIA-158V/F gene have been shown to be a risk in both UK Caucasian and Indian/Pakistani groups.
Cognitive thinking style and coping mechanisms can influence how you deal with symptoms and also impact on pain scores. One study looked at the differences between African Americans and European Caucasians in copying styles. African Americans tended to deal with pain by praying, hoping and redefining pain, whereas European Caucasians tended to ignore pain and enhance feelings of control with coping statements.
Moderate exercise can be very helpful in RA. Some people also find following a certain diet helps. Short-term treatment of painful flare-ups may include a short course of steroids and painkillers. Try to avoid steroids for a prolonged period of time as they can increase the risk of infections such as pneumonia.
In the long term, you should be taking disease-modifying anti-rheumatic drugs. This may include triple therapy (methotrexate, sulfasalazine, prednisone). You may also need orthopaedic surgery if your joints are damaged.
To decide if your RA is in remission, doctors will use another set of criteria. These include:
Morning stiffness less than 15 min
Absence of joint pain
Absence of joint tenderness or pain on movement
No swelling in joints of tendon sheaths
ESR (erythrocyte sedimentation rate) blood test <30 mm/hour (female) or <20 mm/hour (male) If you have five of these over two months or more, your disease is in remission. References 1. Masdottir B. Smoking, rheumatoid factor isotypes and severity of rheumatoid arthritis. Rheumatology 2000; 39 (11): 1202-1205. 2. Steinbrocker O, et al. Therapeutic criteria in rheumatoid arthritis. JAMA 1949; 140: 659–62. 3. Pinals RS, et al. Preliminary criteria for clinical remission in rheumatoid arthritis. Arthritis Rheum 1981;24:1308-15. 4. Mallya R, et al. The assessment of disease activity in rheumatoid arthritis using a multivariate analysis. Rheumatology 1981; 20 (1): 14-17. 5. Hochberg MC, Chang RW, Dwosh I, Lindsey S, Pincus T, Wolfe F. The American College of Rheumatology 1991 revised criteria for the classification of global functional status in rheumatoid arthritis. Arthritis Rheum 1992;35:498-502. Written by Dr Anne Parfitt-Rogers, Medical Writer, UK