Rheumatoid Arthritis - NurseCe4Less.com

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Rheumatoid Arthritis

Elizabeth Bolden, RN, MSN

2008. She has bedside neuroscience ICU.

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 nursing experience in medical neurology and the

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 nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com

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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

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Mouth: Dryness and gum irritation or infection

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

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Lungs: Inflammation and scarring that can lead to shortness of breath

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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.

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Age: Rheumatoid arthritis can occur at any age, but it most commonly begins between the ages of 40 and 60.

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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 (antiCCP). 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.

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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 antiinflammatory 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 nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com

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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

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Reduce inflammation

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Slow down or stop joint damage

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

Current Treatment Approaches 

Lifestyle

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Medications

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Surgery

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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.

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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 diseasediscordant 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


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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


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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


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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


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