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There is no known cure for rheumatoid arthritis (RA). For a few people, the disease has mild symptoms that never get worse. For others, it progressively affects and deforms the joints, causing pain and reducing mobility, and sometimes it affects other parts of the body such as the blood vessels, heart or eyes.

Once diagnosed, RA usually requires lifelong treatment and monitoring. Treatment begins with educating the patient about the disease and risk of joint damage and loss of function. No single treatment plan is effective for all RA patients. Initial treatment may concentrate on alleviating pain, preventing loss of function and slowing the degeneration of joints. Early, aggressive medical treatment can slow the progress of the disease.

Regular monitoring of RA and its effects on other systems is essential. RA patients should have their condition assessed at regular physical examinations every six months. Osteoporosis involves the bones becoming thin, brittle and more prone to fracture, causing pain.RA patients are more likely to develop certain other medical conditions, including coronary artery disease and osteoporosis. Adequate nutrition and attention to diet may minimize this likelihood.

Exercise and loss of excess weight may help RA by relieving excess strain on the joints and maintaining muscle tone around the joints. People with RA should consult their physician before beginning or changing any weight loss or exercise program. A home exercise regime may be part of a physical therapy program that addresses strength, range of motion, flexibility and endurance. Occupational therapy may also help RA patients identify their abilities and the best ways to use their joints.

Many lifestyle factors can be adjusted for RA. Adequate amounts of sleep and resting when experiencing fatigue are important. The National Institutes of Health recommends that RA patients account for their flare-ups and take shorter rest breaks sporadically during activity, rather than complete bed rest. Rest can reduce inflammation from RA, whereas exercise relieves stiffness.

Home life can be adjusted with special fasteners and grips for weakened hands and items such as grab bars in showers and raised toilet seats. Assistive devices that support joints can reduce the stress on them. These include braces, splints, canes, walkers, and shoes with inserts.

The chronic nature of RA and its symptom flare-ups can frustrate many patients. Relaxation methods and stress reduction techniques (e.g., yoga) may help some people cope with the disease. Biofeedback helps some patients increase control over muscle tension and certain body functions.

Some people respond to heat treatment (thermotherapy) or cold treatment (cryotherapy). A physician or physical therapist can indicate which kind of therapy should be used. Heat relieves pain and stiffness. Cold relieves pain and may reduce swelling. Either may incorporate water therapy (hydrotherapy). People with some medical conditions, such as poor circulation, should not use cryotherapy, and conditions such as impaired sensation may rule out thermotherapy.

Some patients may consider complementary and alternative therapies to relieve pain associated with RA. For example, many people take the nutritional supplements glucosamine and chondroitin for arthritis pain relief and to strengthen cartilage. Studies have found that these two supplements may be helpful with some cases of osteoarthritis, but scientific evidence of their usefulness with RA is lacking.

Topical treatments and supplements may also alleviate RA pain. Capsaicin cream has the same active substance as hot chili pepper and may lessen the pain for some patients. Patients should consult with their physician before using any alternative therapy.

RA generally responds well to early, aggressive medical intervention. A range of prescription and nonprescription medications are used to alleviate RA pain and inflammation and to slow the disease’s progress.

Some of the medications used to treat RA include:

* Acetaminophen. May relieve pain associated with RA but does not affect inflammation.

* Nonsteroidal anti-inflammatory drugs (NSAIDs). These drugs are used to reduce pain and inflammation but do not stop RA’s progression. They come in prescription and nonprescription forms. Some may affect renal or gastrointestinal function.

Among the prescription NSAIDs are a group called COX-2 inhibitors. However, several of these drugs have potentially serious side effects, such as increased risk of heart attack, stroke and gastrointestinal bleeding. Several COX-2 inhibitors were withdrawn from sale, but others remain on the market with more specific warning labels.

* Disease-modifying antirheumatic drugs (DMARDs). This category includes many types of drugs that suppress the overactive immune response of RA and slow its progress. Prompt, aggressive use of DMARDs may be indicated for people with high rheumatoid factor (RF) levels in their blood or RA involvement in other systems.

DMARDs work long term and can take several months to produce results. All DMARDs have some side effects, including gastrointestinal problems, some serious liver or kidney complications and repressed immune responses to infection. Studies show that DMARDs alone tend to be less effective over time. Some are used in combination with NSAIDs or other drug therapies.

* Biologic response modifiers (BRMs). Drugs that slow progression of the disease and inhibit the production of the proteins called cytokines, which contribute to inflammation. BRMs block proteins that cause inflammation, such as tumor necrosis factor (TNF) or interleukin-1. Many RA patients respond favorably and achieve lengthy remissions when BRMs are combined with DMARD treatment. The BRMs known as TNF inhibitors may reduce the increased risk of cardiovascular problems in RA patients, according to some research.

Some studies have suggested that some BRMs may increase the risk of lymphoma and other cancers, but recent data from the U.S. National Data Bank of Rheumatic Disease indicate that risk of cancer is not increased, with the exception of skin cancer.

* Corticosteroids. May be given as pills or injections into the affected joint. These anti-inflammatories have some benefits for RA patients, but those may diminish in time. When corticosteroids are administered with DMARDs, they enhance the effectiveness of DMARDs. Physicians monitor corticosteroid use closely because it can cause bone loss, which is more likely for RA patients, regardless of treatment. Any bone loss can contribute to osteoporosis and fractures. Other possible complications of long-term use of corticosteroids include diabetes, glaucoma and cataracts.

Combination therapy, such as taking DMARDs and a corticosteroid or taking a DMARD and a BRM, may be more effective than monotherapy. Selection of medication requires a preassessment of the prognosis. Usually prognosis is poor if there is onset of RA at early age, high titers of rheumatoid factor, elevated sedimentation rate and swelling of more than 20 joints. All medications have some side effects, which may vary from patient to patient. Physicians monitor their patients and may adapt the medications depending on response and side effects.

Another medical treatment is immunoadsorption (Prosorba column). In this process, the patient’s blood is removed through a tube and filtered through a small device that treats the antibodies from the blood and then sends the blood back to the body. The procedure is performed weekly for 12 weeks and takes two to three hours at a time.

Immunoadsorption is usually reserved for people with severe RA who have not responded to drug therapies. Studies have shown the treatment has slowed RA progress in one-third to one-half of people treated. Side effects may include an increase of RA joint pain during or after the procedure, infections related to the use of catheters, anemia, fever and a drop in blood pressure. The procedure is not recommended for patients with certain heart problems, including those taking ACE inhibitors, a class of blood pressure drugs.

Some physicians may recommend transcutaneous electrical nerve stimulation (TENS), a form of electrical therapy in which a device delivers mild electric current to the nerves to interfere with transmission of pain signals. Several studies have had conflicting results about its effect on RA pain. It has no effect on the inflammation.

Several types of surgery can correct damage to joints affected by RA. Joint surgeries range from minor procedures to total joint replacements. They are commonly performed on the knees, hands, hips and parts of the spine.

Some of the most common surgeries for RA include:

* Synovectomy. The synovial lining of a joint can be removed, either by open surgery or arthroscopy.

* Arthroscopy. A minimally invasive procedure where a lighted tube is inserted into a joint to examine tissue. Instruments attached to the tube can remove cartilage, fluid or bone fragments.

* Osteotomy. Surgery that reshapes deformed bones by removing damaged tissue and torn or loose fragments. It is most commonly performed on the knee.

* Arthrodesis. Surgery to fuse bones in a joint. It can reduce pain, but the joint will no longer move.

* Arthroplasty. Open surgery on damaged joints may also be performed to repair or replace all or part of a joint. When a joint is completely degenerated, surgeons can replace the entire joint. This is most commonly performed for the knees and hips but can also be performed in fingers, shoulders and other joints.

* Spinal surgery. Several spinal operations may be performed for RA patients, to realign the spine, ease pressure on compressed nerves or fuse the vertebrae.

In most cases, there is no known way to prevent RA. However, early intervention can limit the progression of the disease. The average disability levels experienced by RA patients have declined by 40 percent from 1977 to 1998, according to an analysis sponsored by the National Institute of Arthritis and Musculoskeletal Diseases. Disability is likely to decline further because of medications introduced since those data were compiled.

People may be able to help prevent RA by not smoking. Scientists have found that smokers have increased risk of RA if they have antibodies against the amino acid citrulline, especially if they carry two copies of a gene called HLA-DR shared epitope (SE) genes. Recent research has also found an increased risk of RA in female smokers who have no known genetic risk factors for the disease. Patients who have RA also should avoid smoking to reduce their cardiac risks.

Some recent research suggests that regular, moderate consumption of alcohol might reduce the risk of developing RA, but further study is needed.

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