There have been unbelievable improvements in the diagnoses and treatment of rheumatoid arthritis (RA) in the recent years. RA has in the past, led to joint damage and disability. But, today, there are new drugs and new ways of using those drugs, new diagnostic tools, and a new understanding of how RA affects the body that allows the doctors to reduce the symptoms and even slow down the process of joint destruction. This allows someone who develops RA today to have a very good chance of a more active and productive life.

Because of the advances of more recent years, the discovery of joint damage begins early in the course of RA. There is a consensus that if caught in a “window of opportunity”, the early stages, with the right treatment RA can be slowed down or even prevent the irreversible damage to the joints. Diagnosing the condition early and treating it aggressively from the start, is the goal of RA treatment.

The cells of the immune system mistakenly attack the body's tissues, mainly the tissues in the joints, causing pain and inflammation; this is what RA is and does. RA, if left unchecked, can eat away at the joint lining, cartilage, bones and any other structures in the joint, causing more pain and mobility will be diminished.

One in a hundred people in the world are affected by RA and it looks like it is more common in women than in men. The symptoms of RA will first appear between the ages of 30 and 40, although RA starts at any age, and people are never too young or too old to develop it.

Symptoms most common to RA are stiffness, pain, and swelling of the hands and feet. The jaw, neck, shoulders, elbows, wrists, hips, knees, and ankles can also be affected by RA. Stiffness that is worse in the morning and goes away as the day progresses is the mark of RA. There are many with RA that describe difficulty closing their hands and some who say that their feet feel like they're stepping on pebbles when they walk.

RA affects more than just the joints, meaning it is a systemic disease. There are some people with RA who have unusual tiredness or extreme fatigue, while yet some experience fevers or loss of appetite, and there are more common systems such as dryness of their eyes or mouth due to a related condition known as Sjogren syndrome. There are rare cases where individuals develop a skin rash or have trouble breathing because the RA has affected their lungs. There are also times when the eyes are inflamed and painful, and it can affect the heart. People with RA are at a higher risk of heart disease and stroke, and that is why it is important for a person to discuss with their doctors a way to reduce these effects of RA on the heart.

RA has to be diagnosed before treatment can be prescribed, and the first step in getting a diagnosis would be to see a doctor. There are some things to look for when you're shopping for a good doctor. The first would be to make sure you don't sit in the waiting room for more than 20 minutes; the second is that you understand and learn something in the short time he will be spending in the room with you. Doctors who specialize in rheumatoid arthritis are not the only ones who can diagnose your condition. Now days there are doctors who are internist, and who specialize in pain management that help in the diagnoses of RA. Your input at the doctor’s office is essential to getting an accurate diagnosis. The diagnosis is based largely on the description of the symptoms you give. Keeping a journal of your symptoms will make it easier to relay those descriptions to your doctor. Be sure you document your joint stiffness, pain, and swelling along with the times of day they occur, what you had to eat (diet can

affect RA), the weather conditions and the amount of stress you are under (believe it or not stress can play a huge role in your pain levels). Also, if you can, explain your symptoms started, when they are at their worst, and what if anything seems to improve them, this is so helpful in getting the right diagnosis. I did this for over five years and it made it so much easier to talk to the doctor.

The doctor will do a physical exam to evaluate the affected joints for signs of inflammation and any reduced range of motion, along with blood test and imaging tests to support or rule out a diagnosis of RA. The two most common blood tests used are the rheumatoid factor test and the anti-cyclic citrullinated peptide (anti-CCP) antibody test. The rheumatoid factor test screens for the antibody (or immune system protein) called rheumatoid factor (RF) which is present in the blood of RA patients. RA may be present in people with other conditions, and some people with RA do not test positive for RF, at least early on, so the RF test alone is not enough to diagnose. This is very true, I had hepC and because of that my RF was high according to my Fibro/Arthritis doctor. The anti-CCP antibody test is a newer test, which is not yet widely used for determining the RF. Those who test positive for anti-CCP antibodies have RA, and in some cases the test can be positive very early in the course of their condition. But not everyone with RA will test positive for anti-CCP antibodies, either. What does that mean? It means that those who test negative for rheumatoid factor and anti-CCP antibodies may still have rheumatoid arthritis.

There are other blood tests that can give the doctor clues about an individual's condition. The erythrocyte sedimentation rate (ESR) test and the C-reactive protein (CRP) test record general levels of inflammation in the body and can help support an RA diagnoses. Blood test for anemia is another tool for the doctor because it also can point to RA.

Imaging test are very important and doctors will order x-ray the hands and feet to check for damage to the joints, such as erosions or holes in the bones. Early on, x-rays may show no signs of damage, but they are being used as a base line with which to compare later x-rays. In some cases, when physical exams, blood tests and x-rays don't show any signs the doctor may decide to order an MRI which shows much more than the x-rays can. MRI's are more sensitive and can show damage to bones and other joint tissues earlier than an x-ray.

When diagnosing RA, your doctor must also determine how active your RA is. This helps in choosing the best treatment for you, RA patients are also usually described as having mild, moderate, or severe disease activities. Patients with mild RA have little or no impact on physical health, mental health, or ability to function. The moderate patient with RA has some impact, and severe RA has a major impact.

There are several ways to monitor the activity of a person's RA, the most commonly use is the Disease Activity Score (DAS). The DAS takes into account how well a person reports feeling on a scale of 0 – 100; the blood level of inflammation; using either the ESR or CRP test; the number of swollen joints as seen by the doctor; and the number of joints that the individual describes as tender when the doctor squeezes them. Total up your DAS score which can range on a scale of 0 – 10, with a score greater than 5.1 indicates high disease activity; a score below 3.2 indicates low disease activity; a score below 2.6 is considered clinical remission, meaning the RA is no longer active.

Another tool that can be useful is the Health Assessment Questionnaire (HAQ). This questionnaire determines a person's disease activity as a reflection of how well you function in everyday life. It will ask you about your ability to do everyday things, such as dressing yourself, open a milk carton, and turn off a faucet.

Doctors use the DAS and HAQ, and similar tools not only help to diagnosis your RA, but also monitor how RA affects an individual's life over time and to measure how well treatment is going. As your quality of life improves and RA grows less active, the HAQ score should increase and the DAS score decreases.

The goal of RA treatment is to prevent joint damage and to keep you functioning independently or to improve function if RA has already caused limitations in mobility. Reduced pain and stiffness and joint swelling, as well as reduced fatigue, are essential to keeping an active lifestyle and maintaining independent living.

RA treatment combines many different approaches that include exercise, rest, heat and cold, and some other non-drug strategies that are all important elements of treatment. A combination of drugs is the cornerstone of treatment. Medications used to treat your RA may include non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin) and naproxen (Aleve, Naprosyn), and oral corticosteroids, such as prednisone. Both NSAIS and corticosteroids can quickly reduce the pain and inflammation in the joints. Evidence is now overwhelming that adding other types of drugs early on can reduce, limit, or even prevent joint damage. These drugs are the disease-modifying anti-rheumatic drugs (DMARDs); these were once reserved for the later stages of RA, and the biologic response modifiers, or biologics, which have only become available in the last decade.

The most commonly used DMARD for RA is methotrexate (Rheumartex, Trexall). There are yet other commonly used DMARDs such as sulfasalazine (Azulfidine), leflunomide (Arava), hydroxy-chloroquine (Plaquenil). I don't know the side effects from the other drugs, but I have taken Plaquenil. After only 3 months of using it and the blood test you have to take, that blood test showed my liver enzymes to be elevated. The next step the doctor did was to draw more blood and did a test for Hep C. That test came out positive and this is the side effect of the Plaquenil. These drugs work to alter the disordered immune process that is responsible for RA. The biologics mount a more focused defense against the immune system. Biologics come in the form of a shot or intravenous infusion and include etanercept (Enbrel), infliximab (Remicade), adalinmumab (Humira), rituximab (Rituxan), and abatacept (Orencia). Enbrel, Remicade, and Humira are known as INF-blockers because they all block the action of an inflammation-causing molecule called TNF-alpha. The remaining biologics target different parts of the immune system.

There are a number of studies evaluating how well the currently available DMARD's and biologics work to prevent or at least limit joint damage when used early. There was a study published in 2005 that showed treatment with methotrexate and a biologic within the first year of onset can significantly reduce the symptoms of pain and swelling and prevent further joint damage as seen on MRI exams. A review published in 2008 found that there are several studies showing that early treatment with a combination of methotrexate and a TNF-alpha-blocker is better at reducing damage to joints than just one medicine. In yet another recent study, people who were given a combination of medicines, either two DMARD's or a DMARD and a biologic, earlier in the course of their RA had less joint damage than those who were treated with only one medicine. Some of the participants from the study were able to stop their medications over time and still remain symptom free. Researchers are still following these individuals to see whether they can continue to remain off RA medicines.

There are also other studies that looked at whether early treatment affected the quality of life. In a review of two separate studies, the researchers looked at the ability to work in people with early onset

of RA and people with longstanding RA. The results of that review was that when treated early, the
people with recent onset RA were better able to keep working than those with longstanding RA. Both studies used the HAQ to evaluate participants' physical functioning.

There was another study that looked at whether biologics can make a difference in quality of life even if they're used late rather than early in the course of RA. Researchers looked at people with severe, long time RA who taken DMARD’s but had showed no improvement, to see if a biologic would improve their quality of life. The study showed that the biologics did not reduce their everyday use of personal assistance aids such as wheelchairs, walkers, and many study participants sill needed assistance with household car and transportation. But, the participants did have decreases in morning stiffness and pain and some even saw improvement in their ability to work. This could show that not only does the biologics can help people whose joints are already damaged but that it also has an even greater effect on those who the early stages of RA.

Once you have a diagnosis, you and your team of doctors will need to come up with a treatment plan that will give you the best possible chance to prevent or at least limit the irreversible damage to your joints. There a number of factors that will decide which medications are appropriate for you and the stage of the RA. Your general state of health is another factor, because it may rule out some drugs. Yet another is the risks associated with the different drugs. Like all drugs, the RA drugs can cause side effects. You should know about these potential side effects when you are contemplating using these drug treatments for your RA. Some of the side effects of these drugs are worse than the pain from the RA. Cost is another factor if your doctor wants you to take a biologic. The cost of biologics is expensive but the cost of being disabled is higher. Talk to your doctor, he may be able to help you find a way to get the biologic if he believes you really need it. The drug companies are now helping patients to get the drugs they need. You can contact the drug companies on line or you can call them. Your doctor may have an application that you can fill out.

Once your treatment starts your doctor should monitor you closely for side effects. If your medications are giving you problems, be sure to tell your health care team so your treatment plan can be adjusted if necessary. Don't be afraid to speak your mind about the care you are receiving. There may not be a cure for RA, but at least an individualized treatment plan, with the appropriate medications, and frequent conversions with your doctor can make it more likely that you will be able to lead a healthy and productive live with RA.

Rheumatologists is a doctor who has specialized training in the management and care of individuals with arthritis and other problems of the bones, joints, and muscles. There are very few in some parts of the country, so it is a good thing if have osteoarthritis, which can be treated by an internist or family doctor. But if you feel that you need to see a rheumatologist, ask your primary care doctor to refer you to one. Another good source is the local Arthritis Foundation chapter, which should have a list of rheumatologists who practice in the area the chapter covers. Link your local chapter by going to the Foundation's Web site, http://www.arthritis.org, and type in your zip code at “Find Programs near You.” When the chapter's web page comes up, click on “Physicians” and you'll get either a list of rheumatologists or a phone number to call to get a list. If you prefer, you can call the Foundation at (800) 283-7800 to get the chapter's phone number. The Web site of the American College of Rheumatology also lists rheumatologists by location. Go to http://www.rheumatology.org and click on “Find a Rheumatologist.”

Other possible sources are your county or state medical board, your local hospital, a local medical

school (contact the Department of Medicine, which will very likely have rheumatologists on staff), and people you know who are satisfied with the care they are receiving from a particular rheumatologist.