Download 1 Rheumatoid Arthritis Elizabeth Bolden, RN, MSN Elizabeth Boldon

1
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.
nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com
2
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.
nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com
3
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.
nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com
4
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.
nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com
5
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
nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com
6
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
7
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:
nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com
8
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
nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com
9
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.
nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com
10
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.
nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com
11
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.
nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com
12

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.

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
13
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.
nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com
14
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
nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com
15
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
nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com
16
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.
nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com
17
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.
nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com
18
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
nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com
19
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.
nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com
20
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
nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com
21
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:
nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com
22
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.
nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com
23
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
nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com
24
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
nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com
25
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
nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com
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.
nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com
27
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
nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com
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
nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com
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
nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com