Rheumatoid arthritis (RA) is a chronic and debilitating disease that is characterized primarily by joint pain and deformities, among other systemic manifestations. It occurs when the body’s immune system erroneously targets its cells, resulting in inflammation within joint spaces and subsequent destruction of articular tissues. The disease mostly affects multiple small joints, especially in the hands and wrists, with specific joints affected on both limbs. This is referred to as symmetric polyarthritis and causes pain and stiffness that becomes worse on rest. This progresses to produce several characteristic joint deformities. Treatment of the disease is aimed at the prevention of progression of deformities, as well as pain reduction and improvement of overall personal functioning.
Current treatment guidelines are framed to enable health practitioners to diagnose the disease early and prevent the development of permanent complications. This paper intends to review existing epidemiology as well as national standards for screening, surveillance, and diagnosis, using this information to propose useful primary, secondary, and tertiary interventions needed to manage the disease better from a community health perspective.
Background of the Disease
RA is defined by chronic systemic inflammation without a prominently identifiable cause. The disease characteristically presents with symmetric polyarthritis, especially of the small joints of the hands and wrists (Smith & Diamond, 2018). Other synovial joints may also be affected, such as those in the feet and ankle, as well as the knee and the elbow. RA may also affect other extra-articular tissues: the lungs, the eyes, the skin, and the heart. The disease progresses gradually, causing severe pain, stiffness, and eventually permanent deformity of joints, which profoundly limits the affected person’s ability to conduct activities of daily living.
The pathophysiology of RA is poorly understood, but the current scientific consensus is that the disease is caused by an improper activation of the immune system, which produces autoantibodies against self-antigens within the joints and other tissues. Various etiological factors have been associated with this process. Genetic susceptibility, such as carrying specific HLA-DR gene epitopes, accounts for about 50% of the overall RA risk (Smith & Diamond, 2018). Infectious agents such as Epstein-Barr and rubella viruses, as well as Mycoplasma, have also been implicated in the development of the disease. A high proportion of middle age women affected by the disease suggests that there may be a link between hormonal changes, especially during menopause. Environmental, socioeconomic, and lifestyle factors, such as tobacco and alcohol use, may also play direct and indirect roles in disease development and progression.
RA commonly starts in middle age and affects 0.5% to 1% of people worldwide; 5 to 50 people per 100,000 are newly diagnosed with the condition every year. It is estimated that 1.3 million adult Americans are afflicted by the disease (Freeman, 2018a). Detailed information on the epidemiology of RA within the city of Miami, or the state of Florida, is currently unavailable. The statistics in Table 1 below compare the age-adjusted prevalence of all types of arthritis among adults within Florida to similar national statistics in 2016 (Centers for Disease Control and Prevention, 2018):
Table 1. Comparison of prevalence of all types of arthritis.
|Region||Overall Prevalence of arthritis||Prevalence of Arthritis in Females||Prevalence of Arthritis in Males|
RA manifests in middle age and tends to affect women up to 3 times more than men (Smith & Diamond, 2018). The disease also shows varying prevalence in different racial and ethnic groups; Native Americans show higher prevalence rates, while people of Afro-Caribbean descent tend to be less affected. The disease shows a familial inheritance pattern due to its associations with the HLA genes, and first-degree relatives of people with RA are at 2 to 3 times more likely to develop RA themselves (Smith & Diamond, 2018). However, the disease concordance between monozygotic twins is estimated to be around 15-20%, meaning that non-genetic factors are also crucial in the development of the disease (Smith & Diamond, 2018). RA also shows patterns of higher risk among women who have had a history of complications during pregnancy, such as hyperemesis gravidarum, gestational hypertension, and pre-eclampsia. This phenomenon has been attributed to two different possible etiologies: reduction of adaptability of the immune system in women susceptible to RA, and microchimerism, which refers to the presence of fetal cells within the mother’s circulation.
RA is a long-term ailment that causes chronic pain and permanent deformities and reduces the range of motion of joints and limbs. This leads to severe limitations of occupational activities and activities of daily living for its sufferers, creating profound physical, psychological, and socioeconomic effects. It may also occur concomitantly with other autoimmune and noncommunicable diseases, multiplying the impact on the person’s quality of life. The illness and its associations may, therefore, lead to loss of personal and family income, increased medical costs, increased reliance on others for even the most straightforward private functions, and significant strain on the individual’s psychological state. The most significant financial impact is the health expenses. The medication can cost up to 30,000 dollars each year (Freeman, 2018b). The cost is expected to rise as newer, effective but more costly drugs are used by these individuals. The reliance on other people and inability to perform previous activities affects their social circles and may cause them to become withdrawn.
Disease Diagnosis, Screening and Surveillance
The diagnosis of RA is achieved through clinical history taking and examination, laboratory investigations, and medical imaging of the affected areas. The typical presentation of RA is symmetrical pain, swelling, and stiffness of multiple small articular surfaces of the extremities. Deformities develop over time with the progression of the disease and are caused by nonreducible extension and flexion of these joints. Such deformities include boutonniere and swan-neck deformities of the interphalangeal joints, ulnar deviation of the fingers due to metacarpophalangeal joint deformities, and rheumatoid nodules found at the elbow and other dependent areas (Smith & Diamond, 2018). The disease may also affect other joints such as the knee, hip, and cervical spine, as well as extra-articular tissues, generating systemic manifestations such as cardiovascular disease, renal impairment, nerve entrapment, anemia of chronic disease, and keratoconjunctivitis.
The deformities and other effects of RA are permanent and cause substantial disability. It is therefore essential that the disease is diagnosed early before these effects have taken root. With this goal in mind, the American College of Rheumatology (ACR) and the European League against Rheumatism (EULAR) came together to develop comprehensive classification criteria for the screening and diagnosis of RA (Aletaha et al., 2010). The criteria were adopted in 2010, improving on previous ACR criteria developed in 1987 by allowing for early identification of disease and prompt intervention in people with inactive or subclinical infection, as well as those already presenting with typical manifestations. These new criteria assess the level of joint involvement, duration of symptoms, presence of autoantibodies, and acute phase response to grade the likelihood of being clinically diagnosed with RA.
The 2010 ACR/EULAR Classification Criteria are targeted at patients who have clinical synovitis in at least one joint, which cannot be attributed to another disease, such as lupus, gout, or septic arthritis. The criteria are scored out of 10, with a score of 6 or more suggesting a clinical diagnosis of RA. Table 2 below explains the scoring of the criteria:
Table 2. 2010 ACR/EULAR Classification Criteria for RA. (Aletaha et al., 2010).
|One large joint||0|
|Two to 10 large joints||1|
|One to three small joints (with/without the involvement of large joints)||2|
|Four to ten small joints (with/without the involvement of large joints)||3|
|>10 large joints (at least one small joint)||5|
|Serology (at least one test result is needed for classification)|
|Negative RF andnegative ACPA||0|
|Low positive RF orlow positive ACPA||2|
|High positive RF orhigh positive ACPA||3|
|Acute phase reactants (at least one test result is needed for classification)|
|Normal CRP and normal ESR||0|
|Abnormal CRP or abnormal ESR||1|
|Duration of symptoms|
|< six weeks||0|
|≥ six weeks||1|
The 2010 ACR/EULAR criteria are considered the national standard for screening, diagnosis, and classification of severity of RA. Several studies have been conducted to assess the value of the criteria in the correct diagnosis of RA, which have estimated their sensitivity and specificity to be 90% and 54% respectively when compared to expert opinion (Radner, Neogi, Smolen, & Aletaha, 2014). The 2010 criteria show a higher sensitivity for RA than the 1987 criteria, meaning that more patients with the disease can be accurately diagnosed using the 2010 criteria (Radner et al., 2014). However, they also show a lower specificity than the 1987 criteria, leading to the wrong diagnosis of more patients with RA. This suggests that, while the 2010 criteria are more valuable in diagnosing more patients with the disease early, they tend to over-diagnose arthritis that may be attributed to other causes. One must, therefore, be careful when applying them to patient screening and diagnosis, by relating the conclusions thus generated to the clinical situation of the patient and other medical investigation parameters.
A screening test used for rheumatoid arthritis involves the measurement of the levels of anti-cyclic citrullinated peptide (ACCP). It has a sensitivity of 74.3 percent, a specificity of 92.8 percent, and a positive predictive value of 83.4 percent (Soroush, Mahmoudi, & Akhlaghi, 2016). The results of these tests are used in conjunction with the 2010 criteria as it assigns value for the positive test. This test is based on the 2010 ACR/EULAR criteria. The test costs around $55.
Various tools have been developed for the surveillance of disease activity and progression. The most commonly used indicator is the Disease Activity Score of 28 joints (DAS28), which monitors the current tenderness and swelling of the joints of the hands, wrists, elbows, shoulders, and knees, as well as improvement on treatment. It also incorporates the ESR measurement and the subjective assessment of the patient on disease activity over the previous seven days in the calculation of the score. Use of this score in clinical practice has been shown to improve treatment and rehabilitation outcomes.
Interventions in Clinical Practice and Community Health
The approach to RA from clinical practice and community health perspectives should consider disease characteristics, available treatment modalities, and epidemiological information, to formulate effective plans and policies to reduce the individual and collective burden of disease. This can be considered in terms of primary, secondary, and tertiary interventions (Finckh & Deane, 2014). Primary interventions involve prevention of development of RA in susceptible individuals while still in the preclinical stage. Primary prevention can be achieved by reduction of known modifiable risk factors, such as tobacco smoking, inhaled pollutants like silica dust, and metabolic predispositions such as obesity. The exact role of these factors in the development of the disease is unclear, but advising people to reduce their exposure may have tangible benefits in lessening the risk of developing RA. These interventions can be measured through assessing the prevalence of people at risk to these factors.
Secondary interventions are concerned with retardation of disease progression when a diagnosis of RA has been made, but severe complications have not yet ensued. Pharmacological interventions may be needed to halt progression, through the use of disease-modifying antirheumatic drugs (DMARDs) such as hydroxychloroquine and methotrexate. This has been shown to limit progression to persistent joint inflammation, and while currently, available research evidence is limited.However, DMARDs are used as long-term therapy and cause significant side effects. Thus, a balance must be found between the benefit of preventing progression and the effects of DMARD therapy. These interventions can be measured by assessing the number of people with well-controlled RA and minimal complications.
Tertiary prevention of disease comprises efforts to reduce the impact of the established disease on quality of life. This has been the mainstay of RA treatment, as a majority of RA patients present with established disease. Tertiary prevention involves the use of DMARDs in conjunction with other interventions such as exercise, physiotherapy, occupation therapy, and cognitive behavior therapy. This intervention is measured through assessing whether patients have their complications managed properly.
RA is a chronic, debilitating disease that primarily affects the small joints of the extremities, causing symmetrical pain, stiffness, and deformities of these joints. It is a systemic inflammatory disease that may also affect large joints, as well as other tissues, organs, and organ systems. RA commonly affects middle-aged adults and shows a female preponderance. The disease affects up to 1% of the world’s population, and 1.3 million Americans have been diagnosed with RA. Diagnosis of the disease depends on clinical examination, accompanied by laboratory investigations and medical imaging. The 2010 ACR/EULAR classification criteria are useful for screening and diagnosis, targeting people with the subclinical disease as well as those with clinical manifestations. Surveillance tools such as the DAS28 score are essential in monitoring disease progress and response to treatment. Primary-, secondary-, and tertiary-level interventions are needed to manage the burden of disease from clinical practice and community health perspectives.