Rheumatoid Arthritis: What I Need to Know

Dr Sheila Vasoo
Senior Consultant & Rheumatologist
FRCP (Edinburgh), FAMS (Rheumatology)
Mt Elizabeth Novena Specialist Centre

What is rheumatoid arthritis? Does it affect just the joints?

Rheumatoid arthritis (RA) is the most common form of autoimmune arthritis that if left untreated can lead to complications in other organs, disability and premature death. It occurs when the immune system becomes 'faulty' and instead of protecting oneself from foreign invaders, it begins to attack one's own tissues. The target of the immune system in RA is the lining of the joint known as the synovium. Patients typically experience pain, early morning stiffness and swelling in multiple joints such as the small joints of the hands, wrists and feet. Sometimes in very active disease, there may be fever, tiredness and weight loss as well.

RA does not affect the joints alone, other organs such as the eyes, lungs, heart and nerves may be affected as well. Moreover, longstanding untreated or active inflammation can cause hardening of the arteries leading to an increased risk of cardiovascular complications such as strokes or heart attacks.

Damage occurs early and will lead to disability. Studies have shown that damage can occur as early as within 4-6 months of the onset of disease and thus early treatment is crucial.

Who is more likely to get it?

Older age, a family history of RA and female sex are associated with an increased risk of RA. Cigarette smokers current and past are twice as likely to develop RA than non-smokers if they carry certain genes. Smoking also increases the risk of other RA complications beyond the joints.

How prevalent is it in Singapore?

RA affects up to 1% of the population, commonly between 30-50 years of age and women are 3 times more likely to develop RA than men.In a recent Singapore study in 2010, RA was the 12th leading cause of overall disease burden in Singapore and the 7th leading cause of overall years lost to disability.

How does one get it?

The exact cause of RA remains unknown but studies have shown that certain genes along with environmental triggers such as smoking, gum disease and infections may activate the immune system causing it to target the joint lining (synovium).

How do you treat it?

In the past, the treatment strategy was to 'watch & wait' and treat only if the disease was very severe. However in the past 2 decades, there has been a paradigm shift in our understanding of this disease, with earlier diagnosis and treatment such that the outlook of patients with RA has dramatically improved. The availability of newer targeted therapies have revolutionized care in RA and given us rheumatologists, more options in tailoring therapies specific to our patients.

Therapy in RA must be holistic and success in getting well requires a strong partnership between the patient and the rheumatologist. Patient education, addressing lifestyle factors including diet, exercise, stress management is highly important. Medications known as DMARDS or disease-modifying anti-rheumatic drugs are the cornerstone of RA treatment. Studies have shown that DMARDs significantly reduce disease progression, delay joint damage and prevent other complications including early death. DMARDs can be divided broadly into two groups: conventional such as methotrexate which is an anchor drug in RA but works more slowly and newer targeted drugs such as biologics such as anti-TNF agents, small molecule JAK inhibitors like Xeljanz, which are generally used when patients fail to respond or cannot tolerate conventional DMARDs. These newer targeted agents are very effective in reducing symptoms quickly and also delaying or stopping disease progression.

What happens when it's not treated?

If RA is left untreated, not only will the joints be destroyed leading to permanent disability and poor quality of life but extra-articular complications such as eye, lung, heart and nerve inflammation and damage may also occur.

Case study: a tale of two cities

One of the most vivid contrasts I can share with you is a tale of two patients from two cities separated in time by 20 years. The first is a patient whom I met as a young doctor when I worked in England 20 years ago. She had severe active RA which had not only left her in a wheelchair but RA also attacked her blood vessels and nerves, a fearful condition known as rheumatoid vasculitis. Back then, treatment options were limited and apart from steroids and a few conventional DMARDs, there was not much else. She was in constant pain and chose to give up on life and was referred to the hospice for terminal care. It was heart-wrenching and I could not understand as a young doctor why there were no drugs that could help her.

Fast forward 20 years to Singapore and this time another patient with the identical complications under my care had the opportunity the first patient never had. The opportunity to start on targeted RA treatment. Over the course of several months, the inflammation was brought under control and now this patient has a new lease of life and started traveling again, no longer in pain and suffering. What a reminder that as rheumatologists, we live in exciting times, where we can witness new therapies changing the outlook for patients dramatically.

Can you share a little-known/ fun fact about rheumatoid arthritis?

Vitamin D deficiency has been linked with a high risk of developing RA in some recent studies. So take get enough Vitamin D!
The risk for heart attacks in RA is on par with diabetes!
Early diagnosis improves outcomes in RA.

My mentor Prof Graham Hughes always reminded me to listen to the patient. A recent patient I met highlighted this.....

- Dr Sheila Vasoo

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Doctor, My Joints Hurt!