Author: Dr. Melissa LaRusso
As a rheumatologist, I frequently see patients for joint pain and stiffness. I’m often asked, “how do I know if I have rheumatoid arthritis (RA) or osteoarthritis (OA)?”. Although RA and OA can have similar presentations, the specific symptoms can be quite different. The treatment for each disease varies, therefore, it is crucial that an accurate diagnosis is made.
Osteoarthritis is one of the most common causes of pain in middle age and elderly population. It is often referred to as the oversimplified, descriptive term, ‘wear and tear arthritis’. The changes seen in OA include destruction of cartilage, deterioration of tendons and ligaments, and a small amount of inflammation in the joint lining. A diagnosis is based on the clinical history and physical exam. X-rays and other imaging is useful to evaluate the extent of the disease.
Though there is no cure for OA, treatment is aimed at reducing pain and improving function. A 10% loss of body weight can improve pain due to OA. Physical therapy is also recommended to improve muscle strength and decrease joint pain and stiffness. Oral medications such as nonsteroidal anti-inflammatory drugs are commonly used to help alleviate pain. However, they should be used cautiously. The U.S. Food and Drug Administration strengthened its warning in July 2015 regarding the risk of heart attack and stroke. The use of topical diclofenac can help reduce the amount of NSAIDs that are ingested and mitigate the cardiovascular risk. Duloxetine is another medication approved for pain due to OA. This medication is also used for fibromyalgia, pain due to shingles, depression and anxiety. Joint injections such as corticosteroids and hyaluronic acid are also employed in the treatment of OA. One of the newer treatments for OA is platelet-rich plasma (PRP). This office procedure involves taking a sample of the patient’s blood and preparing it in a centrifuge. A portion of the sample that contains the platelets, which have many healing properties, are then injected into the joint being treated.
Surgery remains an option in severe cases that fail to respond to medical treatment for pain relief, loss of function or if there is severe damage.
Rheumatoid Arthritis is an autoimmune disease. When the immune system works properly, it protects the body from such things as bacterial and viral infections.
With an autoimmune disease, this defense mechanism becomes dysregulated and it begins to attack organs and tissues. In the case of RA, the immune system attacks the tissue that surrounds the joint, known as the synovium. RA can also attack the lungs in some cases, if left untreated. Symptoms of RA can be subtle in the early stages. Patients usually develop joint pain and stiffness, especially in the morning. It is not uncommon to develop swelling in the joints.
Your primary care doctor may refer you to a rheumatologist if she or he suspects a diagnosis of RA. An office visit will start with a detailed history to get a better understanding of when the joint pain started, what joints are involved and any other symptoms that are involved such as a rash or fever. During the physical exam, all your joints will be carefully evaluated for tenderness, warmth, swelling and range of motion. Blood tests such as Rheumatoid factor (RF), antibodies to cyclic citrullinated peptides (CCP antibody) and elevated inflammatory markers such ESR and C-RP, can help confirm a diagnosis of RA. Imaging such as x-rays, MRI and ultrasound are used to look for such features as erosions, joint space narrowing and soft tissue swelling. Once a diagnosis is made, you will be monitoring regularly for disease activity with a physical exam and assessment of your pain level as well as periodic imaging and blood tests. Vectra DA is a new, advanced blood test that gives more comprehensive look at disease activity.
Early and aggressive treatment is the goal in RA care. DMARDs, or disease modifying anti-rheumatic drugs, can slow down or stop disease progression as well as relieve symptoms. Oral DMARDs include methotrexate, sulfasalazine, Hydroxychloroquine and leflunomide. If oral DMARDs are not effective, biologic agents may be prescribed. Biologics are a powerful class of medication which are generally given with methotrexate, and are very effective in putting RA into a remission. Except for the oral medication, tofactinib (Xeljanz), the biologic agents must be given as an injection. Some examples of biologic agents include adalimumab (Humira), entanercept (Enbrel), certolizumab (Cimzia), rituximab (Rituxan), abatacept (Orencia), golimumab (Simponi), infliximab (Remicade) and anakinra (Kineret). NSAIDs or steroids may be initially prescribed or given during a flare to help decrease pain and swelling.
It’s important to realize that although RA isn’t curable, it is treatable. However, for proper treatment you will need to be followed by a team of healthcare professionals including a primary care physician, rheumatologist, physical therapist and occupational therapist.
If you think you have osteoarthritis or rheumatoid arthritis, speak to your primary care physician or make an appointment to see a rheumatologist for a further work-up.