الاسعاف الاولي : 17My rheumatoid arthritis m. akes me very tired. Is that normal

19‏/12‏/2011

17My rheumatoid arthritis m. akes me very tired. Is that normal

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17My rheumatoid arthritis m. akes me very tired. Is that normal?

Fatigue is a common feature of RA and occurs in most patients. As individuals with RA know all too well, fatigue is different from drowsiness. Fatigue is a feeling of weariness, tiredness, or lack of energy, whereas drowsiness is a lack of alertness and a feeling that you need to sleep. In other words, fatigue is characterized by a lack of energy and motivation. While this symptom is not as commonly discussed as the pain and stiffness associated with RA, fatigue can be just as devastating. For example, some patients complain of severe fatigue four to six hours after waking. This problem keeps them from being able to hold a job or even accomplish things at home.

The fatigue of RA is different from the fatigue most people feel after performing strenuous work or not getting enough sleep. The fatigue associated with RA often occurs despite adequate sleep and nutrition and lasts much longer than typical fatigue. This symptom has many causes, and a patient may suffer from more than one of these causes at the same time:

The inflammatory process itself. The body of a person with RA is busy making extra white blood cells and extra inflammatory chemicals that result in the pain and swelling of joints associated with RA. The energy expended while making these mediators saps the energy that might be otherwise spent getting dressed in the morning or walking the dog.
Chronic pain. Chronic joint pain means that a person walks, lifts, carries, and accomplishes other physical tasks less efficiently. It takes more energy to do less work when you have RA.
Poor sleep quality. The pain and stiffness of RA result in a shorter duration of sleep and more frequent awakenings during the night.
Depression. RA changes a person's life. These changes can have negative repercussions on employment, relationships,
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and feelings of self-esteem. As a result, the patient may experience feelings of hopelessness and helplessness and a lack of motivation.
Anemia. Patients with RA can develop low red blood cell counts. This condition, which is called the ،°anemia of chronic disease,،± results from the inflammatory process that causes RA. Additionally, some of the medications that are commonly prescribed for RA can result in low blood counts owing to their effects on the bone marrow; others may cause stomach ulcers and bleeding.
Lack of exercise. The pain and stiffness of RA keep many patients from participating in exercise programs or even taking a walk. Lack of exercise leads to muscle weakness, which in turn causes the individual to expend more energy doing a task than when he or she was exercising regularly and was in better shape.

Fatigue is very common in patients with RA and can be disabling. Nevertheless, this symptom is treatable in most cases. You should discuss the amount of fatigue you have with your physician. Your doctor can offer advice on how to deal with or eliminate the fatigue. It is especially important to notify your physician of any sudden worsening in your level of fatigue, as such a change may signal a disease flare, depression, or a drug side effect.

I was fortunate in my final working days to have the type of job where I could take power naps for about 1/2 to 3/4 hour when I felt the need. It was a big help and a relief from stress. People with RA learn to adapt to their disabilities and weaknesses and work around them.

،ھJim

18. Can rheumatoid arthritis affect my lungs?

RA can affect the lungs and the lining of the lungs, a complication referred to as rheumatoid lung disease. Rheumatoid lung disease occurs in approximately 25% of all patients with RA.

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Although RA occurs more commonly in women, men with RA seem to get rheumatoid lung disease more frequently. Other risk factors for this problem include smoking and development of severe joint symptoms early in the course of the disease.

Rheumatoid lung disease is not a single disease, but rather a collection of diseases of the lung that are caused by RA. The most common rheumatoid lung diseases are interstitial lung disease and pleural effusions.

Interstitial lung disease affects the lung tissue itself. In this disease, the air sacs (alveoli) of the lungs and their supporting structures become scarred by inflammation. As a consequence of the scarring, the lungs work less efficiently and it becomes harder to breathe.

Pleural effusions comprise a collection of fluid around the lung. In this condition, the lining of the lung, called the pleura, becomes inflamed and produces fluid. This is similar to the way the joints of a person with RA become inflamed and swollen with fluid. If a large amount of fluid collects around the lung, it can compress the lung and make it difficult to breathe.

The symptoms of rheumatoid lung disease include shortness of breath, cough (usually without producing sputum or phlegm), chest pain (which is worse when taking deep breaths), and fever. Your physician may also hear ،°crackling،± sounds or a ،°rubbing،± when he or she listens to your lungs with a stethoscope. These are not universal findings in all patients with RA, however. Decreased breath sounds or normal breath sounds can occur, even with severe lung disease.

If your physician suspects that you may have rheumatoid lung disease, he or she may order the following tests:

Pulmonary function test. This test measures how much air your lungs can hold and how fast your lungs can expel the air.

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X-rays. A chest x-ray or a computerized tomography (CT) scan may show abnormalities consistent with rheumatoid lung disease.
Echocardiogram. An echocardiogram examines your heart using sound waves. It may show that the heart is having difficulty pushing blood through the scarred lungs, a condition called pulmonary hypertension.
Thoracentesis of pleural effusions. A needle is inserted into fluid around the lung and a sample is taken. Examination of this fluid may show characteristics of rheumatoid lung disease.
Lung biopsy. A lung biopsy may show findings consistent with rheumatoid lung disease. The biopsy can be performed by inserting a needle through the chest wall, threading a flexible scope through the mouth and into the lungs, or conducting chest surgery to obtain an ،°open lung،± biopsy.

The cause of rheumatoid lung disease is not well understood, though it is believed to be related to the generalized inflammatory process that occurs in the joints of a person with RA. Methotrexate (a medication that is often prescribed to treat RA) has been associated with lung fibrosis on rare occasions. Shortness of breath or chest pain in patients who are taking methotrexate as RA therapy should prompt a physician's evaluation.

Currently, there are no effective treatments for rheumatoid lung disease. Physicians sometimes prescribe corticosteroids and immunosuppressive therapies to help treat the complications of this disease.

Worsening of lung fibrosis has been described in patients who were taking antitumor necrosis factor (TNF) inhibitors, such as Humira, Enbrel, and Remicade. Although we do not know if these agents cause a worsening of the lung disease, physicians should discuss this risk with their patients who

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have signs of rheumatic lung disease and who are considering treatment with these agents.

19. Can rheumatoid arthritis affect my brain?

An exceedingly rare complication of prolonged, untreated RA is an inflammation of the arteries in the brain. People who experience this problem can present with symptoms similar to a stroke, such as weakness or numbness of their arms or legs. This condition can be treated with medications such as corticosteroids.

Fatigue, malaise, and depression are also commonly associated with RA. Effective treatment of RA frequently helps people feel as if they have more of their normal energy. Antidepressants may be necessary to treat depression, or they may be prescribed to help manage chronic pain.

Many of the medications used to treat arthritis have central nervous system (CNS) side effects. Corticosteroids (such as prednisone and Medrol) frequently cause nervousness, mood disturbances, and insomnia. Psychosis can also occur, although this severe side effect is usually seen only with doses of corticosteroids that are higher than those typically prescribed for RA.

Nonsteroidal anti-inflammatory drugs (NSAIDs) may also cause CNS side effects, albeit more subtle symptoms than those mentioned previously. Headache may be a CNS-related side effect of NSAIDs, for example. This outcome is somewhat ironic, because many of these medications are touted as headache remedies! Difficulty concentrating can also be a side effect of NSAIDs, but is often missed if the doctor and patient aren't on the lookout for it. These side effects may be more common in older people as well as with older drugs such as indomethacin.

Aspirin and other salicylates (such as salsalate and choline magnesium trisalicylate) frequently cause problems with tinnitus.

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Tinnitus is usually described as ،°ringing in the ears,،± but some people have much more colorful auditory experiences. For example, some people may find that tinnitus is like the sensation that there is a radio playing in the next room, for example, or it may sound like people are talking somewhere in a low murmur. Salicylates do not cause visual hallucinations, but difficulty hearing and occasionally dizziness can occur with these medications. Many older people already have some degree of tinnitus and hearing loss and aren't bothered by these medications. In other patients, the problems are additive such that a person who was mildly hard of hearing can return to the doctor's office quite deaf after taking salicylates! The doctor may monitor your blood salicylate levels if he or she suspects this kind of problem, but often it is faster and easier to just decrease the medication dosage or stop the medication temporarily. Once the salicylate level drops, the side effects of tinnitus, hearing loss, or dizziness should resolve promptly.

If you think you are having one of these side effects, speak to your doctor or pharmacist. Changing to a different medication or reducing the dose can often make a big difference.

20. Are dry eyes and dry mouth common in rheumatoid arthritis?

Some patients with RA may develop dry eyes and a dry mouth, but these are not unusual symptoms linked only with this disease. Indeed, nearly one third of all elderly people،ھwith or without RA،ھwill report dry eyes and dry mouth to their physician. Symptoms of dryness can result from the aging process or from taking common medications, such as antidepressants, beta blockers, diuretics, and antihistamines. Alternatively, these symptoms may be the manifestation of a disease that occurs in approximately 10% to 15% of patients with RA, called Sj?gren's syndrome (SS). This syndrome is named after the Swedish eye doctor who first described it, Dr. Henrik Sj?gren's (pronounced ،°show-grin،±).

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Like RA, SS is a chronic autoimmune disorder. Indeed, it is one of the most prevalent autoimmune disorders, affecting as many as 4 million Americans. It strikes both men and women, but affects women in disproportionate numbers: Approximately 90% of all people with SS are female. The men who develop this disorder typically have milder disease. The syndrome usually develops between a person's thirties and forties, but has been reported in all age groups. Approximately 50% of patients with SS have RA or another rheumatological condition, such as lupus or systemic sclerosis. In people with RA, the symptoms of SS tend to develop five to ten years after the arthritic symptoms. The cause of SS is unknown.

Whereas a person's immune cells attack the joints in RA, the immune cells attack and destroy the glands that produce tears and saliva in SS. As a result, the hallmark symptoms of this syndrome are dry mouth and dry eyes. These symptoms tend to become worse with age.

Patients with SS complain of dry eyes that may become red, itchy, and painful. The most common complaint is a gritty or sandy sensation in the eyes. These symptoms tend to worsen throughout the day. The eyelids may become inflamed. In the morning, the eyelashes can become matted (stuck together), making it difficult to open the eyes.

In addition, SS affects the mouth. Patients may complain of their tongue sticking to the roof of their mouth or an inability to eat dry food, such as crackers. Speaking may also be more difficult because of dryness. Affected individuals may mention that they need to keep a glass of water by their bedside because they frequently wake up with a dry mouth. In women with SS, vaginal dryness may lead to pain during sexual intercourse.

Sj?gren's syndrome may affect other organs including the kidneys, gastrointestinal tract, blood vessels, lungs, liver, pancreas,

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and central nervous system. Once damaged, these organs may generate their own symptoms.

21. Is depression a problem with rheumatic arthritis?

Depression occurs frequently in the general population and even more frequently in individuals with chronic diseases such as RA. The pain and disability associated with RA has a detrimental effect on the person's lifestyle and ability to cope with daily life. RA is frequently associated with depression or anxiety; in fact, depression occurs in 20% to 25% of all patients with RA.

Depression is a disorder that is easily missed by physicians because of its nonspecific symptoms. Thus it should be brought to the physician's attention by either the patient or his or her family or friends. Common symptoms of depression include the following:

Changes in appetite
Sudden loss (or gain) in weight
Changes in sleep patterns (either sleeplessness or waking too early)
Feelings of guilt, hopelessness, and despair
Mental and physical fatigue
Inability to make decisions
Withdrawal from others
Lack of pleasure in once-pleasurable activities
Thoughts of death and suicide (These thoughts occur in 10% of all patients with RA.)

If depression is identified, it can be treated and the quality of the patient's life improved. Treatment of depression is the same for the people with and without RA. Treatment strategies include counseling, education, frequent patient monitoring, and medications. These therapies have a high success rate.

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Regular exercise also has a modest antidepressant effect and can be a very useful adjuvant treatment for depression.

Antidepressant medication can be a particularly useful therapeutic choice. Choosing the right antidepressant is important, and the decision should be based on your specific symptoms and tolerance for side effects. All antidepressants should elevate mood, albeit not to the same extent in all patients. If you do not obtain any relief after four to six weeks of taking a particular medication, ask your doctor to change to another option. Some antidepressants can improve chronic pain by influencing the perception of pain. Other antidepressants have a side effect of drowsiness, which can help with insomnia.

22. I have a bump on my elbow that my doctor says is a rheumatoid nodule. What is a rheumatoid nodule?

A rheumatoid nodule is a bump in the skin that is found in approximately 25% of people with RA. In fact, identifying a rheumatoid nodule in a person who has recently developed arthritis can help a doctor to make the diagnosis of RA.

These bumps are found below the surface of the skin and can be moved with your fingers in most cases. Rheumatoid nodules can be as small as a pea or as large as a golf ball. The size of the nodules can change during the course of the disease, getting larger as the activity of RA increases but then regressing when the disease is quiescent. They tend to be firm, but are not rock hard and are usually not tender to the touch. These nodules are found at pressure points on the body such as the elbows and heels as well as points where the skin is irritated or traumatized, such as the knuckles of the hands and fingers and along the back of the forearm.

The exact cause of rheumatoid nodules is unknown. Some experts have theorized that they occur as a result of a minor injury to the blood vessels in the skin. This injury triggers an

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abnormal immune response, which in turn causes inflammation and swelling.

Despite their name, rheumatoid nodules are not found exclusively in individuals with RA. Identical nodules are sometimes seen in patients with systemic lupus erythematosus (SLE), rheumatic fever, and other diseases. They can even be caused by the presence of foreign bodies in the skin, such as splinters.

Most patients with RA don't get rheumatoid nodules; those patients who do develop these nodules tend to have more serious RA. The nodules tend to occur after the disease has been present for several years and are usually found in patients who have a strongly positive rheumatoid factor test (see Question 47) and those with more active disease.

Patients who are treated with the medication methotrexate have noted that their nodules increase in number and appear on the fingers. These new nodules can be painful and limit hand function. Antitumor necrosis factor medications such as infliximab (brand name: Remicade) can also cause nodules to decrease in size and number, though not always.

Rheumatoid nodules are clinical predictors of joint erosion and extra-articular (non-joint-related) complications of RA involving the lungs or eyes. An inflammation of the blood vessels known as rheumatoid vasculitis can occur in patients with these nodules, for example. The presence of rheumatoid nodules often suggests a need for more aggressive treatment of the underlying RA to prevent complications. Some physicians have noted that fewer patients are developing rheumatoid nodules these days thanks to the modern aggressive treatment approaches used in RA.

For the most part, rheumatoid nodules are painless and cause few problems. Nevertheless, larger nodules can cause some problems:

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Pain،ھif they are irritated by rubbing against clothes, shoes, or jewelry, or if they become infected
Limited joint mobility،ھif they are large or too close to the joint or tendon
Neuropathy،ھif they press on nearby nerves
Ulceration،ھif the skin overlying the nodules breaks down, causing bleeding and pain and opening up a portal for bacteria to enter and cause an infection

When ulcerations become large, deep, and long-lasting, they can result in the formation of a fistula. A fistula is an abnormal passage between the skin's surface and the inside of a joint.

Most doctors caution patients to leave rheumatic nodules alone, unless they are painful, become infected, limit the motion of a joint, or are cosmetically unacceptable. Nodules can be removed surgically, but they tend to reoccur in as little as a few months when they are present over an area of repeated trauma. Most dermatologists recommend treating nodules by injecting them with steroids. This treatment has the advantages of being able to reduce the size of the nodule while avoiding surgery and subsequent scarring. Rheumatoid nodules occasionally resolve without medical or surgical intervention.

I have rheumatoid nodules in my elbows and knuckles. The nodules have increased. Hands are stiff and painful in the morning. Soaking in hot water or using a heating pad relieves stiffness and pain.

،ھJim

23. Will my rheumatoid arthritis affect my eyes?

Most people with RA do not develop eye problems because of their RA, although approximately 25% of patients with RA will complain of some eye symptoms. The majority of these eye complaints is mild and requires only symptomatic

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treatment. A very small number of patients develop severe eye inflammation that can affect their vision. These problems require the attention of an eye doctor.

The most common ocular (eye-related) complaint in patients with RA is ،°dry eyes,،± also referred to by the unwieldy medical name keratoconjunctivitis sicca. This condition occurs in as many as 15% of patients and is explained in some depth in Question 20.

A less common, but more serious eye complaint is scleritis. Scleritis is a chronic, painful, and potentially blinding inflammatory disease. Its exact incidence is uncertain, though it is thought to be rare. Some studies indicate that this condition occurs in fewer than 10% of patients with RA and is usually associated with very severe cases of RA. It occurs slightly more frequently in women than men and first occurs in patients who are in their fifties or sixties.

Scleritis is characterized by swelling and redness of the white portion of the eye called the scleral and episcleral tissues. It is sometimes confused with a minor bacterial infection of the eye called ،°pink eye،± (more formally, conjunctivitis) because of the bright red appearance of the eye. Your doctor can tell the difference by taking a thorough history and performing a physical examination.

The most common symptoms of scleritis include pain, tearing, photophobia (pain when the eyes are exposed to bright light), and tenderness when the eye is pressed, and decreased visual acuity. The pain can be severe, so it is often the symptom that prompts someone to seek medical assistance for scleritis. The pain results from stretching of the nerve endings caused by the inflammation.

The initial treatment of scleritis focuses on relieving the eye discomfort and stopping the progression of the disease. This

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therapy includes common pain relievers that are taken orally (by mouth) such as indomethacin (Indocin) or ibuprofen (Motrin). If a patient doesn't respond to this treatment, he or she should be referred to an ophthalmologist (eye doctor) for stronger medical therapy. This therapy may include steroid eye drops, immunosuppressive medication such as cyclosporine, or an anti-TNF medication such as infliximab (Remicade). If scleritis is not treated, it can result in loss of vision or even the loss of the eye itself, though this occurs only in the most serious and destructive type of scleritis (called necrotizing scleritis).

Other, less common eye-related complications of RA include inflammation of the blood vessels in the eye (choroiditis), retinal detachments, and swelling of the retina (macular edema). All of these complications can result in loss of vision. For this reason, patients with RA should have regular eye exams and speak to their doctor if they experience eye redness, pain, or a change in the acuity of their vision.

24. Can rheumatoid arthritis increase my risk of osteoporosis and bone fractures?

Yes, RA can increase your risk of developing osteoporosis and bone fractures. Osteoporosis is a disease of the bones that results in ،°thinner,،± weaker bones that are more prone to fractures. It is a silent disease, however: A person can't feel that his or her bones are getting less dense. Osteoporosis becomes obvious only when the individual suffers a fracture of the hip, wrist, or spine. Osteoporosis-related fractures of the spine, for example, can result in a curvature of the spine called kyphosis (،°dowager's hump،±). These fractures may or may not be painful, can be disfiguring, and may result in disability and hospitalizations.

Risk factors for developing osteoporosis include the following:

Family history of the disease
Thinness or small frame

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Low dietary calcium intake
Inactivity or lack of exercise
Smoking
Excessive alcohol intake
Prolonged use corticosteroids
Being postmenopausal and having an early onset of menopause

Medical studies have found that people with RA have an increased risk of bone loss and bone fracture as compared to people of the same sex and age who do not have RA. There are many reasons why people with RA might develop bone loss:

The inflammation of RA not only causes bone loss at the joints and the areas surrounding the joints, but tends to accelerate bone loss throughout the entire skeleton.
Women, who are at an increased risk for developing osteoporosis relative to men, are two to three times more likely than men to suffer from rheumatoid arthritis as well.
Exercise and weight bearing tend to limit bone loss. The inactivity and lack of exercise caused by the pain, stiffness, and fatigue of RA tend to increase bone loss.
Corticosteroids (also called glucocorticoids،ھfor example, cortisone and prednisone) are often prescribed to decrease inflammation and ease pain. Unfortunately, if they are taken for long periods of time, these medications can cause significant bone loss.
The pain, fatigue, and stiffness caused by RA can also impair a person's ability to walk and cause an unsteady gait. This may result in falls that can cause fractures.

Despite its ،°silent nature,،± osteoporosis is a disease that can be tested for and treated. As with RA, there is no cure for osteoporosis, but the disease can be managed. The management of

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osteoporosis is the same for people with RA as it is for those without RA.

To identify the presence of osteoporosis, your doctor can quantify your bone density. The bone densitometry exam or bone mineral density (BMD) test is painless and is typically performed in a doctor's office or the outpatient department of a hospital. It uses low doses of x-rays to examine the bones in your wrist, hip, and spine and to determine whether they are of a normal density or if they show signs of bone loss. Sometimes bone density of the heel is used as a screening test for osteoporosis.

You can reduce your risk of osteoporosis in several ways:

Increase the amount of calcium and vitamin D in your diet. Your doctor may recommend calcium and vitamin D supplements in the form of pills.
Your doctor may wish to measure the level of vitamin D in your blood. If the test shows that this level is low, you can take a supplement to correct this deficiency.
Increase the amount of exercise you do. Your bones become stronger when they are stimulated by exercise and weight bearing. Of course, you should consult your doctor before starting any new exercise program. Exercise can be avoided when your RA flares up.
Avoid smoking and excessive alcohol intake.
If your doctor determines that it is appropriate, he or she may prescribe one of several medications that are indicated for the treatment of osteoporosis. These medications can slow the rate of bone loss and help strengthen your bones.

Patients with RA should discuss their risk for osteoporosis with their primary care physician or rheumatologist. Even minor changes in lifestyle can reduce your risk for bone loss and fractures.

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25. Can rheumatoid arthritis cause a low red blood cell count?

Anemia،ھan abnormally low number of red blood cells in your bloodstream،ھis a common complication of RA. Indeed, of all the problems associated with RA that are not related to joints, anemia is the most common. It is estimated to occur in 30% to 60% of all people with RA. Anemia tends to occur more frequently in those people who have the most severe disease, defined as a higher number of involved joints and higher levels of functional disability and pain.

Anemia has many different causes and is by no means unique to RA. Nevertheless, this complication can lead to worsening fatigue and shortness of breath in people with RA. Two types of anemia are primarily associated with RA: iron-deficiency anemia and the ،°anemia of chronic disease.،±

Iron-deficiency anemia is caused by a loss of blood. In people with RA, the most common reasons for blood loss are normal menstrual bleeding (in women) and bleeding in the gastrointestinal (GI) tract. Gastrointestinal bleeding can be caused by taking nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen. The use of these medications is associated with gastric ulcers and sometime severe hemorrhages. In one study of patients with both RA and anemia, iron-deficiency anemia accounted for 23% of all cases.

The majority of patients who have both RA and anemia have the ،°anemia of chronic disease.،± In this type of anemia, the abnormal chemicals and proteins that cause the joint inflammation in RA also affect the cells in the bone marrow that produce red blood cells. That is, they inhibit the production of new red blood cells, even though your body has enough iron to make the cells.

You doctor can determine whether you have anemia by obtaining a simple blood test called a complete blood count (CBC).

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Your doctor should perform this test several times each year and anytime you complain of increased shortness of breath or fatigue.

The treatment for anemia depends on its cause. For patients with iron-deficiency anemia, treatment of GI ulcers and replacement of lost iron is often sufficient. Iron is usually replaced by taking iron supplement pills.

The treatment for the anemia of chronic disease is more complicated. It begins with a more aggressive treatment of the inflammation caused by the RA. Iron supplementation is rarely necessary, because people with this type of anemia usually have normal amounts of iron stored in their body. A newer treatment is erythropoietin, a synthetic form of the naturally occurring protein in our bodies that stimulates the production of red blood cells. Patients who are treated with erythropoietin sometimes experience rapid improvements in both their red blood cell counts and their symptoms of fatigue.

If you are experiencing increased fatigue or shortness of breath, discuss the possibility of anemia with your physician. A simple blood test could help to make the diagnosis.

26. I've heard that people with rheumatoid arthritis are prone to heart disease. Is that true?

Yes, patients with RA have an increased risk of developing atherosclerosis and cardiovascular disease. In particular, RA is associated with a 40% increased risk for myocardial infarction (heart attack) and a 60% increased risk for congestive heart failure (CHF). The heart disease associated with RA accounts for 30% to 50% of deaths in patients with RA. Death occurs at an earlier age in individuals with RA as compared with those without RA who have similar heart disease risk factors. By some estimates, patients with RA die 17 years earlier than people without RA.

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Why people with RA have a higher rate of heart attacks is unknown. We do know that the changes that RA causes in a person's body can damage the lining of the arteries. This damage results in inflammation in the lining of the arteries, which in turn leads to cholesterol deposits. These cholesterol deposits (called atheroma or plaque) can block arteries and cause heart attacks. In addition, RA has been associated with other changes that can result in coronary artery blockages, including increased levels of cholesterol and fat (triglycerides) in the bloodstream and an increase in clotting factors.

The increased risk for heart disease observed in persons with RA is independent of the usual risk factors for heart disease, which include high cholesterol, high blood pressure, advanced age, diabetes, smoking, obesity, and family history of heart disease. The risk of heart disease has been correlated with the severity of the RA: The worse the RA, the greater the amount of inflammation, and the higher the risk of heart disease. Researchers have also found an association between an RA patient's C-reactive protein (CRP), sedimentation rate (ESR), and risk for cardiovascular death: The higher the person's ESR, the higher the risk of cardiovascular death. Some researchers believe that decreasing the amount of inflammation a patient has can decrease his or her risk of heart disease. In medical studies, patients who used methotrexate or biologic agents (e.g., Remicade, Humira, and Enbrel) to treat their RA had a lower risk of heart disease. Conversely, the use of prednisone (a potent anti-inflammatory medication) tended to increase the risk of atherosclerosis and heart attack.

Individuals who have RA should be aware of their increased risk for heart attacks. They should discuss this risk with their physicians and develop a plan to modify those risks. While some heart disease risk factors cannot be modified (such as family history of heart disease), others can. You should work to reduce your modifiable risk factors for heart attacks،ھfor example, stop smoking (if you currently smoke), follow a

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low-fat diet, and exercise. Make these changes only after consulting with your physician.

Here are some questions to discuss with your physician:

How do I stop smoking?
How do I change my diet to reduce my fat and cholesterol intake and to achieve an optimal weight?
Which exercises should I do, given the limitations imposed by my RA? How frequently and how long should I exercise? (Exercising 30 minutes three times per week is usually recommended.)
Would I benefit from a cholesterol-lowering medication? A class of cholesterol-lowering drugs called statins should be evaluated in this regard. Not only can statins improve your lipid levels, but they also appear to have anti-inflammatory properties. Recent clinical trials suggest that statins offer a dual benefit of both protection against cardiovascular disease and prevention of RA progression.
Should I take methotrexate to lower the amount of inflammation in my body?
Will taking biologic agents such as Remicade, Humira, and Enbrel improve my arthritis and decrease my risk of heart disease?

Other heart complications associated with RA include inflammation of the heart's outer covering (pericardium) and the heart muscle (myocardium). When the pericardium is inflamed by RA, the condition is referred to as rheumatic pericarditis. Rarely, an inflammation of the heart muscle, called myocarditis, can develop. Both of these conditions can lead to CHF, which is characterized by shortness of breath and fluid accumulation in the lungs.

Individuals with RA should have their blood pressure, blood sugar level, and cholesterol level checked at least every year. For older patients or those with a family history of heart disease,

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an electrocardiogram (EKG) or a cardiac stress test may be indicated. If you have additional risk factors, your doctor may recommend a consultation with a cardiologist.

27. Can rheumatoid arthritis increase my risk for infections?

Infections are a frequent complication in people with RA. Their risk for developing lung infections or pneumonia is also increased, which constitutes a serious problem.

In medical studies, investigators have found that people with RA were nearly twice as likely as people without RA to develop infections, even after adjusting the rates for age, gender, smoking status, low white blood cell count, glucocorticoid use, and diabetes mellitus. The sites of infection with the highest risk ratios were the bones, joints, skin, and soft tissue.

Possible explanations for the increased risk of infection include RA-related immunologic abnormalities, the effects of immunosuppressant drugs, and disease-related factors such as immobility, joint surgery, rheumatoid lung disease, and Felty's syndrome. In addition, patients with RA who also have other diseases such as diabetes mellitus, chronic obstructive pulmonary disease (COPD), and renal failure may have an even higher risk of developing infections. Which of these factors are the most important contributors to the increased risk of infection associated with RA has not been established.

Recent evidence suggests that an abnormality exists in the white blood cells (the T cells) of patients with RA, even when the disease is in its earliest stages. This abnormality may impair the body's immunological response to bacteria and viruses, leaving it unable to fight off these intruders and resulting in increased infection rates.

Corticosteroids (or, more simply, steroids) are commonly used to treat rheumatic diseases. Unfortunately, their ability to

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control RA symptoms comes at the expense of increased immunosuppression, which increases the risk for infections. In one study involving nearly 17,000 people with RA, researchers found that more than 70% of patients were prescribed prednisone (a steroid) at least once during the course of their disease and 35% to 45% used prednisone regularly. Evidence from studies like this one has also indicated that there is a relationship between the dose of steroids and the risk of pneumonia. This association is seen even with small daily doses of steroids،ھless than 5 mg.

The use of disease-modifying antirheumatic drugs (DMARDs, such as sulfasalazine, hydroxychloroquine, and leflunomide), apart from corticosteroids, did not appear to increase infection risk, even after adjustment for demographic and disease-related variables. The effects of the dosages of methotrexate used in RA are less clear, with some studies showing a mildly increased risk of infection and others demonstrating no such increased risk.

28. Can rheumatoid arthritis increase my risk for a joint infection?

Although they are rare, joint infections do occur sometimes. It is important to know about this potential complication for two reasons. First, among all of the many types of arthritis, arthritis caused by infections results in the most rapid destruction of joints. In some cases, a joint can be totally destroyed after only a few days of untreated infection. Second, joint infections are often misdiagnosed, even by experienced doctors.

A joint infection is referred to as septic arthritis. Doctors suspect septic arthritis when they see intense inflammation of a joint along with cloudy fluid inside the joint. A diagnosis of septic arthritis usually requires special tests of joint fluid to determine whether microorganisms, such as bacteria, are present in the joint fluid. While bacteria cause the majority

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of infections, viruses, tuberculosis, and fungi can also cause this problem.

A joint that has been previously damaged by injury or arthritis is more likely to become infected than an undamaged joint. In the general population, joint infections occur at a rate of 10 cases in every 100,000 people. Among individuals with RA, this rate jumps to 70 cases in every 100,000 people.

Although septic arthritis can occur in any joint, the knee is the most common site of infection, accounting for approximately 50% of cases. The hip is the next most common site of infection, accounting for 20% of cases. The shoulders, elbows, ankles, and wrists account for the majority of the remaining cases.

Infectious agents can enter the joint from many sources, though the most common route of infection is via the blood. Bacteria from an infection in a distant location, such as the heart or lungs, can be carried to the joint by the bloodstream. Joints may also become infected during a surgical procedure, such as a joint replacement, arthroscopy, or even the injection of steroids into the joint. Fortunately, these complications, while serious, are very rare. Direct trauma to the joint, such as an open fracture, stepping on a nail, or having a bite wound to a knuckle can also lead to infection of a joint.

In its earliest stages, septic arthritis can be difficult to diagnose. The joint may be sore and swollen. As the infection progresses, the symptoms become more severe. Typically, a person with a septic joint presents with fever and a joint that is hot, red, painful, and bulging. The joint is very painful to flex or extend and may even be too painful to touch. Given that this doesn't sound different from a worse-than-average flare of RA, you can see why your physician might have difficulty making this diagnosis. The following clues should point your doctor to a diagnosis of septic arthritis:

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History of fever
An inability to bear weight on the affected joint
An elevation in your ،°sed rate،± (sedimentation rate،ھspecifically, an erythrocyte sedimentation rate higher than 40 mm/hour) or C-reactive protein (CRP)
An elevated white blood cell count (WBC count higher than 12,000/liter)

Septic arthritis is diagnosed by placing a needle into the joint and aspirating the fluid for analysis. The joint fluid is then examined under a microscope. The presence of bacteria or other infectious organisms confirms the diagnosis.

The treatment of an infected joint starts with the administration of intravenous antibiotics. The joint itself needs to be drained of the excess fluid that contributes to joint destruction. This fluid is drained with a needle as often as is necessary،ھsometimes daily. Sometimes, the joint has to be opened and drained surgically.

Untreated infections can rapidly destroy a joint and lead to more widespread infection; in turn, widespread infection can result in hospitalization and even death. Therefore, any severely inflamed joint should be examined by your doctor, especially if you also have a fever. Early treatment of an infected joint will prevent joint damage and hospitalization.

29. Do patients with rheumatoid arthritis have more dental problems than the average person?

Surveys of large groups of people show that individuals with RA have twice the rate of periodontal disease as people of the same age, sex, and socioeconomic status who do not have RA. Periodontal disease affects the tissues that surround and support the teeth. These tissues include the gums (gingiva), the bones that form the tooth sockets, and the periodontal

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ligament (a thin layer of connective tissue that holds the tooth in its socket, and acts as a cushion between tooth and bone).

In studies, researchers have discovered that patients with RA tend to have more severe periodontal disease than those without RA. Of the patients with both RA and periodontal disease, 62.5% of them suffered from advanced disease and more than half had severe bone loss in the jaw. In addition, the patients with RA averaged 11.6 missing teeth compared with 6.7 missing teeth in the control group in one Australian study.

Both RA and periodontal disease are inflammatory diseases that lead to bone destruction. When researchers examined patients who had both RA and periodontal disease, they found that the rates of other inflammatory diseases, such as cardiovascular disease and diabetes mellitus, were higher in this group than in age-matched people without RA. They also noted a relationship between the severity of the periodontal disease and the risk of having RA: Patients with more advanced periodontal disease were at higher risk of having RA.

One theory suggests that the inflammation and infection associated with periodontal disease help to trigger RA. This relationship suggests that periodontal disease may be the result of the same inflammatory process that affects the joints of patients with RA. Other researchers have suggested that the effects of RA, such as swollen and painful fingers, loss of motion, fatigue, and decreased saliva production, result in poor oral hygiene that causes periodontal disease. Dentists cannot be sure which problem came first, but they do emphasize that good oral hygiene can decrease plaque and gingivitis. They encourage patients with RA to brush with an electric toothbrush, floss daily, and visit their dentist regularly for plaque removal and repair of dental caries (cavities) if present.

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30. Does rheumatoid arthritis increase a person's risk of getting cancer of the lymph nodes (lymphoma)?

Patients with RA appear to have a higher risk of developing cancers of the lymph nodes, known as lymphomas. In the past, studies have shown that the risk of developing lymphoma appears to be greater in patients who have more severe inflammation and in those with a longer duration of RA. The reasons for this increased risk are not clear, but the effects of arthritis drugs, viruses, or increased inflammation have been blamed. Many medical studies have attempted to quantify this risk and find its cause. A few of the seminal studies in this area are reviewed here.

Researchers in Canada evaluated the health records of 1210 patients with a diagnosis of RA to determine their risk of developing lymphoma. They found a three- to fourfold increase in the rate of lymphoma in these patients as compared to other Canadian patients without arthritis. This study was published in the Journal of Clinical Epidemiology in 1993.

In a 1998 study published in the British Journal of Medicine, Swedish researchers offered evidence from a populationbased study that ،°immune alterations،± in patients with RA appear to contribute to the development of lymphomas. In a population-based sample of 11,683 patients with RA in Sweden, these researchers identified 41 patients with lymphoma and 113 without the disease. They found that there was a strong independent association between the severity and duration of inflammatory activity and the risk of lymphoma. Because arthritis drugs such as methotrexate, azathioprine, and infliximab have been suspected to contribute to the risk of lymphoma, the researchers examined the drug treatments for all patients. They found no link between any specific drug used in RA and an increased risk of lymphoma. The Swedish investigators suggested that if inflammation contributed to

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the risk of developing lymphoma, then treatment of RA with anti-inflammatory medications might lower a patient's risk.

In 2004, a study published in the medical journal Arthritis and Rheumatism reaffirmed the connection between RA and lymphoma and cast doubt on the connection between arthritis drugs and this cancer. In this study of 18,572 patients with RA, researchers evaluated known and suspected risk factors for lymphoma, including age, sex, severity of RA, duration of RA, and any RA treatments received. In patients with RA, the overall risk of developing a lymphoma was twice the risk of people without RA. These investigators found that increasing age, male sex, and low educational achievement were associated with increased risk of lymphoma. Conversely, current or previous drug treatment had no effect on cancer risk.

Patients with RA should be aware that they have a slightly increased risk of developing lymphoma. Symptoms such as changes in weight, fevers, and swollen lymph nodes should be reported immediately to your physician. Those symptoms do not mean you have cancer of your lymph nodes; they can also be associated with a variety of other illnesses, including minor ailments such as colds or viruses. As in other serious illnesses, early detection and treatment of lymphoma results in improved outcomes.