I am 47 and have rheumatoid arthritis. I’m a nurse and am especially having trouble with my hands and hips. I’m active but am finding it more difficult to walk on the treadmill and work. I heard about the drug, methotrexate. What do you know about this drug? Can I obtain this by prescription or over the counter?
I cannot adequately discuss rheumatoid arthritis (RA) and the newer treatments for the disease in a single posting, so I have divided this response into two parts, to be posted one after the other, the first a discussion of the disease, and the second a rundown on the available treatments. Since I myself have RA, I will be discussing the treatments I am taking in the second part.
Rheumatoid arthritis is one of the most common of the conditions considered to be autoimmune, a term used to signify that a person’s immune system is in some way acting against one or many of that person’s own tissues. In the case of RA, the tissue responsible for most of the disability of the disease is synovial tissue, which lines the joint spaces of our joints.
Like other autoimmune diseases such as lupus, Hashimoto’s thyroiditis, and Sjogren’s syndrome, women are affected more frequently than men. In the case of RA this female predominance is about three to one. Susceptibility to RA has a genetic component, and both RA and other autoimmune diseases are more common in close relatives of affected people. The disease typically begins in middle age, the 40s to 50s, and can be difficult to diagnose, since the diagnosis depends on a collection of symptoms and signs, not all of which may be present at the beginning. In fact a slow, insidious onset of nonspecific symptoms — such as fatigue, weakness, and vague aches and pains — is the usual picture of the early stages of RA.
A bunch of criteria have been developed by the American Rheumatism Association to aid in the diagnosis of RA. Several of these criteria must be present to make the diagnosis. They include morning stiffness which lasts at least an hour, simultaneous swelling and pain in at least three different groups of joints which must include the hand or wrist joints, typical x-ray changes in the joints, and a positive blood test for rheumatoid factor.
The rheumatoid factor test is often, incorrectly, considered to be the only important part of the diagnosis. In fact even the best laboratories will report a positive test in up to 5 percent of normal people, and this percentage increases with age. Studies have shown that if one looks at all people with positive rheumatoid factor tests, only about 33 percent of them have RA. Since RA occurs in 1-2 percent of the population, and about 5 percent of the normal population has a positive test, this makes sense.
To complicate the picture, there is also a category called sero-negative rheumatoid arthritis, meaning RA in someone with a negative blood test for rheumatoid factor. This is the type of RA that I have. In older people, over 55 or so, the poorly understood disease known as polymyalgia rheumatica may also complicate the diagnosis. All this simply means that one should never diagnose or rule out RA based on the blood test alone.
The inflammation of the synovial tissues in RA slowly damages the joints, and after many years of disease activity, joint deformities are common. The typical course of the disease is one of persistent but fluctuating joint symptoms, and after about ten years 75 percent of sufferers will show some joint deformities. A small percentage will have a short illness that clears up completely; another small percentage will have very severe disease with many joint deformities, and occasionally other manifestations of the disease. These can include nodules under the skin, inflammation of blood vessels, peripheral neuropathy, eye involvement, and an uncommon complication called Felty’s syndrome with enlargement of the spleen and a low white count. The test for rheumatoid factor can be helpful in identifying those people who are at risk for the more severe forms of RA, since it is usually strongly positive in these cases.