A Patient Guide to Rheumatoid Arthritis Table of Contents Understanding Rheumatoid Arthritis

A patient guide to rheumatoid arthritis Table of contents Understanding rheumatoid arthritis

Learning how to manage rheumatoid arthritis (RA) might feel like a challenge, especially at first. But understanding your diagnosis can help you take control of your health. Although there is no cure for RA, a number of treatment options can help you manage pain and stay active.

Beginning treatment soon after diagnosis can help prevent long-term damage to your joints and improve your overall health.1 This booklet provides information about RA, what to expect after Understanding rheumatoid arthritis ��1 diagnosis and how to manage symptoms to live a full and active life. How RA affects joints ...... 1 Causes ...... 2 How RA affects joints Figure: Normal joint and joint affected by RA Diagnosis ...... 2 In most cases, RA is a long-term, or chronic condition. It can get better and worse over time. It Symptoms ...... 3 Normal joint causes inflammation, or swelling, in the joints. This Related conditions ...... 3 leads to pain and stiffness that can make it hard to Cartilage move or complete daily tasks.2 Muscle Tendon

Living with RA ��4 Each joint in the body is where the ends of two Staying on track with treatment ...... 4 bones meet. A flexible coating called cartilage connects the bones. (See Figure at right.) Each joint Bone Lifestyle changes ...... 5 is surrounded by synovium. This is a type of tissue Bone Managing flares...... 9 that helps the bones move smoothly at that joint. In RA, the synovium becomes swollen and thick. This Surgery ...... 10 damages the cartilage and bone. It also weakens Synovium Ongoing care ...... 10 the nearby muscles and the tendons that connect Synovial fluid the muscles to the bone. This makes it hard to Joint capsule move. In some cases, severe swelling can make the References ...... 12 joints crooked and deformed. Joint affected by RA Resources ...... 13 RA usually affects the small joints in the hands and Bone loss/Erosion feet on both sides of the body. But it can affect Cartilage loss many joints, including:

• Ankles • Elbows Bone loss (generalized) • Hips • Knees Inflamed • Neck synovium • Shoulders Swollen joint capsule This publication is for informational purposes only. It is not intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or • Wrists other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read in this publication. If you think you may have a medical emergency, call your physician or 911 immediately. Walgreens does not recommend or endorse any specific Source: Handout on health: rheumatoid arthritis. National Institute of Arthritis tests, physicians, products, procedures, opinions or other information that may be mentioned in this publication. Reliance on any information provided in this publication is solely at your and Musculoskeletal and Skin Diseases Web site. www.niams.nih.gov/hi/topics/ own risk. arthritis/rahandout.htm. Accessed May 29, 2015.

This publication was created by and is provided as a service of Walgreens. 1 Understanding rheumatoid arthritis (continued)

In some people, RA might cause swelling in other • Genes� The chance of developing RA is partly the elbows, ankles, feet and toes before moving to parts of the body, including3: genetic, or passed down through a family. But other joints. RA usually affects joints on both sides many people can inherit and carry the genes for of the body at the same time. This means if the right • Blood vessels—causing arteries to harden, absorb RA without developing it. hand is affected, the left hand is affected, too. more cholesterol and form plaques • Hormones� Certain hormones might play a part • Eyes—causing dryness, pain, redness, blurred RA can affect other parts of the body. Other in who develops RA. Women are more likely than symptoms can include: vision or sensitivity to light men to have RA. Pregnancy, breastfeeding and • Heart—causing chest pain or higher risk of use of hormonal birth control can also affect RA • Dry eyes and mouth heart disease and its symptoms. • Fatigue or tiredness • Lungs—causing difficulty breathing • Lifestyle� Smoking cigarettes can double the risk • Lumps (called nodules) under the skin and at of developing RA. Being overweight might also RA is different from another type of arthritis called pressure points like the elbows increase the risk, especially in women. osteoarthritis. Osteoarthritis is usually caused by • Mild fever “wear and tear” on the joints. It develops slowly over • Numbness or tingling in the arms or legs time, causing stiff joints. It is usually diagnosed later • X-rays, which can show joint damage in advanced • Poor appetite in life. RA by the numbers4 cases of RA In contrast, RA is caused by a problem in the RA symptoms can come and go. Flares are times 1.5 million Americans are living with RA immune system. It can develop quickly, leading to • Blood tests, which can identify problems in the when symptoms get worse. Remissions are times immune system when there might be fewer symptoms or none at all. problems in the whole body. This can include joint 70% of RA patients are women Nearly half of all people living with RA may be able stiffness and swelling, fatigue (feeling tired) and Blood test results of those with RA might include: fever. Unlike osteoarthritis, RA usually begins in 40-60 years old is the usual age to achieve remission. This is because of improved middle age. at diagnosis • Anemia, or a low red blood cell count treatment options and the ability to begin targeted treatment right after diagnosis.8 • Presence of rheumatoid factor, an antibody found Causes in many people with RA Related conditions RA is an autoimmune disease. This means it • A high erythrocyte sedimentation rate or “sed Diagnosis occurs because the immune system is not working rate,” a sign of inflammation in the body Some people with RA seem to be more likely to have certain conditions, including3: properly. Normally, your immune system seeks out RA can be hard to diagnose. This is because its • Presence of anti-citrullinated protein antibody and attacks bacteria or viruses that might make you symptoms are like those seen in other types of joint • Periodontal disease, a chronic bacterial infection of sick. It also helps your body recover from illness or disease. Also, many RA symptoms are not obvious Symptoms the gums that can cause tooth loss injury. But in RA, the immune system mistakenly right away. • Rheumatoid vasculitis, a condition that causes attacks healthy tissue. This can cause pain, swelling RA affects the joints, causing symptoms that 2 swollen blood vessels that can cause sores or and stiffness in the joints.5 There is no single test to diagnose RA. Your can include : doctor likely used many types of information for ulcers on the skin and painful inflammation in the The exact cause of RA is not clear. But certain your diagnosis 2: • Pain and stiffness lasting for more than 30 minutes heart or lungs 2,6-7 after waking in the morning or after a long rest things might raise the risk of developing it : • Sjogren’s syndrome, an autoimmune disease that • Your symptoms, such as joint pain or swelling and • Redness and warmth causes dry eyes and mouth • Environment� For some people, something in the morning stiffness environment, like bacteria or viruses, can trigger • Swelling • A physical examination of your joints, skin, reflexes Because RA can change the immune system, some the disease process. and muscle strength These symptoms can make normal movement people with RA might also have a higher risk of difficult or uncomfortable. Symptoms often appear certain types of cancers, including lymphoma and first in the wrists and fingers. Then they move to other blood cancers.9

2 3 Living with RA

There is no cure for RA. But there are many ways to manage symptoms and minimize joint damage. Lifestyle changes Work with your doctor to find the approach that is best for you. You can find guidance from a Along with medication therapy, lifestyle changes can rheumatologist. This type of doctor specializes in treating arthritis and other bone and joint diseases. help you manage RA symptoms. Staying active, planning for daily tasks, eating well and limiting The main goals of RA treatment are 2: No matter which medications are part of your stress can help you feel better each day. treatment, you must take them exactly as • Relieving pain prescribed by your doctor—at the right times Physical activity • Reducing swelling and the correct doses. Do not stop taking your Regular, gentle exercise can help keep your joints medications without asking your doctor first. If • Slowing or stopping joint damage flexible. Staying active can also help the rest of your treatment routine starts to feel too hard, ask • Improving well-being and ability to function your body stay healthy and help you maintain a your doctor or pharmacist for help managing healthy weight. This can lessen extra strain on your your medications. Staying on track with treatment Medication and lifestyle changes can help most joints. Exercise can also be a good way to relieve 2 is important for controlling your symptoms and people with RA live full, active lives. emotional stress that might make symptoms worse. improving your health. Staying on track with treatment You might consider gentle activities such as: Daily tasks Medication therapies, along with lifestyle changes, • Aerobic activities like walking or swimming 2 Joint pain and swelling might make it hard to can help keep you moving with less pain. Not all • Strengthening routines, like gentle weight training treatments work for everyone. Talk with your doctor complete daily tasks at home or work. You can • Stretching and range-of-motion exercises, about what works best for you. Your needs might make small changes to help make daily routines like yoga or tai chi change over time. Your doctor can adjust your safer and easier. treatment as needed. Consider using a splint, brace or other support item At home: to help stabilize your joints during exercise or even There are several types of medications prescribed during daily activities. • Place items you use most often where they to treat RA10: are easy to reach, like the front of lower Talk to your doctor before starting any exercise • Nonsteroidal anti-inflammatory drugs that help cabinet shelves. program. You might also wish to work with a relieve pain and joint swelling • Replace doorknobs with levers that are easier to physical therapist or exercise specialist. Together, push down and open. • Corticosteroids that help relieve joint swelling you can make an exercise plan that is right for you. • Disease-modifying antirheumatic drugs that • Secure area rugs to the floor with adhesive or Be sure to balance exercise with rest. This is suppress the immune system and slow the fasteners to prevent trip hazards. especially important during flares. Ask your doctor disease process • Tie string or strips of cloth to handles of cabinets how long you should take a break from exercise and drawers to make them easier to open. • Biologic response modifiers that target parts of during flares. the immune system that cause joint swelling • Try to replace heavy appliances, like vacuum • Janus kinase (JAK) inhibitors that block part cleaners, with lighter models that are easier of the body’s immune response to handle.

4 5 Living with RA (continued)

At work: Emotional health • Feeling restless or irritable

• Arrange your workspace so you can complete Sometimes, living with RA can be a challenge. Tasks • Feeling sad, empty or anxious most of the time tasks with the least amount of physical strain. that used to be simple might now be difficult. You • Feeling worthless, helpless or guilty might feel angry or frustrated. This is normal. Being • Complete more important tasks when you have • Having a hard time concentrating or aware of your feelings can help you manage your the most energy. making decisions emotional health and improve your physical health. • Take breaks from repetitive motion as often as • Losing interest or pleasure in things you used you can. For example, stress can make it harder to deal to enjoy with the daily challenges of living with RA. It might 14 • Sleeping too much or too little Healthful eating also raise the risk of flares. You can take steps to understand and control your stress: • Thinking about death or suicide There is no specific RA diet. But the way you eat might affect your symptoms. Eat to maintain a • Find out what causes your stress. Try keeping a If you have thoughts of suicide, call 911 or your healthy weight. Being underweight or overweight journal or diary to help you find possible sources. local emergency services number. You can also call a doctor, mental health professional, crisis center or can affect RA. People with RA have a higher risk • Try to avoid things that cause your stress. Make hotline for help. of getting coronary artery disease. A diet that time for things you enjoy. controls cholesterol helps to lower that risk.11 For example, research has shown that eating • Find positive ways to cope. Share your feelings foods rich in omega-3 fats, such as fish, can help with friends, family or a support group. Try to relax reduce swelling.12 in a quiet space each day. Some days, you might feel helpless or In general, experts suggest a healthy, balanced diet overwhelmed. You might find yourself feeling sad or 13 that includes : depressed about living with RA. This is normal, too. • Fish and other sources of omega-3 fats, like It’s important to know the symptoms of depression olive oil and when to get help. Avoid foods that seem to increase your pain and • Fresh fruits and vegetables swelling. Consider keeping a diary of what you eat Symptoms of depression can include15: and when symptoms get worse. This might help you • Little or no saturated fat, especially fatty meats • Aches and pains that don’t go away with find ways to change your diet. Ask your doctor for and processed foods treatment guidance or a referral to a dietitian who can help you • Low amounts of salt and sugar build a diet that works for you. • Being tired or lacking energy • The daily recommended amount of vitamins • Eating too much or too little and minerals • Feeling hopeless or negative • Whole grains, like oatmeal or brown rice

If you drink alcohol, do so in moderation. Some people taking certain RA medications might need to avoid alcohol completely.2

6 7 Living with RA (continued)

Talk with your doctor if you feel depressed. Your Managing flares doctor might suggest counseling, antidepressant 17 RA and pregnancy 18 medication or a combination of both. In counseling, Protecting your bones Flares can happen suddenly. For some people, stress might bring on a flare. In others, infection you can talk with a therapist about your thoughts Research suggests that RA symptoms People with RA might be more likely to might be the cause. It is not always clear what and feelings. improve during pregnancy. But symptoms develop weak bones that are easy to break. triggers flares. But you can use many techniques to usually return and flares can occur after the This is called osteoporosis. Corticosteroid Antidepressants help balance brain chemicals that manage them and continue your daily activities14: affect your mood. It can take many months before baby is born. If you are pregnant or plan medications for RA, lack of activity and the they start to work. You might notice side effects to be pregnant soon, talk to your doctor effects of RA might all contribute to weak • Balance activity with periods of rest. bones. Work with your doctor to track your sooner. These might include16: about your RA medications. Some are not • Create a back-up plan. Talk to your doctor about bone health. You can take several steps to safe to take while trying to get pregnant or how to manage flares. Plan how you’ll manage • Headache help prevent weak bones: during pregnancy. A new mother who plans tasks at home and work during a flare. • Lack of sex drive to breastfeed should also ask her doctors • Ask your doctor about a bone density test. • Get help from others. Talk to family, friends and It can measure bone strength and your risk • Nausea which RA medications are safe to take co-workers about how they can help during a flare. of breaking a bone. • Restlessness when breastfeeding. • Ask your doctor if it’s safe for you to use hot or • Sleep problems • Do gentle, weight-bearing exercise, like cold packs on swollen joints. walking, as recommended by your doctor. − Some people find heat helps relieve pain and Talk with your doctor if your antidepressant does • Do not smoke cigarettes, which can relax muscles. not help. Do not stop taking the medication on your lower bone-strengthening hormones and − Others prefer cold to lessen swelling and own. Your doctor might need to adjust your dose or minerals. prescribe a different antidepressant. decrease muscle spasms. • Drink alcohol only in moderation. • Use relaxation techniques to keep your mind • Get enough calcium and vitamin D, which off symptoms. can help bone health. • Talk to your doctor about medications to prevent and treat osteoporosis.

8 9 Living with RA (continued)

Preventive health Getting a flu or pneumonia vaccine is a good idea for people with RA, depending on what other medications they may be taking. Only vaccines We’ve provided this information because we believe the more you where the virus has been “killed” should be know about RA, the better prepared you will be to manage it. In given.19,20 Ask your doctor about these and any other vaccines you should get. Your doctor may addition, the Walgreens Specialty Pharmacy Care Team is here to want to administer live vaccines before you start medication therapy. provide you with dependable, personalized support to help you

Surgery manage medication side effects and stay on track with your prescribed

Even with medication therapy and lifestyle changes, therapy. We look forward to being a member of your healthcare team some people with RA might still need surgery. This and helping you get the best results from your treatment. might be more likely if RA has made it extremely painful, difficult or impossible to move certain joints.2

Surgery for RA might include any of the following2:

• Joint fusion connects the ends of two bones together as one. This can limit movement. But it can also relieve pain and increase stability. • Joint replacement removes an arthritic joint and replaces it with a new, artificial joint. Ongoing care • Synovectomy removes swollen tissue around the joints for temporary pain relief. This is often done Work with your doctor to keep track of your as part of reconstructive surgery. progress and your symptoms. You can discuss how well your medication therapy and lifestyle changes • Tendon reconstruction fixes and rebuilds damaged are working. Your doctor can also monitor side tendons, usually in the hands. effects and adjust your treatment as needed. Each Surgery might help a person with RA get through visit can help you stay on track with treatment and daily tasks with less pain and improved joint better manage your RA. movement.2 But it is not for everyone. Ask your doctor if surgery is right for you.

10 11 References 1. Rheumatoid arthritis. Centers for Disease Control and 12. Kennedy K. Nutrition guidelines for people with Prevention Web site. http://www.cdc.gov/arthritis/ rheumatoid arthritis. Arthritis Foundation Web Resources basics/rheumatoid.htm. Updated November 6, 2014. site. http://www.arthritistoday.org/about-arthritis/ Accessed March 9. 2015. types-of-arthritis/rheumatoid-arthritis/daily-life/ You might find it helpful to contact these organizations for additional support and resources�* 2. Handout on health: Rheumatoid arthritis. National nutrition/rheumatoid-arthritis-diet.php. Accessed Institute of Arthritis and Musculoskeletal and Skin March 9, 2015. Diseases Web site. http://www.niams.nih.gov/Health_ 13. The relationship between RA and the food you American College of Rheumatology (ACR) National Institute of Arthritis and Info/Rheumatic_Disease/. Published August 2014. eat. Arthritis Foundation Web site. http://www. www.rheumatology.org Musculoskeletal and Skin Diseases (NIAMS) Accessed March 9, 2015. arthritistoday.org/about-arthritis/types-of-arthritis/ 404-633-3777 www.niams.nih.gov 3. More than just joints: how rheumatoid arthritis affects rheumatoid-arthritis/daily-life/nutrition/ra-and-food 877-22-NIAMS (64267) the rest of your body. Arthritis Foundation Web relationship.php. Accessed March 9, 2015. The ACR is an international clinical group that site. http://www.arthritis.org/about-arthritis/types/ 14. Coping with an arthritis flare. Arthritis Foundation Web supports ongoing education, research and Part of the National Institutes of Health, the rheumatoid-arthritis/articles/rhemuatoid-arthritis site. http://www.arthritistoday.org/about-arthritis/ advocacy about rheumatic diseases, including NIAMS supports research on arthritis and affects-body.php..Accessed May 22, 2015. types-of-arthritis/rheumatoid-arthritis/what-to-expect/ RA. Its website features links to the latest other musculoskeletal and skin diseases. Its flares/rheumatoid-arthritis-flare.php. Accessed 4. What is rheumatoid arthritis? Arthritis Foundation Web rheumatology research and publications as well as website features health information for patients March 9, 2015. site. http://www.arthritistoday.org/about-arthritis/types a searchable directory of rheumatologists. in a number of languages as well as links to the of-arthritis/rheumatoid-arthritis/what-you-need-to 15. Signs and symptoms of depression. National Institute know/what-is-ra.php. Accessed March 9, 2015. of Mental Health Web site. http://www.nimh.nih.gov/ latest research news and a database of current clinical trials. 5. Rheumatoid arthritis. Arthritis Foundation Web site. health/topics/depression/men-and-depression/signs http://www.arthritis.org/arthritis-facts/disease-center/ and-symptoms-of-depression/index.shtml. Accessed Arthritis Foundation May 27, 2015. rheumatoid-arthritis.php. Accessed March 9, 2015. www.arthritis.org 6. Effects of smoking on your health. BeTobaccoFree.gov 16. Antidepressants. MedLine Plus Web site. http:// 800-283-7800 Rheumatoid Patient Foundation (RPF) www.nlm.nih.gov/medlineplus/antidepressants.html. Web site. http://betobaccofree.hhs.gov/health-effects/ www.rheum4us.org smoking-health/. Accessed March 9, 2015. Accessed March 9, 2015. The Arthritis Foundation is the nation’s largest 7. Davis J. Obesity may be a risk factor for developing 17. Hazes JMW, Coulie PG, Geenen V, et al. Rheumatoid nonprofit group that supports advocacy, The RPF is a nonprofit organization dedicated RA. Arthritis Foundation Web site. http://www. arthritis and pregnancy: evolution of disease activity programs, services and research for arthritis and to improving the lives of people with rheumatoid arthritistoday.org/news/obesity-rheumatoid-arthritis and pathophysiological considerations for drug use. 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Immunogenicity org/about-arthritis/types-of-arthritis/rheumatoid and safety of pheumococcal vaccination in arthritis/treatment-plan/medication-overview/ra patients with rheumatoid arthritis or systemic lupus medications.php. Accessed March 9, 2015. erythematosus. Clin Infect Dis. 2002;34:147. 11. Crowson CS, Liao KP, Davis JM 3rd, et al. Rheumatoid arthritis and cardiovascular disease. Am Heart J. 2013; 1664622-628. 12 13 Walgreens.com/Specialty