Rheumatoid Arthritis

Rheumatoid Arthritis

1. Definition
   Rheumatoid arthritis (RA) is a chronic autoimmune disease in which the synovial lining of joints becomes inflamed, producing pain, swelling and, if untreated, progressive joint damage.

2. Causes / Etiology
   The exact cause is not known. It is thought to arise from a mix of genetic predisposition (certain HLA types), abnormal immune response and environmental triggers such as smoking or infections. These factors together set off an autoimmune attack on joint tissue.

3. Types or Classification

• Polyarticular RA – involvement of five or more joints, usually symmetrical.
• Oligoarticular RA – involvement of fewer than five joints.
• Systemic RA – joint disease together with extra‑articular features such as fever, fatigue, weight loss and organ involvement.

4. Pathology (step‑wise)
   step 1 → activation of T‑cells and B‑cells →
   step 2 → release of pro‑inflammatory cytokines (TNF‑α, IL‑1, IL‑6) →
   step 3 → increased vascular permeability and migration of neutrophils, macrophages into the synovium →
   step 4 → synovial membrane thickens (synovitis) and proliferates forming pannus (granulation tissue) →
   step 5 → pannus releases enzymes that erode cartilage and bone →
   step 6 → joint space narrows, deformities appear and function is lost.

5. Clinical Features
   General – morning stiffness lasting >1 hour, fatigue, low‑grade fever, loss of appetite and weight.
   Specific – symmetrical swelling, warmth and tenderness of small joints of hands and feet, joint deformities (e.g., ulnar deviation, swan‑neck), reduced range of motion.

6. Complications
   Acute – joint infection, fracture due to weakened bone, acute coronary events.
   Chronic – permanent joint deformity, chronic pain, disability, osteoporosis, increased risk of cardiovascular disease and pulmonary fibrosis.

7. Diagnosis / Investigations
   Routine – raised ESR (erythrocyte sedimentation rate) and CRP (C‑reactive protein), positive rheumatoid factor (RF).
   Special – anti‑CCP antibodies (high specificity), plain X‑ray showing joint space narrowing and erosions, MRI for early synovitis, ultrasound for effusion and pannus.

8. Management
   General – adequate rest, physiotherapy to maintain joint mobility, smoking cessation and weight control.
   Modern treatment – disease‑modifying antirheumatic drugs (DMARDs) such as methotrexate, leflunomide; biologic agents (TNF‑α inhibitors, IL‑6 blockers) for refractory cases; NSAIDs and low‑dose steroids for symptom relief.
   Dietary advice – balanced diet rich in fruits, vegetables and omega‑3 fatty acids; adequate calcium and vitamin D for bone health; limit processed foods and excess saturated fat.

9. Homeopathic Therapeutics (main remedies)

Bryonia

• Pain and swelling worsen on movement, improve with rest.
• Thirst for large amounts of water, dry hot skin.
• Joint pain is sharp, feels as if stretched.
• Worse in cold, damp weather.
• Restlessness due to pain.

Rhus toxicodendron

• Stiffness and aching improve with gentle motion and warmth.
• Worse on first motion after rest, especially in cold, damp conditions.
• Restlessness, irritability.
• Skin eruptions may accompany joint pain.
• Sensation of sprain or strain.

Apis mellifica

• Swollen, hot, tender joints that feel better with cold applications.
• Burning or stinging pain, worse from heat.
• Marked edema, skin may show hive‑like eruptions.
• Difficulty moving the affected joint.

Ledum palustre

• Joint pain aggravated by warmth, relieved by cold.
• Swelling with a feeling of heaviness.
• Stiffness especially after lying down.
• Skin may be pale, cold, with itching.
• Walking becomes difficult.

Causticum

• Burning, tearing pain in joints, worse in cold, better with warmth.
• Marked stiffness, especially on the left side.
• Swelling with a feeling of tightness.
• Difficulty in walking or climbing stairs.
• Skin may develop cracks or ulcers over joints.