Rheumatoid Arthritis

Overview

What Is It?

Rheumatoid arthritis (RA) is an autoimmune disease that occurs when the body's immune system attacks and damages the joints and, sometimes, other organs.

Rheumatoid arthritis (RA) is a chronic and potentially debilitating inflammatory disease that causes pain, swelling, stiffness and loss of function in the joints.

According to the Arthritis Foundation, RA affects about 1.3 million Americans, mostly women; two to three times more women have RA than men, and the number of women with the disease appears to be increasing. The age of onset can vary, but it typically occurs between ages 30 and 60, with the risk increasing as a person ages. The good news is that new advancements in treatment have made it possible to slow or stop the progression of RA.

Unlike the more common osteoarthritis, which is mainly a disease of the cartilage in joints, RA occurs when the body's immune system attacks and damages the joints and, sometimes, other organs. RA often occurs in a symmetrical pattern, meaning that if one knee or hand is involved, the other one is, too.

The condition is considered an autoimmune disease. Such diseases are characterized by an immune-system attack on the body's healthy tissues. In RA, white blood cells travel to the synovium (the membranes that line the inner surface of the joint capsule) and cause inflammation, namely synovitis. The ensuing warmth, redness, swelling and pain are typical symptoms of RA, which usually affects the wrists, fingers, knees, feet and ankles.

The continuous inflammation associated with RA gradually destroys cartilage- the specialized tissue that coats and cushions the bony ends in the joints. The loss of cartilage leads to narrowing and loss of joint space and, eventually, damage to the bone. The surrounding muscles, ligaments and tendons that support and stabilize the joint also become weak and unable to work normally.

Systemic symptoms often include fatigue, general sense of malaise, low-grade fever, morning joint stiffness and difficulty moving a joint or several joints. Pain and signs of inflammation such as redness and warmth in or around a joint are often severe.

RA varies from person to person, but most cases are chronic, meaning they never go away. Some people have mild or moderate disease, with flares (periods of worsening symptoms) and remissions. For others, the disease is active most of the time. The resulting joint damage can be disabling.

The disease can affect more than just the joints, bones and surrounding muscle. About one-quarter of those with RA develop rheumatoid nodules. These are bumps under the skin that often form close to the joints. Many people with rheumatoid arthritis develop anemia. Other effects, which occur less often, include neck pain and dry eyes and mouth. Very rarely, RA results in inflammation of the blood vessels, the lining of the lungs, or the sac enclosing the heart. If you have RA, you may also be at increased risk for infections and gastrointestinal ailments.

Although no one knows the causes of rheumatoid arthritis, it seems to develop as a result of an interaction of several factors, including genetics, environment and hormones.

Diagnosing and treating rheumatoid arthritis can sometimes be difficult. It may require a team effort between you and several types of health care professionals, including a rheumatologist, a physician who specializes in arthritis and other diseases of the joints, bones and muscles. Physical therapists, psychologists and social workers can also play a role.

RA can be devastating, but current treatment strategies can help you cope and possibly reduce the impact of the disease. These strategies can include pain relievers and other medications, rest, appropriate exercise, education and support programs. Involvement of the rheumatology health care professional is essential in the care of RA.

The psychological element is important: Some studies indicate that if you are well informed about your condition and participate in your own treatment plan, you will probably have less pain and make fewer visits to your health care professional than otherwise. You can find treatment support groups in many cities.

Diagnosis

Rheumatoid arthritis (RA) can be difficult to diagnose in its initial stages, but an early diagnosis can be crucial to limiting its progress and severity. Some studies indicate that rheumatoid arthritis causes the most joint damage in the first two years.

There is no single test to determine if you have RA. The symptoms often are similar to those of other types of arthritis and joint conditions. The types of symptoms you experience—and the severity—may differ markedly from those of another person with RA. To make matters more confusing, symptoms can vary in the same person: Symptoms develop over time, and only a few may be present in the early stages of RA.

Often, RA is diagnosed by recognizing the type and pattern of joint involvement; it is a hallmark of RA, for example, if the same areas are affected symmetrically on both sides of the body.

The typical symptoms of RA include:

• tender, warm and swollen joints
• symmetrical pattern
• joint inflammation often affecting the wrists, fingers, knees, feet and ankles
• fatigue
• occasional fever
• a general sense of malaise
• pain and stiffness lasting for more than 30 minutes in the morning or after a long rest
• rheumatoid nodules (bumps under the skin—often formed close to the joints—that affect about a quarter of those with RA)

Less common symptoms can include neck pain and dry eyes and mouth. Very rarely, RA may cause inflammation of the blood vessels, the lining of the lungs or the sac enclosing the heart.

If you have any of these symptoms, you should visit a health care professional. He or she will take several factors into consideration before rendering a diagnosis:

• Medical history. Your description of the symptoms—including their duration and intensity—can help with the diagnosis.
• Physical examination. Your health care professional will do a physical exam and pay particular attention to your joints, skin, reflexes and muscle strength.
• Laboratory tests. Some lab tests can help establish the presence of RA. Your health care professional will probably order a test to detect rheumatoid factor (an antibody eventually present in the blood of most people with rheumatoid arthritis). It's inconclusive, however, since not all people with RA test positive for rheumatoid factor, especially in the early stages. Some people with other types of rheumatic disease and a small number of healthy individuals also have a positive rheumatoid factor test, so you could test positive and never develop the disease. A test called anti-cyclic citrullinated peptide, or anti-CCP, is now available and is more specific than rheumatoid factor tests. Specificity is even higher when both of the tests are positive. Other common tests include one that indicates the presence of inflammation in the body (the erythrocyte sedimentation rate, or ESR, and the C-reactive protein, or CRP), a test for antinuclear antibodies (antibodies that appear in about 30 percent to 40 percent of people with RA), a white blood cell count and a blood test for anemia.
• X-rays. These can help determine the extent of joint destruction. If you identify RA in its early stages, X-rays may not be helpful in diagnosis. However, they can be used to monitor the disease's progress. Other imaging techniques, such as MRI and particularly joint ultrasound, have been shown to be very useful in assessment of the extent of inflammation and joint damage in RA.

Treatment

The main goals of rheumatoid arthritis (RA) treatment are to relieve symptoms of inflammation and to significantly slow the progression of joint damage. Although there is no cure, you and your health care professional can develop strategies for keeping the disease under good control. You may need to try several approaches and different types of medication before you can satisfactorily relieve pain, reduce inflammation, slow joint damage and improve your ability to function.

In addition to the guidance of your primary health care professional, you may need care from a physical therapist, a rheumatologist (a physician who specializes in diagnosing and treating disorders that affect the joints, muscles, tendons, ligaments and bones) or an orthopedist.

When symptoms occur, you can take steps to lessen their severity. Protecting your joints from undue stress can help. Your health care professional can help you obtain a properly fitting splint. You may want to talk to him or her about self-help devices that can reduce stress on the joints while you participate in everyday activities. Zipper pullers, long-handled shoehorns and products that help you get on and off chairs, toilet seats and beds can all ease the strain on your joints.

Most likely, your treatment plan will include medications to relieve pain and/or reduce inflammation. Although there is no cure, disease-modifying antirheumatic drugs (DMARDs) may slow or stop the course of the disease. In the past, health care professionals often hesitated to prescribe these strong drugs until the disease had become relatively advanced. However, this approach has changed, especially for those who suffer from severe, rapidly progressing RA. Most rheumatologists believe that early treatment with more powerful drugs and the use of drug combinations is the best way to halt RA's progression and to reduce or prevent joint damage. It is therefore important to establish care of RA with a rheumatologist as early as possible.

The following are commonly used rheumatoid arthritis medications:

• Analgesics. Analgesics are drugs that provide pain relief, and they can be used either orally or topically in people with RA. Analgesics include topical capsaicin (Capsagel), oral acetaminophen (Tylenol), tramadol (Ultram) and the more potent narcotics oxycodone (OxyContin) and hydrocodone (Vicodin). Narcotics are usually discouraged in the treatment of rheumatoid arthritis, however, because of the long-term nature of the condition and the danger of dependence.
• Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs such as aspirin, ibuprofen, ketoprofen and naproxen help diminish pain, swelling and inflammation. However, each NSAID is a different chemical and can have different effects in the body.
  
  NSAIDs may cause side effects including ringing in your ears, bruising, heart problems, gastric ulcers, stomach irritation, and liver and kidney damage. The longer you use NSAIDs, the more likely you are to have side effects, and the more serious those effects can be. Many other drugs cannot be taken with NSAIDs—in particular, the blood thinner warfarin (Coumadin). NSAIDS should be used with caution in people over 65 and in those with any history of ulcers or gastrointestinal bleeding, congestive heart failure, renal insufficiency and hypertension. Even the nonprescription, over-the-counter forms of these medications have the same risks. It's important to ask your health care professional for safety information associated with pain relievers with your personal health history in mind.
  
  A newer NSAID (called a COX-2 specific inhibitor) inhibits an enzyme (COX-2), which triggers pain and inflammation, while sparing an enzyme called COX-1, which helps maintain the normal stomach lining. The COX-2 inhibitor celecoxib (Celebrex) is sometimes prescribed for RA, osteoarthritis and other pain-causing conditions, such as acute pain and menstrual cramps. Celebrex is currently the only COX-2 inhibitor on the market. Celebrex may increase the risk of heart attack and stroke; discuss these risks with your health care professional. And if you are currently taking Celebrex and think you are having an allergic reaction or have other severe or unusual symptoms while taking any NSAID, call your health care professional immediately. For more information on the risks associated with Celebrex, visit www.fda.gov.
• Disease-modifying antirheumatic drugs (DMARDs). These are slower-acting drugs, which work by altering the natural course of the disease and therefore slow or even prevent joint and cartilage destruction. They can produce significant results. You may need to wait weeks—even months—before seeing any effect, and you may use some or all of these, depending on the specifics of your condition. In some cases, one DMARD is used by itself. In other cases, more than one DMARD may be prescribed at the same time. You may have to try different medicines or combinations to find one that works best with the fewest side effects.
  
  Common DMARDs include: methotrexate (Rheumatrex, Trexall), sulfasalazine (Azulfidine), hydroxychloroquine (Plaquenil), leflunomide (Arava) and cyclosporine (Sandimmune, Neoral). People taking methotrexate and most other DMARDs need periodic monitoring to make sure that toxicity to the liver or bone marrow does not occur. Although there is clearly a potential for toxicity of a powerful drug like methotrexate, it actually has a remarkable safety profile in RA and can be taken continuously for many years. Side effects of DMARDS vary greatly but may include nausea or vomiting, diarrhea, heartburn, high blood pressure, sun sensitivity, rash, temporary hair loss, damage to the retina, liver or kidney damage, lung infections and bone marrow suppression.
  
  Pay attention to how your body responds to these drugs. Not only do you need to make sure the medications are effective (since efficacy can occasionally diminish over time), you also need to be alert to any problems arising from the drugs.
• Corticosteroids. Also known as glucocorticoids, corticosteroids such as prednisone and methylprednisolone (Medrol) reduce inflammation and pain and may slow joint damage from RA. Because they can cause dramatic improvements in a very short time, health care professionals often use them while waiting for DMARDs to kick in, and then may gradually discontinue use. They may be an option if your RA doesn't respond to NSAIDs and DMARDs. These medications also have serious side effects, especially at high doses, including increased bruising, thinning of bones, increased appetite, weight gain, worsening of diabetes and cataracts.
  
  RA can increase bone loss, leading to osteoporosis. This bone loss is more likely in people who use corticosteroids for longer periods of time. To keep your bones as strong as possible, use the lowest possible dose of corticosteroids for the shortest amount of time, consume at least 1,000 to 1,200 milligrams of calcium and 600 to 1,000 IUs of vitamin D a day and talk to your doctor about medications called bisphosphonates, such as alendronate sodium (Fosamax) and ibandronate sodium (Boniva), that can help reduce bone loss.
• Biologic response modifiers. These are protein drugs that must be administered by subcutaneous injection or intravenous infusion. These drugs help to reduce joint-damaging inflammation by interfering with the inflammation process. The most commonly used short-acting drugs in this category are adalimumab (Humira) and infliximab (Remicade). The longer-acting drugs in this category are certolizumab (Cimzia) and golimumab (Simponi). They all target and inactivate a protein called tumor necrosis factor, or TNF-alpha, which is involved in the cascade of immune responses that cause inflammation in people with RA. Other biologic response modifiers target different molecules involved in the inflammation process. For instance, the drug anakinra (Kineret) blocks a cytokine called interleukin-1 (IL-1). Abatacept (Orencia) blocks the activation of T cells, and rituximab (Rituxan) blocks B lymphocytes. Tocilizumab (Actemra) and sarilumab (Kevzara) are biologic response modifiers that inhibit interleukin-6. The biologic response modifiers are used as a second line drugs in individuals who do not respond to one or several traditional DMARDs.
  
  There have been very rare reports of serious nervous system disorders such as multiple sclerosis, seizures or inflammation of the nerves of the eyes, and serious infections, including sepsis and tuberculosis, with the TNF-inhibitors. The risk of tuberculosis has been greatly decreased with pre-therapy screening of TB skin tests and/or chest X-rays and treating with anti-TB drugs if these tests are positive.
  
  Additionally, there is some evidence that people treated with TNF inhibitors might have a somewhat higher risk of lymphomas. Although you need to be aware of these risks, it is equally important to recognize that the benefits can be substantial
• Non-biological DMARD. Recently, the U.S. Food and Drug Administration approved a new non-biological DMARD for RA treatment named tofacitinib (Xeljanz). This medication is the first in the new category of RA drugs that work by inhibiting intracellular enzymes called kinases. Tofacitinib is a JAK (Janus kinase) inhibitor. Kinases are involved in generation of inflammation in RA. Tofacitinib has been approved as a second-line drug for RA patients who have inadequate response or are intolerant to a first-line DMARD methotrexate. Similarly to biologic response modifiers, Tofacitinib may increase risk for infection and cause liver abnormalities. In addition, in clinical trials, it has been associated with lipid and various blood cell count abnormalities in a small percentage of people. Unlike other biologics, which are injected, Xeljanz is available in pill form. Your health professional will be able to tell if and when this new drug would be appropriate for treatment of your RA.

If you are taking a biologic response modifier and have an infection severe enough to require antibiotics, the biologic should not be given until the infection is gone.

If you are using DMARDs or biologics, you should not receive live-virus or attenuated-virus vaccinations. Discuss how to handle live-virus vaccinations with your health care provider.

Surgery may be an option if you have severe joint damage. In the right circumstance, it can help reduce pain, improve the affected joint's function and appearance and enhance your ability to perform daily activities. However, surgery is not right for everyone, and you and your health care professional need to discuss the best approach. Factors to consider include your overall health, the condition of the joint or tendon that will be operated on and cost of the surgery.

A common type of surgery prescribed for people with RA is joint replacement, which replaces your damaged joint with an artificial one. One thing to consider is that the artificial joints can wear out, necessitating additional surgery.

Tendon repair, most frequently performed on the hands, is a surgery that repairs overly loose or tight tendons around a joint.

In synovectomy, the inflamed synovial tissue is removed. Synovectomy is performed if the lining around your joint (synovium) is inflamed and causing pain, joint damage and loss of function that do not respond to conventional treatments.

RA may also require joint fusion (arthrodesis) or the surgical fusion of a joint to stabilize or realign it for pain relief in cases where joint replacement isn't possible.

ClinicalTrials.gov, a service of the National Institute of Health, provides easy access to information on clinical trials for a wide range of diseases and conditions, including rheumatoid arthritis. The website is located at www.clinicaltrials.gov.

What You Can Do to Combat RA Symptoms

While health care professionals must be involved in your care, there are a number of lifestyle changes you can make to help manage RA. Experts suggest that eating a healthy diet can enhance your overall health and thus help you better manage your RA. Although drinking has no known impact on the disease itself, you may need to avoid alcoholic beverages, depending on the RA medications you are taking, especially the often-prescribed methotrexate. Check with your health care professional. Stress reduction is also important, since your stress level may affect the amount of pain you feel.

Rest and exercise—seemingly opposite ends of the spectrum—are important to your health. When your RA is active, you will want more rest. But moderate exercise is critical to healthy muscles, joint mobility and flexibility. (Note: Discuss any exercise program with your health care professional before starting.)

While exercise may seem unappealing if you're experiencing frequent pain, there are a number of techniques to help you get through a program:

• Moist heat supplied by warm towels, hot packs, a bath or a shower can be used at home for 15 to 20 minutes three times a day to relieve symptoms. Applying heat before exercise can be a good way to start. A health care professional can apply deep heat using short waves, microwaves and ultrasound to relieve pain.
• Cold supplied by a bag of ice or frozen vegetables wrapped in a towel helps stop pain and reduce swelling when used for 10 to 15 minutes. This treatment often is recommended for acutely inflamed joints. Do not use cold treatments if you have numbness or poor circulation.
• Hydrotherapy (water therapy) can decrease pain and stiffness. Exercising in a large pool may be easier because water takes some weight off painful joints. Many community centers, YMCAs and YWCAs have water exercise classes developed for people with arthritis. You may also find relief from the heat and movement of a whirlpool.
• When performed by a trained professional, massage and manipulation (using the hands to restore normal movement to stiff joints) can help control pain and increase joint motion and muscle and tendon flexibility.

Although these types of physical therapy can temporarily relieve symptoms, none have documented anti-inflammatory effects or affect the rate of joint damage that can occur in RA.

Alternative Therapies for RA Pain Relief

• Relaxation techniques: Deep breathing, guided imagery and visualization (where you focus on "seeing" pleasant pain-free scenes or activities in your mind) and stress reduction help provide some pain relief. Physical therapists can teach relaxation techniques.
• Acupuncture: Acupuncture is an important component of traditional Chinese medicine that involves the insertion of thin needles at specific points, which are mostly along the body's nerve pathways, to improve health. A handful of small studies have been conducted on the use of acupuncture in RA, and the findings do not clearly answer the question of whether or not it works. Individuals who want to use acupuncture should discuss their interest with their health care team. Only a licensed acupuncturist should be used.
• Thunder god vine: Studies indicate that preparations made from the peeled root of this plant, used in traditional Chinese medicine to treat inflammatory and autoimmune disorders, may be helpful in the treatment of RA. Possible side effects include menstrual changes, hair loss and diarrhea.
• Nutritional supplements: A few studies have shown that the nutritional supplement gamma-linolenic acid (GLA) and the fish oils eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) may help reduce some of the symptoms of RA. Discuss your interest or questions about such products and reports with your health care professional.
• Biofeedback: Biofeedback is a way to enhance an awareness of your body so that you become focused on how your body functions; usually this enhanced focus is turned toward something—such as muscle control—that typically occurs at a subconscious level. During biofeedback, an electronic device provides information about a body function (such as heart rate) so you can learn to control that function. Biofeedback may help people with arthritis learn to relax their muscles. In this case, an electronic device amplifies the sound of a muscle contracting, so you know that the muscle is not relaxed. The therapy is typically learned with the help of a health care professional and then may be practiced at home once you have mastered the technique, either with a biofeedback machine or without one.
• Some additional techniques under investigation include tai chi (a movement- based form of meditation) and cognitive behavioral therapy (a method of anticipating and preparing yourself for situations and bodily sensations that will cause pain).

With all these treatments—lifestyle, medical and surgical—monitoring which treatments work and which don't and watching for side effects is critical. Monitoring can involve regular consultations with your health care professional as well as blood, urine and other laboratory tests and X-rays.

Prevention and Risk Reduction

Genetic, environmental and hormonal factors probably all play a role in the development of rheumatoid arthritis (RA). However, there is no known way to prevent RA. Cigarette smoking is one environmental risk factor for RA that you can avoid.

Certain genes involved in immune system responses are associated with a predisposition for developing RA, although there is no single "rheumatoid arthritis gene." People with RA are more likely to have human leukocyte antigen (HLA) genes than people without the disease, and other genes also play roles in the development of RA. Having any of these genes is no guarantee that you'll develop RA (in fact, many individuals with this common gene do not develop the disease); likewise, the absence of these genes doesn't rule out the possibility of developing the disease. It appears that a person's genetic make-up is an important part of the story, but not the whole answer.

Recent research shows that tobacco smoking can increase risk for RA. One study looked at more than 370,000 women as part of the Women's Health Cohort Study. The study found women who smoked for more than 20 years were 39 percent to 49 percent more likely to develop RA than nonsmokers.

Facts to Know

1. According to the Arthritis Foundation, rheumatoid arthritis affects approximately 1.5 million Americans, and two to three times more women have RA than men.
2. RA is considered an autoimmune disease. Such diseases are characterized by the immune system attacking the body's healthy tissues. Although RA affects other parts of the body, joint inflammation is the hallmark of this disease.
3. Although no one knows the precise causes of rheumatoid arthritis, it seems to develop as a result of an interaction of several factors, including genetics, environmental factors and hormones. A virus or bacterium could serve as the environmental trigger in people genetically susceptible to the disease.
4. Many researchers think a viral or bacterial infection may help trigger the development of RA. However, this remains unproven.
5. Tobacco smoking may increase risk for developing RA.
6. Rheumatoid arthritis appears to cause considerable joint damage in the first two years. An early diagnosis can be crucial in preventing the worst effects of the disease, especially since there are more effective treatment options today.
7. Common RA symptoms can include fatigue, occasional fever, morning stiffness, difficulty moving a joint or several joints, pain and inflammation in or around a joint and a general sense of malaise.
8. There is no single test you can take to find out if you have RA, although tests are used as part of the diagnosis.
9. Arthritis literally means joint inflammation, but the term often is used to refer to more than 100 rheumatic diseases that can affect children and adults. Osteoarthritis is the most common form.

Questions to Ask

Review the following Questions to Ask about rheumatoid arthritis (RA) so you're prepared to discuss this important health issue with your health care professional.

1. Do I have rheumatoid arthritis (RA)? How can you tell?
2. Can you rule out similar diseases, like osteoarthritis and lupus?
3. What are my treatment options?
4. How can I recognize a flare? What should I do when one occurs?
5. What drugs are available to help me? What are their benefits and side effects? Will these drugs interact with any other medications I am taking?
6. Can you recommend an exercise plan that is compatible with my stage of RA?
7. Should I try nutritional supplements like green tea and fish oils?
8. How far has my RA progressed? How does that affect the management plan you're recommending?
9. Can I benefit from starting therapy with disease-modifying anti-rheumatic drugs (DMARDs) early?
10. Are there any RA support groups in my area?
11. Are there any special devices that can help me stay as independent and active as possible?
12. What is methotrexate and how can it help me? How should I take methotrexate, and what are its risks? Are there any alternative drugs similar to methotrexate that I can try?
13. Should I take the selective COX-2 inhibitor Celebrex or one of the standard NSAIDs? What are the risks and benefits of both?

Key Q&A

Organizations and Support

For information and support on coping with Rheumatoid Arthritis, please see the recommended organizations, books and Spanish-language resources listed below.

American Autoimmune Related Diseases Association (AARDA)
Website: https://www.aarda.org
Address: 22100 Gratiot Avenue
East Detroit, MI 48021
Hotline: 1-800-598-4668
Phone: 586-776-3900
Email: aarda@aarda.org

American Chronic Pain Association
Website: https://www.theacpa.org
Address: P.O. Box 850
Rocklin, CA 95677
Hotline: 1-800-533-3231
Email: acpa@pacbell.net

American College of Rheumatology
Website: https://www.rheumatology.org
Address: 1800 Century Place, Suite 250
Atlanta, GA 30345
Phone: 404-633-3777

Arthritis Foundation
Website: https://www.arthritis.org
Address: P.O. Box 7669
Atlanta, GA 30357
Hotline: 1-800-283-7800

Bone and Joint Decade
Website: https://www.usbjd.org/index.cfm
Address: 6300 North River Road
Rosemont, IL 60018
Phone: 847-384-4010
Email: usbjd@usbjd.org

Healthline Networks, Inc.
Website: https://www.healthline.com/health/rheumatoid-arthritis
Address: 660 Third Street
San Francisco, CA 94107

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
Website: https://www.niams.nih.gov
Address: National Institutes of Health
Bldg. 31, Room 4C02 31 Center Dr. - MSC 2350
Bethesda, MD 20892
Hotline: 1-877-22-NIAMS (1-877-226-4267)
Phone: 301-496-8190
Email: niamsinfo@mail.nih.gov

Books

250 Tips for Making Life With Arthritis Easier
by Shelley Peterman Schwarz

Arthritis 101: Questions You Have. Answers You Need
by The Arthritis Foundation

Arthritis Bible: A Comprehensive Guide to Alternative Therapies and Conventional Treatments for Arthritic Diseases
by Craig Weatherby and Leonid Gordin M.D.

Arthritis Sourcebook
by Amy L. Sutton

Autoimmune Connection: Essential Information for Women on Diagnosis, Treatment, and Getting On with Your Life
by Rita Baron-Faust and Jill Buyon

Exercise Beats Arthritis: An Easy-to-Follow Program of Exercises
by Valerie Sayce and Ian Fraser

Pain-Free Arthritis: A 7-Step Plan for Feeling Better Again
by Harris H. McIlwain and Debra Fulghum Bruce

Walk with Ease: Your Guide to Walking for Better Health, Improved Fitness and Less Pain
by Arthritis Foundation

Spanish-language resources

American Academy of Family Physicians
Website: https://es.familydoctor.org/condicion/artritis-reumatoide/
Email: https://familydoctor.org/online/famdoces/home/about...

National Institute of Arthritis and Musculoskeletal and Skin Diseases
Website: https://www.niams.nih.gov/Portal_en_espanol/Informacion_de_salud/Artritis/rheumatoid_artritis_ff_espanol.asp
Address: National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) / National Intitutes of Health
1 AMS Circle
Bethesda, MD 20892
Hotline: 1-877-226-4267
Email: NIAMSinfo@mail.nih.gov