Inflammatory Arthritis

The most common symptoms of inflammatory arthritis are:

• Joint pain and stiffness after periods of rest or inactivity, particularly in the morning
• Swelling, redness and/or a feeling of warmth in the affected joints
• Inflammation of other areas in the body, such as the skin or internal organs like the lungs and heart
• Restricted movement of the joints
• Weakness and muscle wasting

People with inflammatory arthritis generally experience alternating periods of “flares” of highly intense symptoms with periods of disease inactivity.

The major types of inflammatory arthritis include:

• Rheumatoid arthritis affects more than 400,000 people in the UK. It often starts when a person is between 40 and 50 years old. Women are 3 times more likely to be affected than men. RA often affects the small joints of the hands and feet (fingers & toes) but can also affect the elbows, knees and ankles. RA tends to affect multiple joints affecting both sides of the body in a symmetrical pattern. The joints become swollen and tender to pressure, occasionally appearing red. The outer covering (synovium) of the joint is the first place affected. This can then spread across the joint, leading to further swelling and a change in the joint’s shape. This may cause the bone and cartilage to break down. People with RA can also develop problems with other tissues and organs in their body.

• Ankylosing spondylitis is a long-term inflammatory condition that mainly affects the bones, muscles and ligaments of the spine, leading to stiffness and joints fusing together. Other problems can include the swelling of tendons, eyes and large joints. Ankylosing spondylitis often begins at a young age (from the teens to the third decade of life) and is more common in men (about two to three times more common than in women). AS can also affect children, called juvenile ankylosing spondylitis, and more commonly so in boys than girls.

• Gout is a form of inflammatory arthritis that results from an excess of uric acid in the blood. Uric acid is a chemical that is created in the body when it digests and breaks down certain substances in food called purines. This can form crystals within joints that the immune system attacks causing inflammation and pain. 90% of gout attacks start in a single joint, most often in the big toe. These “attacks” tend to subside after 7-10 days but may be frequent and may lead to permanent joint damage if left untreated. Gout is genetically inherited and affects men more than women by a ratio of about 3 to 1. It is more common in patients with other conditions (comorbidities) such as heart disease, kidney disease, diabetes, high cholesterol and obesity. Amongst people who suffer with attacks of gout 90% of cases result from the kidneys not removing enough uric acid from the body, whilst 10% result from the body producing too much uric acid.

• Psoriatic arthritis is an inflammatory joint condition that can affect people with the skin condition psoriasis and around 1 in 3 people with psoriasis will experience related joint problems. It tends to develop 5-10 years after psoriasis is diagnosed although occasionally people will complain of the joint problems before they notice any skin-related symptoms. Like psoriasis itself, psoriatic arthritis is thought to be the result of the immune system mistakenly attacking healthy tissue.

• Polymyalgia rheumatica (PMR) is a condition that almost always affects people over 50 years of age, where the immune system causes muscle pain and stiffness (myalgia), classically across the shoulders and tops of the legs (the “limb girdles”). It can also sometimes affect the joints. PMR often comes on quickly, perhaps over a week or two. It can start just after a flu-like illness. The stiffness may be so severe that dressing, reaching, washing, climbing stairs or even getting out of bed may be difficult. The symptoms are different from the ache you may feel after exercise that your body isn’t used to. The pain and stiffness from polymyalgia rheumatica is often widespread and is worse when resting or after rest. Symptoms can improve with activity or as the day goes on. The pain may also wake you at night. PMR can also be associated with an autoimmune disease affecting the blood vessels called Temporal Arteritis (TA) or Giant Cell Arteritis (GCA). This can initially cause headaches and facial pain but may rapidly progress to blindness or even stroke if left untreated and requires urgent medical attention. Treatment for PMR and TA/GCA usually involves a prolonged course of corticosteroids to dampen (modulate) the body’s immune response.

• Enteropathic arthritis is a form of chronic inflammatory arthritis associated with inflammatory bowel disease (IBD), the 2 main types being ulcerative colitis and Crohn’s disease. About 1 in 5 people with Crohn’s disease or ulcerative colitis will develop enteropathic arthritis. The most common areas affected by inflammation are the peripheral (limb) joints and the spine.

• Juvenile idiopathic arthritis (JIA) is a form of autoimmune arthritis that causes joint inflammation in children under 16 years of age, most commonly in pre-school age children or teenagers. It is slightly more common in girls and is thought to be due to a combination of genetic factors and trigger factors from the environment, for example the infections that your immune system has been in touch with. The precise cause is not well understood, hence the term “idiopathic”. Around 70% of cases will resolve before adulthood however, in at least 30% of cases the arthritis will remain active into adult life.

• Reactive arthritis can cause inflammation of the joints, eyes and the tube that urine passes through (urethra). It can develop shortly after an infection of the bowel, genital tract or, less frequently, after a throat infection.

• Lupus is an autoimmune illness that affects many organs and systems in the body causing joint pain, skin rashes and tiredness. Lupus is a chronic condition, but symptoms tend to cycle in alternate periods of “flares” (or “flares-ups”) and remissions. There is no known cure, but numerous treatments are available.

There are five recognized forms of lupus:

• Systemic lupus erythematosus (SLE) is the most serious since it involves the entire body.
• Discoid lupus is a skin-only illness in which a specific rash, mostly a scarring rash of circular-shaped lesions, occurs without other symptoms (SLE patients sometimes have the same rash).
• Subacute cutaneous lupus involves a more widespread rash that is often worsened by sun exposure. It is associated with a limited form of SLE in about 50% of cases.
• Drug-induced lupus is relatively rare and is triggered by certain drugs, such as hydralazine and some anti-seizure drugs. Drug-induced lupus causes joint pain in about 90% of cases, rash in 20%, and inflammation of the lining of the heart or lung in 15%. It typically goes away if the drug is stopped.
• Neonatal lupus occurs in infants whose mothers have specific blood abnormalities, but not in infants of mothers who have SLE but do not have these abnormalities. Its symptoms usually consist mainly of a transient, unimportant rash and blood test abnormalities that disappear within a few months. In rare cases, it can lead to a serious form of heart disease.

When detected and treated in its early stages, the effects of inflammatory arthritis can be greatly diminished, or the condition may even disappear completely. The importance of proper diagnosis, particularly in the early stages of the disease, may prevent serious, lifelong arthritic complications.

You should therefore consult your GP if you experience any form of persistent or recurrent pain, swelling or stiffness in your joints.

Early recognition & treatment of inflammatory arthritis significantly improves outcomes whilst delay reduces efficacy of treatment and leads to poorer outcomes. When detected and treated in its early stages, the effects of inflammatory arthritis can be greatly diminished, or the condition may even disappear completely.

The importance of accurate diagnosis, particularly in the early stages of this disease cannot be overstated and may prevent serious, lifelong arthritic complications.

In most cases the initial diagnosis of inflammatory arthritis will be based upon a typical symptom history. Whilst there are several blood tests that can help confirm a suspicion of an inflammatory arthritis, none of these are specific enough to establish a definitive diagnosis is the absence of a good clinical history.

Whilst joint imaging by x-rays or MRI scanning may also be helpful in establishing the diagnosis, these are not diagnostic in their own right and are usually arranged after assessment by the specialist rheumatology service.

With the possible exception of Gout and PMR (which can usually be managed in primary care), when your GP suspects an inflammatory arthritis, you will be referred to a local specialist rheumatology service.

In Devon & Cornwall the Hospital-based Rheumatology Services operate rapid access “Early Arthritis Clinics” through which, after consultant assessment, patients may be seen within 2-3 weeks.

Referral is through your GP and strict referral criteria are in place. These criteria differ slightly between regional hospitals but broadly require a strong clinical suspicion of inflammatory arthritis where symptoms have been present for more than 4 week and less than 6-12 months and cannot be explained by a flare of osteoarthritis or gout.

Inflammatory arthritis is usually treated with a combination of medications that relieve swelling and pain along with others, such as corticosteroids or immunosuppressive drugs, that regulate the immune system. The latter are often divided into two main types: disease-modifying anti-rheumatic drugs (DMARDs) and biological treatments. These are specialist drugs that are normally initiated by a rheumatologist and will require regular monitoring in conjunction with your GP.

Painkillers

In some cases, you may be advised to use painkillers, such as paracetamol or a combination of paracetamol and codeine (Co-codamol), to relieve the pain associated with rheumatoid arthritis.

These medicines do not treat the inflammation in your joints, but they may be helpful in relieving pain.

For example, they may be recommended while you’re waiting to see a specialist or when your symptoms are particularly bad (flare-ups).

Non-steroidal anti-inflammatory drugs (NSAIDs)

In addition to, or instead of, the painkillers mentioned above, your doctor may prescribe a non-steroidal anti-inflammatory drug (NSAID).

This may be a traditional NSAID, such as ibuprofen, naproxen or diclofenac. Or your doctor may prescribe a type called a COX-2 inhibitor, such as celecoxib or etoricoxib.

These medicines can help relieve pain while also reducing inflammation in the joints, although they will not stop rheumatoid arthritis getting worse over time.

Your doctor will discuss with you what type of NSAID you should take, and the benefits and risks associated with it.

Although uncommon, taking NSAIDs can increase the risk of serious stomach problems, such as internal bleeding.

This is because the medicines can break down the lining that protects the stomach against damage from stomach acids.

If you’re prescribed NSAID tablets, you’ll often be given another medicine to take with it, such as a proton pump inhibitor (PPI).

Taking a PPI reduces the amount of acid in your stomach, which reduces the risk of damage to your stomach lining.

Corticosteroids (“steroids”)

Steroids are powerful medicines that can help reduce pain, stiffness and inflammation. They can be given as:

• a tablet (for example, prednisolone)
• an injection directly into a painful joint
• an injection into a muscle (to help lots of joints)

They’re usually used to provide short-term pain relief – for example, while you’re waiting for DMARD medicines to take effect or during a flare-up.

Steroids are usually only taken for a short time because long-term use can have serious side effects, such as:

• weight gain
• osteoporosis (weakening of the bones)
• easy bruising
• muscle weakness
• thinning of the skin

They’re usually used to provide short-term pain relief – for example, while you’re waiting for DMARD medicines to take effect or during a flare-up.

Steroids are usually only taken for a short time because long-term use can have serious side effects, such as:

Disease-modifying anti-rheumatic drugs (DMARDs)

DMARDs work by blocking the effects of the chemicals released when your immune system attacks your joints, which could otherwise cause further damage to nearby bones, tendons, ligaments and cartilage.

The DMARDs that may be used include:

• methotrexate
• leflunomide
• hydroxychloroquine
• sulfasalazine

Methotrexate is usually the first medicine given for rheumatoid arthritis, often with another DMARD and a short course of steroids (corticosteroids) to relieve any pain. These may be combined with biological treatments.

Common side effects of methotrexate include:

• feeling sick
• loss of appetite
• a sore mouth
• diarrhoea
• headaches
• hair loss

The medicine can also affect your blood cells and liver, so you’ll have regular blood tests to monitor this.

Less commonly, methotrexate can affect the lungs, so you may have a chest X-ray and possibly a breathing test when you start taking it. This is to provide a comparison if you develop shortness of breath or a persistent dry cough while taking it. But most people tolerate methotrexate well.

It can take a few months to notice a DMARD working. It’s important to keep taking the medicine, even if you do not notice it working at the beginning.

You may have to try 2 or 3 types of DMARD before you find the one that’s most suitable for you.

Once you and your doctor find the most suitable DMARD, you’ll usually have to take the medicine long term.

Further information can be obtained at the National Rheumatoid Arthritis Society (NRAS) website: starting DMARD therapy

Biological treatments

Biological treatments, such as etanercept and infliximab, are a newer form of treatment made from proteins and other substances produced by the body. When used for rheumatoid arthritis they’re usually taken in combination with methotrexate or another DMARD and are usually only used if DMARDs have not been effective on their own.

Biological medicines are given by injection. They work by stopping certain chemicals in your blood from activating your immune system to attack your joints.

Side effects from biological treatments are usually mild but include:

Some people may also be at risk of getting more serious problems, including the reactivation of infections such as tuberculosis (TB) if they have had them in the past.

Further information can be obtained at the National Rheumatoid Arthritis Society (NRAS) website: biological treatments

JAK inhibitors

JAK inhibitors are a new type of medicine available on the NHS for adults with severe rheumatoid arthritis. They are offered to people who cannot take DMARDs or biologicals or tried them but found they were not effective.

This medicine is usually used in combination with methotrexate.

JAK inhibitors can also be taken on their own by adults who cannot take methotrexate.

Further information can be obtained at the National Rheumatoid Arthritis Society (NRAS) website: JAK inhibitors

Physiotherapy

To prevent loss of mobility and joint function, it is essential that patients strive to balance between periods of rest (which can help to prevent flare of symptoms) and activity (which helps prevent joints from becoming too stiff). Physiotherapy can therefore play a large part in the management of these conditions and their associated problems. Physiotherapists can help you maintain function and strength in your joints and muscles and provide support for pain management.

Surgery

As with osteoarthritis, joint replacement surgery may need to be considered when these nonsurgical methods have failed to provide lasting benefit.

To learn more about the treatments available for arthritis click here.

To learn more about a specific medication used to treat arthritis click here.

Whatever type of arthritis you are suffering from, self-management can help.

• Exercising the joints cannot cause more damage and will usually help reduce pain and ease stiffness.
• Eating a healthy diet and keeping to a healthy weight can reduce the pressure on the joints, reduce pain and improve function.
• Reducing stress, improving your sleep, relaxing, socialising and sharing your experiences with others can help you better manage your pain.

Read more about self-management of arthritis

Useful information about inflammatory arthritis

• Keep Moving – Arthritis UK
• Online Arthritis Self-Management Resource – Arthritis Action
• Arthritis Action
• Arthritis UK
• The National Rheumatoid Arthritis Society (NRAS)
• Juvenile Arthritis Research (JAR)

Videos about inflammatory arthritis

• Biologics & advanced therapies – The Health & Care Video Library
• What is rheumatoid arthritis & how is it treated? – The Health & Care Video Library
• What is gout & pseudogout? – The Health & Care Video Library
• What is psoriatic arthritis? – The Health & Care Video Library

If you have been referred for a specialist opinion your details will be reviewed and it may be recommended that you are seen by a hospital clinician. Information to support you in choosing your preferred hospital, including waiting times can be found using the links below.

How long will I wait?

If a hospital assessment and/or treatment is clinically recommended your information will be sent to a specialist. Click below to find out more about waiting times for routine hospital assessment and/or treatment.

• Waiting times
• Find services near you