Rheumatoid arthritis is a chronic illness, which in the worst case is a progressive disease, and can have a profound effect on the general physical and mental well-being of patients. The assessment of the severity of rheumatoid arthritis is very important in terms of monitoring the course of the disease and measuring the effectiveness of treatment.
There have been many proposals as to how to assess severity. Some have said it is necessary to consider joint swelling, evidence of damage on x-rays, abnormal labs, and disability, as the damage to the joints may make it difficult or impossible to go about one’s daily activities. In addition, rheumatoid arthritis can occasionally affect other organs, such as the lungs, the heart, the blood system and the nervous system; so, the presence or absence, and the severity, of involvement of the other body systems must also be considered. Of course, disease activity can fluctuate over time. This being said, there is a need for an easy measure of severity.
Many rheumatologists consider rheumatoid arthritis disease activity to be the potentially reversible effects of inflammation: pain, stiffness, fatigue, joint swelling, weight loss, elevated sedimentation rate (which is a laboratory measure of inflammation) and anemia.
The most complete method of measuring rheumatoid arthritis severity is based on the American College of Rheumatology standards, whereby the evaluating rheumatologist examines the patient, checks the lab tests and x-rays. Researchers have found that the amount of joint pain and swelling correlates well with the amount of destruction seen on joint x-rays. The lab test known to many as the sedimentation rate itself correlates with how poorly a patient is doing in terms of muscle strength and general daily activities.
There is no truly easy way of explaining the difference between mild, moderate and severe rheumatoid arthritis to the arthritis patient: all patients just want to feel normal again. I, however, will try:
Mild Rheumatoid Arthritis
Mild disease is, in my opinion, when the patient has no evidence of joint damage on x-rays; that is, there is no loss of bone density, and no sign of bone destruction due to the inflammation of rheumatoid arthritis. In mild disease, the patient most likely has less than an hour of significant morning stiffness. These patients typically have at the most slight fatigue, no anemia, a mildly elevated sedimentation rate, no weight loss, and only mild swelling and joint pain. With the more mild medications such as Plaquenil and sulfasalazine, the mild rheumatoid arthritis patient can usually continue with the usual daily activities, missing very little work.
Moderate Rheumatoid Arthritis
Patients with more moderate disease will likely have some evidence of loss of bone density, and perhaps evidence of early bony erosions due to the destructive inflammation. These patients may have a couple hours of morning stiffness, fatigue, evidence of anemia, and a moderately elevated sedimentation rate; all of which may be accompanied by slight weight loss and significant joint pain and swelling involving at least ten joints. Patients with moderate rheumatoid arthritis often need stronger drugs, such as methotrexate and Arava; often, these fail over time, and thus the patient is next put on a “biologic” drug such as Enbrel, Humira, Simponi, Cimzia or Remicade. Usually, a biologic drug is added to methotrexae, or whatever traditional agent the patient was taking, and which was not doing the job in terms of allowing the patient to be able to perform daily activities, including going to work.
Severe Rheumatoid Arthritis
It is not difficult to picture the typical severe rheumatoid arthritis patient: He or she has hours upon hours of morning stiffness, significant joint destruction on x-ray, profound fatigue, difficulty getting out of bed in the morning, significant anemia, a high sedimentation rate, joint pain and swelling involving most of the joints. Sometimes the anemia and weight loss are so significant that the severe rheumatoid arthritis patient is suspected of having a cancer. Severe rheumatoid arthritis patients often do not respond very well to the stronger traditional drugs such as methotrexate and Arava. Unfortunately, many will not be helped by Enbrel or Humira. Fortunately, newer biologics, such as Orencia, Rituxan and Actemra are approved for rheumatoid arthritis patients who fail the anti-tumor necrosis factor drugs (such as Enbrel, Humira, and Remicade).
Of course, the hope is that one day we will not have to worry about a mild rheumatoid arthritis patient becoming a severe patient; because, hopefully, there will one day be a cure for rheumatoid arthritis.