• Rheumatoid arthritis is an autoimmune inflammatory disorder in which the body’s immune system mistakenly attacks healthy cells. The condition usually affects the joints and results in painful swelling and joint stiffness. 
• There is no known cause of rheumatoid arthritis but several risk factors such as age, disease history, obesity, and gender increase the chances of developing the condition.
• There are several stages of rheumatoid arthritis; mild, moderate, severe, and end-stage. Disease progression occurs from one stage to another and results in severe and prolonged symptoms. Every disease stage requires specific treatments ranging from medicines to surgery.
• Mild rheumatoid arthritis begins with swelling and joint stiffness followed by a moderate disease stage in which joint mobility gets restricted. After the moderate stage, comes the severe disease stage in which joint fusion occurs with fibrous tissue and deformities become visible. In end-stage rheumatoid arthritis, the joint disappears and bone fusion takes place which hinders mobility.
• Early and aggressive treatment increases the chances of rheumatoid arthritis remission which is the time when disease symptoms disappear or are under control.

Overview of Rheumatoid Arthritis

Rheumatoid arthritis is a chronic autoimmune disorder characterized by swollen, painful, and stiff joints in the body.

An autoimmune is the one in which your body’s immune system mistakenly perceives healthy and normal body cells as foreign objects or particles and attacks them resulting in abnormalities. This inflammatory condition starts from the smaller joints in your body and then progresses to larger ones. Rheumatoid arthritis can affect multiple joints at once. Not only this, but the condition also impacts other organs in your body such as the eyes, lungs, heart, etc. 

There is no specific known cause of rheumatoid arthritis. However, several factors can increase a person’s risk of developing a condition. These risk factors include age (>60 years), genetics, obesity, gender (females are more susceptible), not having given birth, smoking, etc.

Symptoms of rheumatoid arthritis include swollen, painful, and stiffened joints. However, disease symptoms don’t remain the same as arthritis is a progressive disease and has multiple stages. So, your symptoms can vary depending on your disease stage. We’ll talk about rheumatoid arthritis stages in detail later.

The condition not only takes a toll on a patient’s physical health but also impacts the quality of the patient’s life. Painful or swollen joints can affect a person’s mobility or in some cases can result in permanent disability. Other than this, rheumatoid arthritis can result in premature death and increase the risk of developing other chronic health conditions such as diabetes and heart health conditions.

When it comes to the diagnosis of a disease, there are two common ways to do it.

• Blood Tests: The first method is to conduct a series of blood tests including complete blood count (CBC), erythrocyte sedimentation rate (ESR), rheumatoid factor (RF), anti-cyclic citrullinated peptide antibody (anti-CCP) test. Other blood tests can include liver function tests (LFT), autoimmune markers, thyroid function tests, etc. Be mindful that no single blood test can diagnose rheumatoid arthritis.
• Imaging Test: Another common diagnostic approach for rheumatoid arthritis is imagining tests such as X-rays, magnetic resonance imaging (MRI), computed tomography (CT) scan, dual-energy X-ray absorptiometry (DEXA), and positron emission tomography (PET) scan, etc.

Rheumatoid arthritis treatment options are many and the choice of treatment option is dependent upon the rheumatoid arthritis stage, individual’s health condition, and response to the treatment. Some of the common treatment options include:

• Medicinal Treatment: Medicinal treatment includes the use of non-steroidal anti-inflammatory drugs (NSAIDs), disease-modifying antirheumatic drugs (DMARDs), and other novel drugs working on specific target mechanisms. 
• Surgical Treatment: In patients where joint damage is severe replacement surgeries are considered as a treatment option. In replacement surgeries, the damaged part of the joint is replaced with a healthy joint. Common replacement surgeries include shoulder joint, knee, and hip replacement surgery. 

Other than the treatment options, there is a need for disease management through lifestyle changes. These lifestyle interventions include keeping a healthy weight, eating nutritious foods, avoiding smoking, staying physically active, etc. There are many other rehabilitation programs for arthritis sufferers that help people to manage their condition. Other than this, every rheumatoid arthritis patient needs customized treatment plans for individuals which is according to the person’s health condition. So, make sure that you stick to your disease treatment plan.

Let’s talk about the rheumatoid arthritis stages in detail. 

Stages of Rheumatoid Arthritis

There are four stages of rheumatoid arthritis having variable systems. These include:

Stage 1: Synovium (Early-Stage Rheumatoid Arthritis)

Stage 1 rheumatoid arthritis is also known as early-stage rheumatoid arthritis. During this stage, joint stiffness is inside the joint as the synovium becomes swollen. Synovium is the lining of the joint cavity where synovial fluid is produced. Under normal conditions, synovial fluid keeps the cartilage surface lubricated and provides nutrition. However, in the case of rheumatoid arthritis, an inflammatory process begins at the synovial lining resulting in pain. Early-stage rheumatoid arthritis doesn’t affect your bones and there are no visible destructive changes.

Symptoms of early-stage disease are not very obvious so often go unnoticed. A person suffering from the condition may develop joint stiffness and mild pain which usually disappears with the movement. In case of early diagnosis followed by a treatment plan, there are chances of disease remission.

Stage 2: Pannus (Early-Stage Rheumatoid Arthritis)

The second stage of rheumatoid arthritis is also known as moderate-stage rheumatoid arthritis. This stage of arthritis is characterized by pannus formation. Pannus is the extra tissue growth that forms when extra synovial tissue or joint lining thickens. This extra growth then covers the joint bone and cartilage surface releasing chemicals that damage those tissues. Pannus formation occurs in small joints such as feet, hands, or wrists. Later the pannus formation can affect larger joints such as the shoulder or knee.

Patients suffering from moderate rheumatoid arthritis have noticeable symptoms due to bone and cartilage damage in joints. The symptoms get worse or become prolonged which makes stage 2 rheumatoid arthritis easier to diagnose than stage-1 disease. Disease symptoms become prominent as well as antibodies are produced which is a sign of ongoing autoimmune reactions in the body. However, blood tests may or may not detect the antibodies in the blood. In this stage of rheumatoid arthritis, joint swelling, and stiffness becomes evident with limited joint motion. Stage 2 rheumatoid arthritis if left untreated then progresses into stage-3 rheumatoid arthritis.

Stage 3: Fibrous Ankylosis (Severe Rheumatoid Arthritis)

This is the advanced stage of rheumatoid arthritis in which typical rheumatoid arthritis symptoms become severe. Pain and inflammation get worse and damage to bone and cartilage becomes severe with restricted mobility and visible joint deformities. The wearing of cartilage due to inflammation results in the erosion of bone near the joints. 

The lack of mobility during stage 3 rheumatoid arthritis is due to the fusion of bones and fusion of joints with connective fibrous tissues (that’s why it’s named fibrous ankylosis). Some of the common symptoms of fibrous ankylosis rheumatoid arthritis include:

• Formation rheumatoid nodules
• Deformities of joints such as curved, bent, or knobbly joints
• Restricted joint movement.

At this stage, disease diagnosis is not only dependent on blood tests or imaging results as symptoms are quite visible. If at this stage, the patient isn’t treated properly, then the disease progresses to stage 4 of rheumatoid arthritis. 

Stage 4: Bony Ankylosis (End Stage Rheumatoid Arthritis)

This is the most advanced stage of rheumatoid arthritis that comes after the diseases progress from severe rheumatoid arthritis. At this stage, bone fusion of actual bone occurs instead of fibrous tissue. There is no more inflammation in the joints and they lose their normal function. However, people with end-stage rheumatoid can still experience pain, swelling, and stiffness.

The joint destruction results in the fusion of bones which takes away the ability to bend or flex the area. At this stage, the joint inflammation goes and it can also weaken your body muscles. The absence of joints makes it really difficult to perform normal activities and patients become dependent on assistive mobility devices. Also, the signs of damage to other body organs are also visible at this stage. If the disease is timely treated, then there is little chance that a patient will reach end-stage rheumatoid arthritis.

Each rheumatoid arthritis stage has its own hallmark signs and symptoms which may vary from person to person. Depending upon the stage of rheumatoid arthritis, the treatment plan also varies. Before discussing these, let’s talk about the signs of rheumatoid arthritis progression. 

Signs of Rheumatoid Arthritis Progression

Rheumatoid arthritis is a progressive condition in which disease symptoms get worse with time. Knowing about disease progression is important because there is a specific treatment option for each stage of rheumatoid arthritis. Here are a few signs that would tell you about your disease progression:

• Severe or prolonged symptoms such as joint pain, swelling, and stiffness of joints
• Less range of motion
• Other non-joint symptoms such as shortness of breath etc.

A few factors that could affect the progression of rheumatoid arthritis are family history, current disease stage, any specific disease trigger, lifestyle choices, presence of antibodies in your body, etc. Knowing all your risk factors, your physician can help you in dealing with progressing diseases and adjusting treatments accordingly.

Treatment Plan According to Rheumatoid Arthritis Stages

Progression through the disease stages may take years or might not happen at all. For each stage, there is a different treatment plan required. So let’s find out how your treatment options change:

Stage 1 Rheumatoid Arthritis Treatment

During the initial phase, disease treatment is mainly focused on controlling inflammation. So, initially, medical treatment works quite well. Your physician can recommend NSAIDs, DMARs, or low-dose steroids to overcome the pain and limit joint inflammation. Also, several lifestyle modifications can also be a part of your treatment plan such as losing weight, quitting smoking, etc to make conditions more manageable.

Stage 2 Rheumatoid Arthritis Treatment

The aim of Stage 2 arthritis treatment is to control the extent of pain and inflammation as well as enable you to perform routine activities. During this stage, different combinations of DMARDs and steroid shots are used for the symptoms management of rheumatoid arthritis. Biological DMARDs or JAK inhibitors are also being used for moderate arthritis treatment. Other than medication, physical therapy, and other lifestyle management tips help with the management of symptoms. 

Stage 3 and 4 Rheumatoid Arthritis Treatment

Advanced stages of rheumatoid arthritis are treated by using a different type of TNF inhibitor or biological DMARDs. If none of the medicines work, then surgery comes as a suitable disease treatment option. Some of the common surgical procedures used for the treatment include tendon repair, joint fusion, and joint replacement surgery.

Rheumatoid Arthritis Remission

Disease remission means the period where disease is at a very low activity level and patients may experience little or no disease symptoms. Early and aggressive disease treatment increases the chances of disease remission. Several rheumatoid arthritis assessments are used to measure disease remission, including:

• Disease activity score (DAS/ DAS28) – assessment of rheumatoid arthritis disease activity based on the information collected from 28 joints.
• Health Assessment Questionnaire (HAQ) – pain scale that assesses the presence or absence of arthritis pain and measures severity. 
• C-reactive protein level – a measure of inflammation that is an indicator of ongoing autoimmune reactions in the body.

Conclusion

Rheumatoid arthritis is a chronic autoimmune disorder that affects the joints in the human body. This inflammatory condition is characterized by painful, swollen, and stiff joints. The disease can take a toll on a patient’s physical health as well can impact daily life activities due to limited mobility caused by joint damage. The disease initially begins as joint inflammation due to damage to the joint lining and then progresses to moderate, severe, and end-stage rheumatoid arthritis.

Disease progression from one stage to another may take years or can never happen at all. Each disease stage requires different treatment options to be considered. Alongside medicinal and surgical disease treatment, a variety of lifestyle interventions are found to be effective in disease management such as weight control, healthy food choices, physical activity, quitting smoking, etc.

References

• WebMD. Progression and Stages of Rheumatoid Arthritis (RA). https://www.webmd.com/rheumatoid-arthritis/ra-progression
• Medical News Today. The 4 Stages of Rheumatoid Arthritis. https://www.medicalnewstoday.com/articles/stages-of-rheumatoid-arthritis
• Creaky Joints. The 4 Stages of Rheumatoid Arthritis Progression. https://creakyjoints.org/about-arthritis/rheumatoid-arthritis/ra-overview/rheumatoid-arthritis-stages-progression/
• Johns Hopkins Arthritis Center. Rheumatoid Arthritis Signs and Symptoms. https://www.hopkinsarthritis.org/arthritis-info/rheumatoid-arthritis/ra-symptoms/
• GoodRX Health. What Are the Stages of Rheumatoid Arthritis? https://www.goodrx.com/conditions/rheumatoid-arthritis/rheumatoid-arthritis-stages
• Drugwatch. Rheumatoid Arthritis. https://www.drugwatch.com/health/arthritis/rheumatoid-arthritis/

Springer. Rheumatoid Pannus Formation. https://link.springer.com/article/10.1007/bf03041243