Chronic musculoskeletal conditions

What is rheumatoid arthritis?

Rheumatoid arthritis is an autoimmune disease where the body’s immune system attacks its own tissues. Rheumatoid arthritis can affect anyone at any age, and may cause significant pain and disability.

Rheumatoid arthritis is a chronic autoimmune disease characterised by inflammation of the joints, causing inflammation, pain, swelling, stiffness and loss of function in the joints. Rheumatoid arthritis most often affects the hand joints and both sides of the body at the same time (CDC 2019).

In a healthy joint, the tissue lining the joint (called the synovial membrane or joint synovium) is very thin and produces fluid that lubricates and nourishes joint tissues (RACGP 2009). In rheumatoid arthritis, the immune system attacks the synovial membrane (RACGP 2009). The synovial membrane becomes thick and inflamed, resulting in unwanted tissue growth (Figure 1). As a result, bone erosion and irreversible joint damage can occur, leading to permanent disability (RACGP 2009).

Rheumatoid arthritis is a systemic disease, affecting the whole body, including the organs. This can lead to problems with the heart, respiratory system, nerves and eyes (CDC 2019). Its cause is not well understood although there is a strong genetic component (CDC 2019). Genetic factors are estimated to contribute 50–60% of the risk of developing rheumatoid arthritis (Tobón et al. 2010).

Figure 1: Comparison of healthy joint and joint with rheumatoid arthritis

Source: AIHW 2015.

How common is rheumatoid arthritis?

An estimated 456,000 Australians (1.9% of the total population) have rheumatoid arthritis, based on self-reported data from the Australian Bureau of Statistics (ABS) 2017–18 National Health Survey (NHS) (ABS 2018). Rheumatoid arthritis represented 13% of all arthritic conditions in 2017–18.

Rheumatoid arthritis is most common in people aged 75 years and over (Figure 2), although the onset of rheumatoid arthritis most frequently occurs in those aged 35–64 (AIHW 2009; Duarte-Garcia 2019). The prevalence of this disease is 1.5 times higher in women (2.3%) than men (1.5%).

Figure 2: Prevalence of self-reported rheumatoid arthritis, by age and sex, 2017–18

Note: refers to people who self-reported that they were diagnosed by a doctor or nurse as having rheumatoid arthritis (current and long term) and also people who self-reported having rheumatoid arthritis.

Source: AIHW analysis of ABS 2019 (Data table).

Impact of rheumatoid arthritis

Rheumatoid arthritis can severely affect a person’s quality of life and cause significant disability. Physical limitations, pain, fatigue and mental health issues are symptoms of rheumatoid arthritis that can impact a person’s ability to engage in daily activities (Radner et al. 2010). In Australia, rheumatoid arthritis accounted for 15% of the total burden of disease due to musculoskeletal conditions in 2015 (AIHW 2019a). Additionally, there is an economic impact to rheumatoid arthritis. In 2015–16, rheumatoid arthritis cost the Australian health system an estimated $1.2 billion, representing 9.6% of disease expenditure on musculoskeletal conditions and 1% of total disease expenditure (AIHW 2019b).

Perceived health status

People aged 45 and over with rheumatoid arthritis had lower self-assessed health status compared with people without the condition­ – based on self-reported data from the ABS 2017–18 National Health Survey (NHS). People with rheumatoid arthritis were 3.2 times as likely to describe their health as poor (18%) compared with those without the condition (5.6%) (Figure 3).

Figure 3: Self-assessed health of people aged 45 and over with and without rheumatoid arthritis, 2017–18

Note: Rates are age-standardised to the Australian population as at 30 June 2001.

Source: AIHW analysis of ABS 2019 (Data table).

Pain

Rheumatoid arthritis is a significant cause of physical disability. Functional limitations arrive soon after the onset of the disease and worsen with time. Joint damage in the wrist is reported as the cause of most severe limitation even in the early stages of rheumatoid arthritis (Koevoets et al. 2019).

Based on findings from the ABS NHS, in 2017–18, more than 2 in 3 people with rheumatoid arthritis aged 45 and over (68%) experienced ‘moderate’ to ‘very severe’ pain in the last 4 weeks. People with rheumatoid arthritis were 3.1 times as likely to have severe or very severe bodily pain in the last 4 weeks (30%) compared with those without the condition (10%) (Figure 4).

Figure 4: Pain^(a) experienced by people aged 45 and over with and without rheumatoid arthritis, 2017–18

(a) Bodily pain experienced in the 4 weeks prior to interview.

Note: Rates are age-standardised to the Australian population as at 30 June 2001.

Source: AIHW analysis of ABS 2019 (Data table).

Psychological distress

People with rheumatoid arthritis are more likely to suffer from anxiety, depression and low self-esteem (Kovic et al. 2012). Rheumatoid arthritis can affect a person’s ability to participate in work, hobbies and social and daily activities. Combined with the chronic pain associated with rheumatoid arthritis, this can lead to mental health issues including stress, depression and anxiety (Arthritis Australia 2017).

People aged 45 and over with rheumatoid arthritis were 2.5 times as likely to describe very high levels of psychological distress (11%) compared with those without the condition (4.3%), according to the 2017–18 NHS (Figure 5).

Figure 5: Psychological distress^(a) experienced by people aged 45 and over with and without rheumatoid arthritis, 2017–18

Notes: Rates are age-standardised to the Australian population as at 30 June 2001.

Source: AIHW analysis of ABS 2019 (Data table).

Treatment and management of rheumatoid arthritis

At present there is no cure for rheumatoid arthritis. The Australian Models of Care for the management of the disease focus on early diagnosis, early management, and coordination of multidisciplinary care needs (Arthritis Australia 2014; Speeran et al. 2014). The goal of rheumatoid arthritis treatment is to stop inflammation (put the disease in remission), relieve symptoms, prevent joint and organ damage, reduce complications and improve physical function. Early treatment for rheumatoid arthritis is aggressive in order to stop inflammation as soon as possible (Arthritis Australia 2014).

Medications are primarily used to treat rheumatoid arthritis, however physical therapy and surgery can also be used.

Medications

Treatment for rheumatoid arthritis has improved dramatically over the past 20 years, with new medicines now very helpful for people, particularly in the early stages of the disease.

Medications for symptoms

Simple analgesics (such as paracetamol) may be used for pain management. Based on the patient’s needs doctors may also prescribe other medications to manage pain and/or stiffness such as fatty acid supplements, nonsteroidal anti-inflammatory drugs (NSAIDs), COX-2 inhibitors and low dose corticosteroids (RACGP 2009).

Medications for slowing disease

Disease-modifying anti-rheumatic drugs (DMARDs), biologic disease-modifying anti-rheumatic drugs (bDMARDs), and corticosteroids may slow disease progression (Nam et al. 2014; RACGP 2009). Corticosteroids and DMARDs are typically prescribed and monitored by specialist rheumatologists and require close medical monitoring to ensure effectiveness and to minimise side effects (RACGP 2009). Evidence suggests initiation of aggressive treatment with DMARDs within 12 weeks of symptom onset is associated with less joint destruction and a higher chance of achieving DMARD-free remission as compared with a longer delay in assessment (van der Linden 2010).

bDMARDs are specialised immunosuppressant medications that have been shown to halt or slow the disease process sufficiently to reduce the joint destruction and disability associated with early rheumatoid arthritis (Nam et al. 2014). bDMARDs are also used for other autoimmune conditions such as juvenile arthritis, psoriatic arthritis and Crohn's disease.

Treatment options for rheumatoid arthritis, including bDMARDs are available through the Pharmaceutical Benefits Scheme (PBS) and Repatriation Pharmaceutical Benefits Scheme (RPBS) (AIHW 2013).

Physical therapy

Maintaining a healthy and active lifestyle is an important management strategy in rheumatoid arthritis. Low-impact physical activity can assist in reducing inflammation, increasing and maintaining mobility and strengthening muscles around affected joints (Cooney 2011).  A physiotherapist can prescribe an exercise program to assist in the management of rheumatoid arthritis.

Joint replacement surgery

Joint replacement surgery can relieve pain and restore function to joints severely damaged due to rheumatoid arthritis.

General practitioners and rheumatoid arthritis treatment

Treatment of rheumatoid arthritis often begins with the patient visiting a general practitioner (GPs). This is an important step in the treatment of rheumatoid arthritis because it is optimal for inflammation to be managed early on to reduce the chances of joint damage occurring (Speerin et al. 2014) and improve long-term outcomes (Bakker et al. 2011). GPs often conduct initial assessment and diagnosis of rheumatoid arthritis. The time from onset of rheumatoid arthritis symptoms and referral to a specialised rheumatologist for treatment needs to be as efficient as possible to improve long-term treatment outcomes (Nam et al. 2014). The RACGP recommends GPs complete diagnosis of rheumatoid arthritis as soon as possible and refer patients to a rheumatologist if joint swelling persists beyond 6 weeks (RACGP 2009).

Hospitalisation and the treatment of rheumatoid arthritis

Data from the National Hospital Morbidity Database (NHMD) show that, in 2020–21:

• There were 12,800 hospitalisations with a principal diagnosis of rheumatoid arthritis, a rate of 50 hospitalisations per 100,000 population.
• Three-quarters (75%) of rheumatoid arthritis hospitalisations were for females.
• The hospitalisation rate increased with increasing age until 75–79, and then decreased among people aged 80 and over (Figure 6).

Figure 6: Rate of hospitalisation for rheumatoid arthritis, by sex and age, 2020–21

Between 2010–11 and 2020–21, the hospitalisation rate for principal diagnosis of rheumatoid arthritis peaked in 2015–16 at 55 per 100,000, compared with 50 per 100,000 in 2020–21. The hospitalisation rate peaked at 81 per 100,000 for females and at 29 per 100,000 for males, in 2015–16 (Figure 7). 

The hospitalisation rate for rheumatoid arthritis among both males and females dropped in 2019–20, more markedly among the latter. This may have been due to widespread public health mandates to pause elective surgery due to the COVID-19 pandemic. In 2020–21 the hospitalisation rate returned to near or slightly above the pre-pandemic rate. The rate of hospitalisations was higher for females than males in all years (Figure 7).

Around 20% of hospitalisation for a principal diagnosis of rheumatoid arthritis are overnight stays with the majority being same day separations. Of overnight stays, the average length of stay has increased slightly over time and was 6.1 days in 2020–21.

Figure 7: Rate of hospitalisation for rheumatoid arthritis, by sex, 2010–11 to 2020–21

Comorbidities of rheumatoid arthritis

People with rheumatoid arthritis often have other chronic conditions, or ‘comorbidities’ (2 or more health conditions occurring at the same time). For this analysis, these selected comorbidities were considered:

• heart, stroke and vascular disease
• kidney disease
• arthritis
• mental and behavioural conditions
• asthma
• diabetes
• chronic obstructive pulmonary disease (COPD)
• osteoporosis
• cancer.

According to self-reported data from the ABS NHS 2017–18, among people aged 45 and over with rheumatoid arthritis:

• 36% also had back problems compared with 25% of people without rheumatoid arthritis.
• 35% also had mental and behavioural conditions compared with 22% of people without rheumatoid arthritis.
• 22% also had heart, stroke and vascular disease compared with 11% of people without rheumatoid arthritis.

Most chronic diseases are more common in older age groups. The average age of people with rheumatoid arthritis is older than the average age of the general population, therefore people with rheumatoid arthritis are more likely to have age-related comorbidities. The rates of back problems, mental and behavioural conditions, heart, stroke, and vascular disease, asthma, osteoporosis, and COPD as comorbidities remained significantly higher for people with rheumatoid arthritis compared with those without after adjusting for age (Figure 8). There was no significant difference for diabetes, cancer or kidney disease.

It is important to note that regardless of the differences in age structures, having multiple chronic health problems is often associated with worse health outcomes (Parekh et al. 2011), in addition to a poorer quality of life (McDaid et al. 2013) and more complex clinical management and increased health costs. Rheumatoid arthritis is also associated with increased mortality due to comorbidities and related complications (Lassere et al. 2013).

Figure 8: Prevalence of other chronic conditions in people aged 45 and over, with and without rheumatoid arthritis, 2017–18

Notes

1. Rates are age-standardised to the 2001 Australian population.
2. These components do not total 100% as one person may have more than one comorbidity.

Source: AIHW analysis of ABS 2019 (Data table).