Rheumatoid arthritis can make normal daily activities incredibly challenging. Claybrooke talks symptoms, treatment, and underwriting implications
There are many different types of arthritis—inflammatory and degenerative for example–but it the case of Rheumatoid Arthritis (RA), it is inflammatory and progressive in nature, and also the result of an autoimmune disorder.
This means the body’s immune system, which produces antibodies to destroy viruses and foreign bacteria, mistakes its own tissue as foreign and fires antibodies to attack it, therefore causing inflammation. With RA, inflammation primarily occurs at the lining of the joints and can affect virtually any joint in the body depending on the case.
Symptoms most often occur first in peripheral joints like the hands, feet, and wrists, presenting as fluctuating pain, loss of strength and stiffness, or a feeling of particular stiffness in the morning. Many also find that RA also gives them flu-like symptoms or makes them feel tired, agitated, or depressed.
Due to the nature of RA, the symptoms will likely come and go. The times when symptoms relapse are known as ‘flare ups’ and are caused by increased blood flow to the area around the joint. The joints become red, warm, and painful as fluid gathers around them and the ligaments are forced to stretch.
As the condition progresses, cartilage protecting the end of the bones starts to thin, which can lead to possible bone erosion. Eventually, erosion of the bones leads to loss of movement and shape in the joint, and ultimately the joint will need to be replaced. Without good treatment response, disabling joint destruction can occur in a short amount of time.
The level of handicap varies and depends on how aggressive each individual case is. In milder cases, only peripheral joints are affected; however, in more progressive cases, RA can spread to more major joints, such as the shoulders, elbows, and hips. The disease’s course cannot be predicted, but it generally follows the more progressive tract. Periods of remission are normal after the first display of symptoms, but after two or three relapses, it’s likely a chronic form of the condition will set in.
RA is not just a disease of joint degeneration–because of its auto-immune nature, RA can cause inflammation in any part of the body. This type of inflammation is known as an extra-articular disorder (not limited to the joint).
In more serious cases of RA, inflammation can appear in the following locations:
Skin. Damage to the blood vessels is called vasculitis, and these vasculitic lesions can cause skin ulcers.
Heart. A collection of fluid around the heart from inflammation is not uncommon. This typically causes only mild symptoms, but they can be severe. Inflammation can affect the heart muscle, its valves, and its blood vessels.
Lungs. The lungs can be affected in two ways: (1) fluid can collect around one or either lung, or (2) tissues in the lungs may become stiff or overgrown. Both forms of inflammation can have a negative effect on breathing.
Eyes. The eyes usually become dry, inflamed, or possibly both, and this type of inflammation is called Sjogren syndrome. This condition’s severity depends on the part of the eye affected.
RA is not fatal on its own, but life expectancy is shorter than the general population for those with the disease, due to the extra-articular complications and the side effects of treatment. Extra-articular complications increase with occurrences of ischaemic heart disease and stroke in those with RA.
RA can be hard to diagnose due to the many other conditions that cause joint pain and also a lack of a definitive diagnostic test to distinguish RA from the rest. A diagnosis of RA comes from the body’s symptoms and is supported by blood test results. One test used is for the Rheumatoid Factor (RF) antibody in the blood–RF is positive in about 80 percent of RA patients. However, RF also tests positive in around 5 percent of people without RA, and therefore further tests are necessary.
Other common tests used to support an RA diagnosis include the following:
Erythrocyte sedimentation rate (ESR)This test shows the presence of inflammation in the body, showing that there is activity of the disease.
C-reaction protein test (CRP) This test also indicates inflammation and RA activity.
Full blood count (FBC) About 80 percent of RA patients develop anemia, a decrease in red blood cells in the blood, which when anemic cannot carry oxygen to the brain. This test also provides strong support.
X-rays. These are used to check for physical changes in joint structure throughout the body.
To treat RA symptoms, doctors can prescribe anti-inflammatory drugs, which reduce pain and swelling but do not slow down joint damage. During relapse flare-ups or in more severe cases, immunosuppressant’s or oral steroids may be necessary though these too have their own complications.
Immunosuppressant’s bring the immune system back to a normal state, but they can also reduce response to infections. Oral steroids, such as prednisone, reduce pain and swelling and also slow joint damage, but they can only be used for a short time. Steroids become less effective the longer they are used, and long-term use can cause bone thinning, cataracts, raised blood pressure, and diabetes.
Facts and Figures
- RA affects more than 350,000 people in the UK.
- The cause of RA is unknown and can set at any age (most common between 30-50).
- Females are three times more likely to receive an RA diagnosis compared to males.
- Smoking increases the risk of RA, especially in non-menopausal women.
- RA is more common than leukemia and multiple sclerosis.
In general, of people with RA:
(1) 20 percent only have very mild symptoms.
(2) 75 percent continue to have flare ups.
(3) 50 percent of RA patients are unable to work ten years after onset.
(4) Around 10-20 percent of affected persons deteriorate to the point of being wheelchair-bound or bedridden.
Insurance Underwriting Implications
When considering filling out an application for life protection, critical illness (CI) cover, and disability benefits, underwriters try to gather as much information from the clients at their condition’s outset.
The disease’s level of severity can be evaluated from the extent of the symptoms, treatment, and level of handicap. In the mildest cases, terms-for-life cover, critical illness, and disability benefits may be offered without further specific medical proof of illness. For more moderate to severe cases, a general practitioner’s report is required.
In their report, underwriters look to establish the disease’s pattern, the severity of symptoms, any blood test or x-ray results, the facts of any prescribed treatment, and any complications.
From all of this, the disease’s severity can be categorized as one of the following:
Mild -slight pain and stiffness in the peripheral joints, minimal swelling, and no deformities. RF is negative, and ESR and CRP are normal. No erosions were found on x-rays, and patient is able to perform all normal facets of daily life.
Moderate -difficult pain, major joint involvement, or constraint of movement in affected joints. Patient requires frequent and continuous drug therapy. RF is positive, and ESR or CRP is slightly increased. Patient is able to perform all facets of daily life with slight difficulty.
Severe -chronic, active disease, with no release from pain and also serious restriction of movement and impairment of function. RF is positive, and ESR or CRP is greatly increased. Patient is at a restricted level of activities that he or she can perform in daily life and may require physical assistance.
For mild cases, underwriters look to offer life at ordinary rates or with a smaller rate and exclude RA from CI and disability benefits.
For moderate cases, life cover, CI, and disability benefits may be rated at 75 percent with an RA exclusion for CI and disability benefits.
For severe cases, underwriters are only able to offer life cover with a minimum rating of +100 percent. Additional ratings also apply to ongoing steroid treatment or additional cardiovascular risks.