Living with rheumatoid arthritis can make normal daily activities incredibly challenging. Scott Robertson talks symptoms, treatment and underwriting implications
There are many different types of arthritis. Some are inflammatory while others are degenerative in nature. Rheumatoid Arthritis (RA) is the result of autoimmune disorder and is inflammatory and progressive in nature. This means that where normally the body's immune system produces antibodies to destroy foreign substances such as viruses and bacteria, it mistakes its own tissue as being foreign and attacks it, causing the inflammation. In the case of RA, the inflammation primarily occurs at the lining of the joints.
RA affects everyone differently as symptoms can affect any joint in the body. Symptoms most commonly first occur in the peripheral joints such as the hands, feet or wrists; presenting as fluctuating pain, stiffness and loss of strength, or as a feeling of being particularly stiff in the morning. Many people also find that the condition gives them flu-like symptoms or makes them tired, irritable or depressed.
Due to the nature of the condition, it is likely that symptoms will come and go. The occasions where symptoms relapse are known as 'flare ups' and are caused by increased blood flow to the area around the joint. The joints become warm, red and painful as fluid collects around them and the ligaments are stretched. As the condition progresses, cartilage protecting the end of the bones becomes thinned and can lead to the bone becoming eroded. Over time, erosion of the bone will lead to loss of movement and shape of the joint and ultimately requires the replacement of the joint. Without good response to treatment, disabling joint destruction can occur in a short space of time.
Varying degrees
The level of disability varies and depends on how aggressive each individual case. In milder cases, only the peripheral joints are affected. In more progressive cases it can spread to more major joints, such as the shoulders, elbows and hips. The course of the disease is unpredictable but generally follows a progressive course. Periods of remission are normal at outset, but after two or three relapses, a chronic form of the disease is likely.
RA is not solely a disease of joint destruction. Due to the auto-immune nature of RA, it can cause inflammation to develop in any part of the body. Inflammation in other parts of the body are known as extra-articular (not limited to the joint) disorders. In the more severe cases of RA, inflammation can appear in the following locations:
- Skin. Damage to the blood vessels is called vasculitis, and these vasculitic lesions may cause skin ulcers.
- Heart. Collection of fluid around the heart from inflammation is not uncommon. This usually causes only mild symptoms but it can be severe. Inflammation can affect the muscle of the heart, its valves, or blood vessels.
- Lungs. The effects on the lungs may take several forms. Fluid may collect around one or either lung, or tissues may become stiff or overgrown. Any of these can have a negative effect on breathing.
- Eyes. The eyes commonly become dry and/or inflamed. This is called Sjogren syndrome. The severity of this condition depends on which parts of the eye are affected.
RA itself is not fatal, but life expectancy is shorter for those with the disease than for the general population due to the extra-articular complications and the side effects related to treatment. Extra-articular complications also increase the occurrence of ischaemic heart disease and stroke among those with RA.
It can be difficult to diagnose RA due to the number of conditions that can cause joint pain and the lack of definitive diagnostic test. The diagnosis of RA is based on the body's symptoms and supported by the results of blood tests. One test used is the Rheumatoid Factor (RF) antibody in the blood. RF is positive in around 80% of people with RA. However, this test is also positive in about 5% of people without the disease and therefore further tests are required. Other common tests to support a diagnosis of RA are as follows:
- Erythrocyte sedimentation rate - this test (ESR) shows the presence of inflammation in the body, indicating activity of the disease.
- C-reactive protein test (CRP) - this test also indicates inflammation and activity of the disease.
- Full blood count (FBC) - about 80% of people with RA develop anaemia.
- X-rays - to check for physical changes in the joint structure.
Treatment
To treat the symptoms of RA doctors may prescribe anti-inflammatory drugs. These medicines reduce pain and swelling but do not slow down the damage to joints. During flare-ups or in more severe case, immunosuppressants or oral steroids may be required but these too have complications.
Immunosuppressants bring the immune system back to normal, but these medicines can lower response to infections. Oral steroids such as prednisone reduce pain and swelling and slow the damage to joints but they can only be used for a short period. The longer steroids are used, the less effective they become, and long-term use can also cause side effects such as 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 onset may be at any age. It is most common at ages 30-50, but the prevalence of the condition increases with age.
- Females are 3 times more likely to be diagnosed with RA compared with males.
- Smoking increases the risk of RA especially in pre-menopausal women.
- RA is a more common than leukaemia and multiple sclerosis.
In general, of people with RA:
- 20% will only have very mild symptoms.
- 75% will continue to have flare-ups.
- 50% of RA patients are unable to work 10 years after onset.
- About 10% to 20% of affected individuals deteriorate to such a degree they become wheelchair-bound or bedridden.
Scott Robertson is life and disability underwriter at Aegon Scottish Equitable
Sources:
Swiss Re. Lifeguide
National Rheumatoid Arthritis Society
RGA
www.bbc.co.uk/health
www.bupa.co.uk
Underwriting implications
When considering an application for life protection, critical illness (CI) cover and disability benefits underwriters will try to obtain as much information from the client at outset. The severity of the disease can be judged from the extent of the symptoms, treatment and level of disability. In the mildest of cases, terms for life cover, critical illness and the disability benefits may be able to be offered without further medical evidence. For cases where the symptoms appear more moderate or severe, a general practitioner's report will be required.
In the report, underwiters will look to establish the pattern of the disease, the severity of the symptoms, the results of any blood tests or x-rays performed, the details of the treatment prescribed and any complications. From this, the severity of the disease can be classified into the following categories:
- Mild - slight pain and stiffness in peripheral joints, minimal swelling and no deformity. Negative RF and ESR and CRP normal. No erosions on x-ray. Able to carry out all normal activities of daily living.
- Moderate - troublesome pain, extensive joint involvement or limitation of movement in affected joints. Frequent or continuous drug therapy. RF positive and ESR or CRP slightly increased. Able to carry out all activities of daily living with limited difficulty.
- Severe - chronic active disease, no complete freedom from pain with serious restrictions of movement and impairment of function. Positive RF, ESR or CRP greatly increased. Restricted level of activities of daily living or requiring physical assistance.
For the mild cases, underwriters would look to offer life at ordinary rates or with a small rating and exclude rheumatoid arthritis from CI and the disability benefits.
For moderate cases, life cover, CI and disability benefits may be rated by 75% with a rheumatoid arthritis exclusion for CI and disability benefits.
For severe cases, underwriters would only be able to offer life cover with a minimum rating of +100%.
Additional ratings would also apply for ongoing steroid treatment or additional cardiovascular risks.
