Rheumatoid Arthritis

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Rheumatoid Arthritis

Overview

Picture of the skeletal system Is this topic for you?

There are many types of arthritis (disease of the joints). This topic is about rheumatoid arthritis. If you are looking for information about how juvenile idiopathic (rheumatoid) arthritis affects young children, see the topic Juvenile Idiopathic Arthritis. If you are looking for information on the most common form of arthritis in older adults, see the topic Osteoarthritis.

What is rheumatoid arthritis?

Rheumatoid arthritis (RA) causes tissues lining the joints to become swollen, stiff, and painful (inflamed).

Over time, this inflammation may destroy the joint tissues. This can limit your daily activities and make it hard for you to walk and use your hands.

Rheumatoid arthritis is more common in women than in men. It often begins between the ages of 40 and 60.

What causes rheumatoid arthritis?

The exact cause is not known. But rheumatoid arthritis is an autoimmune disease. This means that the body's natural defense system attacks the joints. The disease may run in some families.

What are the symptoms?

The main symptoms of rheumatoid arthritis are pain, stiffness, and swelling in the joints of the hands, wrists, elbows, feet, ankles, knees, or neck. The disease usually affects both sides of the body at the same time. In rare but severe cases, it may affect the eyes, lungs, heart, nerves, or blood vessels.

See a picture of the most commonly affected joints.

Sometimes the disease can cause bumps called nodules to form over the elbows, knuckles, spine, and lower leg bones.

How is rheumatoid arthritis diagnosed?

There is no single test for rheumatoid arthritis. Your doctor will do a physical exam and look at your joints for signs of swelling or tenderness. He or she will also ask about your symptoms and past health.

You may have blood tests, X-rays, and other tests to find out if another problem is causing your joint pain.

How is it treated?

Treatment for rheumatoid arthritis continues throughout your life. It includes medicine, exercise, and lifestyle changes. Getting treatment early may control the condition or keep it from getting worse.

Many of the medicines used to treat rheumatoid arthritis have side effects. So it is important to have regular checkups and talk with your doctor about any problems. This will help your doctor find a treatment that works for you.

At home, there are things you can do to relieve your symptoms.

  • Rest when you are tired.
  • Protect your joints from injury by using devices like special kitchen tools or doorknobs.
  • Use splints, canes, or walkers to ease pain and take stress off your joints if your symptoms are severe.
  • Eat a balanced diet.
  • Exercise regularly.
  • Stay at a healthy weight.

If you try medicine, exercise, and lifestyle changes for at least a few years but they don't help, surgery may be an option. Total joint replacement of the hip and knee are the most successful.

It can be hard to live with a long-term illness that can limit your ability to do things. It is common for people with rheumatoid arthritis to feel depressed. Your mood can affect how you feel and how well you cope with pain. Be sure to seek the help and support you need from friends and family members. Professional counseling can also help.

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  Arthritis: Managing Rheumatoid Arthritis

Cause

The cause of rheumatoid arthritis (RA) is not fully understood. Genes play a role, but experts don't know exactly what that role is. For most people with RA, the disease doesn't run in their families and they don't pass it along to their children. One or more genes may make it more likely that the body's immune system will attack the tissues of the joints. This immune response may also be triggered by bacteria, a virus, or some other foreign substance.

More information

Symptoms

Joint pain can be an early symptom of many different diseases. In rheumatoid arthritis, symptoms often develop slowly over a period of weeks or months. Fatigue and stiffness are usually early symptoms. Weight loss and a low-grade fever can also occur.

Joint symptoms include:

  • Painful, swollen, tender, stiff joints. The same joints on both sides of the body (symmetrical) are usually affected, especially the hands, wrists, elbows, feet, ankles, knees, or neck.
  • Morning stiffness. Joint stiffness may develop after long periods of sleeping or sitting. It lasts at least 60 minutes and often up to several hours.
  • Bumps (nodules). Rheumatoid nodules ranging in size from a pea to a mothball develop in nearly one-third of people who have rheumatoid arthritis. Nodules usually form over pressure points in the body such as the elbows, knuckles, spine, and lower leg bones.

In addition to specific joint symptoms, rheumatoid arthritis can cause symptoms throughout the body (systemic). These include:

  • Fatigue.
  • A loss of appetite.
  • Weight loss.
  • Mild fever.

Some of the symptoms of rheumatoid arthritis may be similar to symptoms of other health conditions.

More information

What Happens

The course of rheumatoid arthritis is hard to predict. It usually progresses slowly, over months or years. In some people it doesn't get worse, and symptoms stay about the same. But in rare cases, symptoms come on rapidly, within days.

Symptoms can come and go. You may have times in your life when joint pain goes away on its own for a while. This is called remission.

If the disease progresses, joint pain can restrict simple movements, such as your ability to grip, and daily activities, such as climbing stairs. It is a common cause of permanent disability. But early treatment may control the disease and keep it from getting worse.

Rheumatoid arthritis is more likely to get worse when:

  • A rheumatoid factor blood test is positive.
  • A blood test for the antibody CCP (cyclic citrullinated peptide) is positive.
  • The disease fails to respond to therapy.
  • Bumps (nodules) form rapidly.
  • Many joints are affected.
  • X-rays show early loss of bone or cartilage.

Joint damage

The ongoing inflammation caused by rheumatoid arthritis affects the tissues that line joints. It causes a breakdown in cartilage and loosens ligaments and tendons that support the joints. The resulting joint destruction can lead to deformed joints.

The pain, stiffness, fatigue, and whole-body (systemic) symptoms of rheumatoid arthritis can be disabling. Over time, the deformity caused by the disease can lead to difficulty with daily activities. Specific joint problems may also occur later in the course of the disease.

Hands and wrists are the most common location for deformities. See a picture of the most common problems in the hands.

The feet are also often affected. See a picture of common problems in the feet caused by rheumatoid arthritis.

Inflammation of the knees, if not controlled by treatment, can cause erosion of cartilage and can later lead to the need for knee replacement surgery.

Rheumatoid arthritis can also damage the cervical spine, or neck. This damage can limit how easily you can move your neck. In rare cases, the damage can pinch a nerve or affect the spinal cord and cause numbness, pain, weakness, or paralysis in the arms or legs.

Other problems

In a small number of severe cases, the disease may damage other organs. It is common for people with rheumatoid arthritis to feel depressed. These feelings may be caused by pain and progressive disability.

Most women with rheumatoid arthritis can become pregnant and have a healthy baby.

More information

What Increases Your Risk

The only known risk factor for rheumatoid arthritis is a possible inherited factor in some families (genetic predisposition). A genetic factor may affect how the immune system works. It can cause inflammation and eventual destruction of the membranes that line the joints.

Other factors that may increase your risk for rheumatoid arthritis include:

  • Being female. Rheumatoid arthritis affects women 2 to 3 times as often as men.1
  • Being between the ages of 40 and 60. Rheumatoid arthritis can begin at any age, but it most often begins in adulthood.2

When to Call a Doctor

Call your health professional immediately if you have:

  • Sudden, unexplained swelling and pain in any joint or joints.
  • Joint pain associated with a fever or rash.
  • Pain that is so severe that you cannot use the joint.

Call your health professional within the next few days if you have:

Watchful Waiting

It is reasonable to try home treatment for mild joint pain and stiffness. If there is no improvement after 6 weeks, or if any other symptoms are present, call your doctor.

Early treatment can slow and sometimes prevent significant joint damage. So if you have symptoms similar to rheumatoid arthritis, see your doctor to find out if you have rheumatoid arthritis. Early diagnosis and treatment allows for possible reduction of joint pain, slows joint destruction, and reduces the chance of permanent disability.

Who to See

Early arthritis symptoms can be diagnosed by:

Rheumatoid arthritis can be treated by:

  • A rheumatologist.
  • A family medicine doctor or an internist who consults with a rheumatologist.

Supportive treatment can be provided by:

Exams and Tests

No single lab test can diagnose rheumatoid arthritis. Instead, doctors look at symptoms and physical signs and then rule out other diseases that can cause similar symptoms.

A medical history and physical exam are usually done to help find the cause of joint pain. The pattern and nature of joint symptoms are the most important clues to the diagnosis.

Diagnosis is based on a set of classification criteria. The following tests may be done:

Other tests may be done to check for side effects of treatment. These tests may include:

Regular checkups

Because rheumatoid arthritis can lead to severe joint destruction and disability over time, regular checkups are important to see if treatment is working or needs to be adjusted.

More information

Treatment Overview

Rheumatoid arthritis is most often treated with medicine, exercise, and lifestyle changes. Treatment may help relieve symptoms and control the disease, but there is no cure. Treatment for rheumatoid arthritis usually continues throughout your life, but it will vary depending on:

  • The stage (active or in remission) and severity of your disease.
  • Your treatment history.
  • The benefits and risks of treatment options.
  • Your preferences for treatment options, such as cost, side effects, and daily schedules.

The goal of treatment is to help you maintain your lifestyle, reduce joint pain, slow joint damage, and prevent disability.

Making a plan

Treatment of rheumatoid arthritis should start with education about the disease, the possibility of joint damage and disability, and the risks and benefits of potential treatments. A long-term treatment plan should be developed by you and your team of doctors.

Treatment with medicines

Early and ongoing treatment of RA with medicines called disease-modifying antirheumatic drugs (DMARDs) can slow or sometimes prevent joint destruction.3 Other medicines may be combined with DMARDs to relieve symptoms. These medicines include:

For more information, see Medications.

Lifelong care

Treatment for rheumatoid arthritis usually continues throughout your life. Your doctor will want to closely monitor your condition. A rheumatologist should evaluate you regularly. Depending on your symptoms and treatment, this could be done as often as every 2 to 3 months or every 6 to 12 months. Testing, such as blood tests, may be done more often.

During each follow-up visit, your doctor will assess:

  • The amount of joint pain.
  • How long morning stiffness lasts.
  • The number of actively inflamed joints.
  • How well you are functioning.
  • Results of lab tests.

In some cases, the disease does not respond to the first several treatments. When this happens, the disease may be treated with much higher doses of medicines or with different combinations of medicines.

Surgery may be considered when the joints—especially the hips, knees, or feet—are severely damaged or deformed and are causing extreme pain. Surgery may include total joint replacement or other techniques to improve joint function. For more information, see Surgery and Other Treatment.

Exercise and lifestyle changes

Exercise, physical therapy, and lifestyle changes can help relieve joint pain. Many people with RA benefit from self-care plans that balance rest and activity. You can take steps at home to relieve your symptoms and help control your disease. For more information, see Living With Rheumatoid Arthritis.

More information

Living With Rheumatoid Arthritis

Living with rheumatoid arthritis often means making changes to your lifestyle. You can do things at home, such as staying active and taking medicines, to help relieve your symptoms and prevent the disease from getting worse. For help managing your disease, see:

Click here to view an Actionset. Arthritis: Managing Rheumatoid Arthritis.

You can also plan for those times when the disease symptoms may be more severe. It is important to work closely with your health professionals, who may include a physical therapist or counselor, to find ways to reduce pain.

Rest when you're tired

The disease itself causes fatigue. And the strain of dealing with pain and limited activities also can make you tired. The amount of rest you need depends on how bad your symptoms are.

  • With severe symptoms, you may need long periods of rest. You might need to rest a joint by lying down for 15 minutes several times a day to relax. Try to find a balance between daily activities that you must do or want to do and the amount of rest you need to do those activities.
  • Plan your day carefully, including rest periods. Pace your activities so that you don't get overtired.

Protect your joints

You may need to change the way you do certain activities so that you are not overusing your joints. Try to find different ways to relieve your joint pain.

  • Joint pain and stiffness may improve with heat therapy, such as:
    • Taking warm showers or baths after long periods of sitting or sleeping.
    • Soaking hand joints in warm wax baths.
    • Sleeping under a warm electric blanket.
  • Use assistive devices to reduce strain on your joints, such as special kitchen tools or doorknobs.
  • Use splints, canes, or walkers to reduce pain and improve function.

Stay active

Keep moving to maintain muscle strength, flexibility, and overall health.

  • Physical therapy may be recommended by your doctor.
  • Exercise for arthritis takes three forms—stretching, strengthening, and conditioning. Both weight-bearing exercise and strength training improve or maintain the quality of life for people with rheumatoid arthritis.4, 5 Your specific joint problem may guide the type of activity that will help the most. For example:
    • Swimming is a good activity if you have joint problems in your knees, ankles, or feet.
    • Bicycling and walking are good activities if your joint problems are not in your legs or feet. Learn more about walking as aerobic exercise.

Eat a balanced diet

Try to eat a healthy, balanced diet. It should be low in saturated fat, cholesterol, and salt and high in fiber and complex carbohydrate (whole grains, beans, fruits, and vegetables). According to some studies, fish oil may improve your symptoms.6

  • Be sure to get enough calcium and vitamin D to protect your bones against osteoporosis. For more information, see the topic Osteoporosis.
  • Lose weight, if you are overweight. For more information, see the topic Weight Management.
  • People who have rheumatoid arthritis also have an increased risk of heart disease. But healthy lifestyle changes, such as exercise and a healthy diet, may reduce your risk.7 For more information, see the topics Healthy Eating and Fitness.

Medications

Medicines are the main treatment for rheumatoid arthritis. The types of medicines used depend on how severe your disease is, how fast it is progressing, and how it affects your daily life.

If your symptoms ease, you and your doctor will decide if you can take less medicine or stop taking medicine. If your symptoms get worse, you will have to start taking medicine again.

Medicines are used to:

  • Relieve or reduce pain.
  • Improve daily function.
  • Reduce joint inflammation. Signs of joint inflammation include swelling, tenderness, and limited range of motion.
  • Prevent or delay significant joint damage and deformity.
  • Prevent permanent disability.
  • Improve quality of life.

Medicines called disease-modifying antirheumatic drugs (DMARDs) can slow or sometimes prevent joint destruction. Starting treatment early with DMARDs can reduce the severity of the disease.3 DMARDs are also called immunosuppressive drugs or slow-acting antirheumatic drugs (SAARDs). These medicines work best when taken over a long period to help control the disease.8

DMARDS can be divided into two general categories based on how they work: oral DMARDs and biologic DMARDs. Oral DMARDS are taken by mouth. They interfere with the making or working of immune cells that cause joint inflammation. Biologic DMARDS are given by injection (infusion). They act in several different ways to affect how immune cells work. DMARDs decrease joint inflammation and damage.

Medicines may be given together. This is called combination therapy. Oral medicines are combined with each other or with biologic DMARDs. But biologic DMARDs are not used with each other because of a higher risk of infection. By combining medicines, you may be able to take lower doses of individual medicines. This may reduce your risk of side effects.

Some medicines for rheumatoid arthritis may cause birth defects. If you are pregnant or are trying to become pregnant, talk with your doctor about your medicines.

Medication Choices

Medicines to slow the disease

Disease-modifying antirheumatic drugs (DMARDs) are usually started within 3 months of your diagnosis. They are used to control the progression of RA and to try to prevent joint damage and disability. DMARDs are often given in combination with other medicines.

Commonly used oral DMARDs:

Less commonly used oral DMARDs:

Biologic DMARDs:

Medicines to relieve symptoms

  • Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, and naproxen. NSAIDs are used to control pain and may help reduce inflammation. They don't control the disease or stop it from getting worse. NSAIDs may be combined with DMARDs.
  • Corticosteroids such as prednisone or Medrol. These medicines are used to reduce disease activity and joint inflammation. But using only corticosteroids for an extended time is not considered the best treatment. Corticosteroids are often used to control symptoms and flares of joint inflammation until DMARDs reach their full effectiveness.
  • Analgesics (pain relievers). These don't reduce inflammation but may help with pain control. They include:
    • Nonprescription acetaminophen.
    • Acetaminophen with codeine (such as Tylenol with codeine).
    • Acetaminophen with hydrocodone (such as Vicodin).
    • Tramadol.

What to Think About

  • Some DMARDs can take up to 6 months to work.
  • In some people, a certain DMARD may not work at all. So a different DMARD will be used.
  • If you're taking DMARDs, it's a good idea to have a rheumatologist manage your care.
  • Many DMARDs have serious side effects. You will need regular blood and urine tests to check the drug's effects on blood-producing cells (bone marrow), the kidneys, and the liver.
  • Other medicines are being studied. One example is tacrolimus (Prograf), an inhibitor of a protein called calcineurin. In one 6-month trial, people who had rheumatoid arthritis that had not responded to DMARDs had fewer symptoms.9

Surgery

Surgical treatment for rheumatoid arthritis is used to relieve severe pain and improve function of severely deformed joints that don't respond to medication and physical therapy.

Total joint replacement (arthroplasty) can be done for many different joints in the body. Its success varies depending on which joint is replaced.

Surgery Choices

Surgeries considered for people who have severe rheumatoid arthritis include:

What to Think About

Joint surgery often restores near-normal movement in a person who has osteoarthritis in just one or two joints. But this is not the case in people affected by rheumatoid arthritis.

  • Rheumatoid arthritis usually affects multiple joints, particularly smaller joints, such as finger joints, which are needed for many daily activities. Surgical treatment may not be an option for all of the affected joints.
  • Joint surgery or replacement can relieve disabling pain and restore enough motion to allow you to do your daily activities. But it will seldom restore the joint to normal.
  • The most successful procedures for this disease are carpal tunnel release (in the wrist), resection of the metatarsal heads (in the foot), and total hip and total knee joint replacements.

Before you decide to have surgery, consult with an orthopedic surgeon who is experienced in joint surgery for rheumatoid arthritis. For more information, see:

Questions to Consider About Joint Surgery.

Other Treatment

Other types of treatment that may help you control some of the symptoms of rheumatoid arthritis include:

  • Physical therapy, to improve joint function. Physical therapy includes exercise, hot and cold therapy, and massage.
  • Occupational therapy. This helps you learn how to maintain movement in the joints while carrying out the activities of daily living.
  • Assistive devices such as household aids or mobility aids. For more information and a catalog, contact the Arthritis Foundation, listed in the Other Places to Get Help section of this topic.
  • Behavioral modification techniques to reduce pain and stress. These include biofeedback and relaxation therapy, such as breathing exercises and muscle relaxation.
  • Counseling. It can help you cope with long-term pain and disability.

Complementary and alternative medicine therapies

Although not proven in scientific studies, complementary therapies are used by many people to relieve symptoms and improve their quality of life. These therapies include:

  • Acupuncture. This treatment is used to relieve pain and treat certain health conditions. It is done by inserting very thin needles into the skin at specific points on the body.
  • Massage. It can help relieve stress and reduce pain. But don't massage swollen or painful joints.
  • Transcutaneous electrical nerve stimulation (TENS). This therapy uses electrical current delivered through electrodes to the skin for pain relief.
  • Herbs and dietary supplements. If you decide to use herbs or dietary supplements, be sure to tell your doctor.
    • For some people, herbs (such as ginger or evening primrose) or essential fatty acids (such as fish oil) may provide some relief of symptoms.10
    • The dietary supplement glucosamine is sometimes used to try to relieve joint pain. But studies don't show that it is effective for rheumatoid arthritis.11

Other Places To Get Help

Organizations

American College of Rheumatology
2200 Lake Boulevard NE
Atlanta, GA  30319
Phone: (404) 633-3777
Fax: (404) 633-1870
Web Address: www.rheumatology.org
 

The American College of Rheumatology (ACR) and the Association of Rheumatology Health Professionals (ARHP, a division of ACR) are professional organizations of rheumatologists and associated health professionals who are dedicated to healing, preventing disability from, and curing the many types of arthritis and related disabling and sometimes fatal disorders of the joints, muscles, and bones. Members of the ACR are physicians; members of the ARHP include research scientists, nurses, physical and occupational therapists, psychologists, and social workers. Both the ACR and the ARHP provide professional education for their members.

The ACR website offers patient information fact sheets about rheumatic diseases, about medicines used to treat rheumatic diseases, and about care professionals.


Arthritis Foundation
1330 West Peachtree Street
Suite 100
Atlanta, GA  30309
Phone: 1-800-283-7800
Web Address: www.arthritis.org
 

The Arthritis Foundation provides grants to help find a cure, prevention methods, and better treatment options for arthritis. It also provides a large number of community-based services nationwide to make living with arthritis easier, including self-help courses; water- and land-based exercise classes; support groups; home study groups; instructional videotapes; public forums; free educational brochures and booklets; the national, bimonthly consumer magazine Arthritis Today; and continuing education courses and publications for health professionals.


National Center for Complementary and Alternative Medicine (NCCAM) Clearinghouse
P.O. Box 7923
Gaithersburg, MD  20898
Phone: 1-888-644-6226
(301) 519-3153 for international calls
Fax: 1-866-464-3616 toll-free
TDD: 1-866-464-3615 toll-free
Email: info@nccam.nih.gov
Web Address: www.nccam.nih.gov/health/clearinghouse (or www.nccaminfo.org/livehelp/ for live help online)
 

The National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health (NIH) explores complementary and alternative healing practices in the context of rigorous science, trains complementary and alternative medicine researchers, and gives out authoritative information. Send all requests for information and questions about NCCAM to the NCCAM Clearinghouse.


National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), National Institutes of Health
1 AMS Circle
Bethesda, MD  20892-3675
Phone: 1-877-22-NIAMS (1-877-226-4267) toll-free
(301) 495-4484
Fax: (301) 718-6366
TDD: (301) 565-2966
Email: niamsinfo@mail.nih.gov
Web Address: www.niams.nih.gov
 

The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) is a governmental institute that serves the public and health professionals by providing information, locating other information sources, and participating in a national federal database of health information. NIAMS supports research into the causes, treatment, and prevention of arthritis and musculoskeletal and skin diseases and supports the training of scientists to carry out this research.

The NIAMS Web site provides health information referrals to the NIAMS Clearinghouse, which has information packages about diseases.


References

Citations

  1. O'Dell JR (2005). Rheumatoid arthritis: The clinical picture. In WJ Koopman, LW Moreland, eds., Arthritis and Allied Conditions: A Textbook of Rheumatology, 15th ed., vol. 1, pp. 1165–1194. Philadelphia: Lippincott Williams and Wilkins.
  2. Harris ED Jr, Firestein GS (2009). Clinical features of rheumatoid arthritis. In GS Firestein et al., eds., Kelley’s Textbook of Rheumatology, 8th ed., vol. 2, pp. 1087–1118. Philadelphia: Saunders Elsevier.
  3. Kwoh CK, et al. (2002). Guidelines for the management of rheumatoid arthritis. Arthritis and Rheumatism, 46(2): 328–346.
  4. Häkkinsen A (2004). Effectiveness and safety of strength training in rheumatoid arthritis. Current Opinion in Rheumatology, 16(2): 132–137.
  5. De Jong Z, et al. (2003). Is a long-term, high-intensity exercise program effective and safe in patients with rheumatoid arthritis? Arthritis and Rheumatism, 48(9): 2415–2424.
  6. Genovese MC (2009). Treatment of rheumatoid arthritis. In GS Firestein et al., eds., Kelley’s Textbook of Rheumatology, 8th ed., vol. 2, pp. 1119–1143. Philadelphia: Saunders Elsevier.
  7. Nicola PJ, et al. (2005). The risk of congestive heart failure in rheumatoid arthritis: A population-based study over 46 years. Arthritis and Rheumatism, 52(2): 412–420.
  8. Verstappen SMM, et al. (2003). Five-year follow-up of rheumatoid arthritis patients after early treatment with disease-modifying antirheumatic drugs versus treatment according to the pyramid approach in the first year. Arthritis and Rheumatism, 48(7): 1797–1807.
  9. Yocum DE, et al. (2003). Efficacy and safety of tacrolimus in patients with rheumatoid arthritis. Arthritis and Rheumatism, 48(12): 3328–3337.
  10. Murray MT, Pizzorno JE Jr (2006). Rheumatoid arthritis. In JE Pizzorno, MT Murray, eds., Textbook of Natural Medicine, 3rd ed., vol. 2, pp. 2089–2108. St. Louis: Churchill Livingstone Elsevier.
  11. Firestein GS (2007). Rheumatoid arthritis. In DC Dale, DD Federman, eds., ACP Medicine, section 15, chap. 2. New York: WebMD.

Other Works Consulted

  • Saag KG, et al. (2008). American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis and Rheumatism, 59(6): 762–784.
  • Steultjens EEMJ, et al. (2009). Occupational therapy for rheumatoid arthritis. Cochrane Database of Systematic Reviews (1).

Credits

By Healthwise Staff
Primary Medical Reviewer Anne C. Poinier, MD - Internal Medicine
Specialist Medical Reviewer Stanford M. Shoor, MD - Rheumatology
Last Revised April 14, 2011

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