So the doctor has found inflammation and a positive test for rheumatoid factor, and he is most likely to refer the patient to a specialist.

You might expect him to x-ray the joints but at this stage this would not help him and would delay specialist advice. X-rays do help in making a diagnosis of RA, but the changes take a few months to appear.

The GP refers the patient to a specialist physician who deals especially with diseases affecting the muscles and joints.

If everything appears clearly the right pattern for RA - the blood tests suggest it, the disease is not settling but is slightly advancing - he may decide to start a different type of drug, or he may delay a little further to arrange more sophisticated immune tests and x-rays.

At this stage he needs to explain what these drugs are about. He will probably suggest an immune suppressant agent, or possibly a short course of steroids.

Steroids, do not cure RA but suppress the inflammatory reaction at all points: the fast-acting cells and the slow-acting cells, and they do so extremely well at high doses.

These doses however, cause serious side-effects within months to years. The discovery of steroids was a fantastic advance, but they were definitely not the cure for RA  Steroids in high doses cause high blood pressure, diabetes, thinning of the bones (osteoporosis) and reduce the ability to fight infections.

These side-effects attack all who take a high enough dose for long enough.

The doctor, if he does prescribe a steroid, is prescribing it in a low dose for a short time, to improve mobility whilst the immune suppressant slow-acting anti-rheumatic drugs are starting to work.

These are also known as disease-modifying anti-rheumatic drugs or 'immune-normalisers'.

What these drugs do is to damp down the exaggerated inflammatory response, particularly at the slow or immune end of the system that occurs in people with RA.

All the drugs that the consultant is now thinking about are immune-normalisers. Since then other drugs with variable immune normalising properties have been discovered - sulfasalazine, methotrexate and leflunomide are the most useful.

Careful long-term trials on lots of people have been done. Methotrexate is the most widely used. It is taken once a week - taking more causes a lot of trouble.

At low doses, and for RA it has good immune normalising properties. At much higher doses it is a major immune suppressant in everyone and is used to treat some cancers. For many, though not all people with RA, it can more or less stop the disease in its tracks, but the doctor must find the right dose. That dose will be different for each person.

It seems better to push the dose up high, get on top of the disease and then, when it is nicely suppressed, start reducing the dose.

Let's jump another six months to a year and again presume the worst though this is unlikely. The fatigue is getting worse, the joints aren't settling and the doctor will have probably already added another immuno-normaliser in. Sulfasalazine and methotrexate are a common combination.

If they haven't worked, he will now consider anti-cytokine therapy, a relatively new treatment, which can be remarkably effective. It is, however, extremely expensive.

These drugs worked very well in animals with arthritis, and showed promise in small numbers of patients.

Anti-TNF has to be given by injection under the skin or into a vein. One cannot yet predict who will do very well.

People who respond well lose their tiredness within a few days of the first injection and many only then realise how down the disease had made them.

They had accepted life at this level. People who respond by losing their tiredness usually then get a good anti-arthritis effect and some recent trials indicate that the erosive bone damage stops or heals a little. It is also becoming clear that the earlier this treatment is started, the better the results are.

Final words. RA can be a mild inconvenience or a devastating illness - everyone is different. An individual patient has little control over the eventual outcome.

However, a positive attitude and a desire to get on with it, not only helps to prevent disabilities and handicaps, but also mysteriously affects our immune system for the better.

In the next of this series we talk to patients and their experience of the impact of discovering their diagnosis.

prof@cardiacclinic.co.bw