Diseases

Rheumatoid Arthritis

Rheumatoid Arthritis is a common Rheumatological condition in the community. It affects 1% of the population in India. In Rheumatoid Arthritis multiple joints are effected, these joints are painful, swollen and are tender to touch. The other important symptom in the disease is early morning stiffness in the joints. The early morning stiffness in the joints usually lasts for more than one hour. Rheumatoid Arthritis usually affects the same joint on both sides of the body, for e.g., arthritis affecting the left and right wrist. Rheumatoid Arthritis starts in the small joints of the hands and feet, later affect the big joints like knees and hips. In the normal joint end of the each bone is covered with healthy cartilage, which will be eroded in Rheumatoid   Arthritis. A membrane, called synovium surrounds the joint, which will be inflamed and thickened in Rheumatoid Arthritis. Inflamed synovium secrets more synovial fluid in to the joints, causing swelling and pain in the joint. In a healthy joint cartilage provides smooth slippery surface, which helps free joint movement and the synovial fluid, acts as lubricant. Sometimes patient notice nodular swellings over the elbows these are called Rheumatoid Nodules, which are very characteristic of Rheumatoid Arthritis. Rheumatoid Arthritis rarely affects other parts of the body e.g., lungs, blood vessels and eyes etc.

Nobody knows exactly what causes Rheumatoid Arthritis; this is mainly due to imbalance in the immune system (not due to Immune Suppression). This immune imbalance sets off inflammation in several joints causing pain and swelling of the affected joints. Patients also feel generally ill and tired. Most of the patients develop flare-ups (periods of increased pain and swelling in the joints). The disease can start at any age from children to elderly; the most common age groups prone to Rheumatoid Arthritis are between 3rdand 5thdecades. Rheumatoid Arthritis does not run in families, occasionally it may affect more than one in same family. Typically it starts as painful, swollen, stiff hands and feet, especially in the morning. Less commonly it presents as Monoarthritis or relapsing and remitting arthritis. At the beginning of the illness the fingers look like sausages, in the late stages the fingers and toes will be deformed. The other symptoms include tiredness, weight loss, depression and irritability. The routine tests in Rheumatoid Arthritis include complete blood picture, erythrocyte sedimentation rate (ESR), Serum Creatinine, SGPT, Rheumatoid Factor (RF), anti CCP antibody and radiographs of the affected joints. The progression of the disease varies with the individual. Most people develop flare-ups now and then. Anemia (low Hemoglobin) is very common association, related to disease activity. There is no single diagnostic clinical or laboratory test to confirm the diagnosis of Rheumatoid Arthritis. It is a rather clinical diagnosis, made by physician depending of the signs and symptoms and also based on the laboratory reports. Erythrocyte Sedimentation Rate (ESR) is a marker of Inflammation, will be high in Rheumatoid Arthritis. C-Reactive Protein (CRP) is another marker of inflammation like erythrocyte sedimentation rate (ESR). Rheumatoid Factor (RF) is positive in the blood in 70% of the patients. In remaining 30% of the Rheumatoid Arthritis  rheumatoid factor will be negative at the time of diagnosis. Presence of rheumatoid factor does not make the diagnosis certain. About 5% of healthy individuals will have positive rheumatoid factor without having the disease. Plain radiographs of the affected joints may show erosions.

Treatment

Modern medicines are very effective in treating this arthritis. They help in reducing the pain, joint swelling and also suppress the arthritis. When the disease is quite active patient needs to take rest, but as the disease symptoms are getting better with medication, the patient may need to exercise the joints regularly. Regular exercise will definitely help the arthritis patients.

Basically there are three types of medicines available for treating this arthritis.

Anti-Inflammatory drugs like Brufen, Diclofenac Sodium, and Celecoxib etc., help in reducing the joint pain and swelling. They do not have any role in suppressing the arthritis. Where as Disease Modifying Anti Rheumatic Drugs (DMARDs) will not only suppress the arthritis, but also helps in preventing further progression and relapses. Commonly used anti rheumatic drugs are Methotrexate, Hydroxychloroquine, Sulfasalazine and Leflunomide. Drugs like Gold and Pencillamine are rarely used. Steroids are usually used at the beginning of the therapy only for few months. Though they are very effective in relieving the arthritis symptoms, they are not used for long term maintenance therapy due to side effects, for e.g., weight gain and Osteoporosis. Steroid injections are helpful when only few joints are affected.

The new biologic drugs available in India are

These drugs are very effective in controlling Rheumatoid Arthritis, but are quite expensive.

Frequently Asked Questions (FAQ)

Is there any diet restrictions for Rheumatoid Arthritis?

There is no diet restriction for this kind of arthritis. Very rarely dairy products may aggravate arthritis symptoms. Vitamins C rich foods (ex. Amla and Lemon) and sea fish will help arthritis patients.

Is there any relation with climate?

Many people think that weather in winter may aggravate the arthritis. This is a myth. Cold weather may cause  more stiffness in the joints, but it will not aggravate or precipitate the arthritis.

Does it run in families?

Ankylosing Spondylitis (AS)

Ankylosing Spondylitis is a chronic progressive arthritis condition, mainly affecting the spine. It may affect the peripheral joints and rarely it affects the eyes and heart. Ankylosing means fusing together, Spondylitis means inflammation involving the joints of the spine (Spondylos means vertebrate). The exact cause for Ankylosing Spondylitis is not yet known. Most of the patients who are suffering from this disease carry a genetic cell marker “HLA B27”. It is more common in men, affects 20 – 40 years age group. Usually the disease starts in the Sacroiliac joints, causing severe low back pain. Most of the non-Rheumatologists interprets it as ‘Mechanical back pain’, disc prolapse or Sciatica. Most people are confused with term Spondylosis, which means wear and tear e.g., Cervical Spondylosis and Lumbar Spondylosis (part of ageing process). The common symptom of Ankylosing Spondylitis is chronic low backache, especially more in the morning(>1hour). It usually starts before the age of 40 years. Typically activity helps and rest deteriorates the low back pain. Some times patient gives a typical history of alternating buttock pain (left or right side) and also down the legs. In Ankylosing Spondylitis the arthritis may affect the other joints too for eg, hips, knees or ankles. The affected joints are painful, swollen, slightly warm and tender to touch. Sometimes patient also has chest wall pain (rib cage) and heels. The routine blood tests would show an elevated erythrocyte sedimentation rate. HLAB27 would be positive in most of the patients. But this is not a must test to establishing the diagnosis of Ankylosing Spondylitis. In the late stages of Ankylosing Spondylitis, the back and spine would be very stiff (bamboo spine). The patient would not be able to bend the spine either forward, backward or side wards. When the neck is affected patient would not be able to bend his neck or turn to the sides. At this stage if the patient wants to see any objects on his side he has to turn the whole body to look at the object.

The most commonly used drugs are NSAIDs. These drugs give good pain relief, comfort and the patient would be able to carry out exercises. When the disease is active Disease Modifying Drugs (DMDs) like Methotrexate, Sulfasalazine, and Azathoiprine will be useful. Two biologic drugs available in India are Remicade and Enbrel. The most important part of treatment in Ankylosing Spondylitis is exercise, rest would freeze joints. Good exercise programs would help to maintain the flexibility of the joints.

Systemic Lupus Erythematosus (SLE)

Systemic Lupus Erythematosus (SLE) is a type of autoimmune rheumatological disease, which not only affects the joints but also involves the other systems in the body. The other name for SLE is lupus (means wolf in Latin). SLE can cause skin rashes on the face, which may resembles face of a wolf but we hardly see these facial features nowadays with the latest treatments available. The common symptoms of lupus are skin rashes, joint pains and swellings (arthritis). The arthritis usually starts in small joints of the hands and feet. Sometimes these joint pains are migratory. Red colour skin rash is commonly seen over the cheeks is called butterfly rash. These rashes may be also seen in other parts of the body, gets worse with sun exposure. The other common symptoms are recurrent mouth ulcers, hair loss (alopecia), extreme tiredness, fever and anemia.

Systemic Lupus Erythematosus (SLE) is 9 times more common in women. Lupus may affect the other organs like kidneys, heart, lungs, brain and nerves. Rheumatologist makes the diagnosis of lupus based on symptoms, signs and some important laboratory tests. The important blood tests, which help in the diagnosis of lupus are ANA, Anti ds-DNA and Anti-sm antibodies. The commonly used medicines are NSAIDs, Corticosteroids, Hydroxychloroquine, Methotrexate, Cyclophosphamide, MMF and Azathioprine.

Psoriatic Arthritis

Psoriatic arthritis is due to inflammation of the affected joints, in patients who have psoriasis.

Psoriatic arthritis is a clinical diagnosis .There is no specific test to confirm Psoriatic arthritis. In 2/3 rd of the patients, skin lesions precede the arthritis whereas in 1/3 rd of the patients arthritis precedes the skin lesions. When psoriatic arthritis affects fingers and toes, they appear like sausages (dactylitis).Psoriatic arthritis can occur in any joint. Sometimes it can affect the nails and eyes. Common nail changes are pitting, nail thickening and nail destruction .The common eye symptoms are recurrent, painful red eye, (Uveitis). The drugs commonly used in Psoriatic arthritis are Methotrexate, Sulfasalazine , Leflunomide, steroids and NSAIDS. Regular physiotherapy of affected joints also help the patient.

Osteoporosis

Osteoporosis is disease of bones. People can get easily confused with osteoarthritis which is a wear and tear type of arthritis [degenerative joint disease] of weight bearing joints e.g. Hip and knee.

In osteoporosis bones become weak due to low bone mass. These weak and fragile bones will break easily even with a trivial injury like slipping on the floor. This is a disease of elderly people especially postmenopausal women.

The risk factors for osteoporosis are lack of exercise, hysterectomy or menopause at early age, excessive smoking, excessive drinking, family history of osteoporosis and drugs like corticosteroids. The usual symptoms are bony pains, fractures with trivial injuries and kyphosis.

The confirmation of diagnosis is by measuring the bone density with DXA scan.

The treatment options available for osteoporosis are

Prevention is by giving diet rich in calcium like diary products, green leafy vegetables, nuts, dry fruits etc.

Osteoarthritis

Osteoarthritis is due to the degeneration in the hyaline cartilage. The incidence increases with age. It mainly affects the weight bearing joints like knees and hip; sometimes it also affects finger joints.

The bony swellings involving distal interphalangeal joints are called Heberden’s nodes and those involving proximal interphalangeal joints are called Bouchard’s nodes. The affected joint is painful, sometimes associated with swelling. Initially the pain is variable and intermittent, with long symptom free intervals. Later as the disease progresses pain becomes constant.

The therapies available for osteoarthritis are physiotherapy, glucosamine, chondroitin, diacerin, paracetamol, codeine and NSAIDS. The routine laboratory tests are usually within normal limits. Radiography of the affected joints will show narrowing of the joint space, subchondral sclerosis and osteophyte formation. In severe osteoarthritis patient needs arthroplasty.

Gout

Gouty arthritis is due to excess accumulation of uric acid in the blood. It is much more common in men than women. The excess uric acid in the blood may accumulate in the joint that leads to irritation of the joint lining, causing pain and swelling of the affected joint. Gout usually starts at the base of the great toe. Usually the attack starts in the midnight or early morning. The affected joint is usually red, swollen; warm and very tender to touch .the initial attacks will subside within days with or without treatment. Gradually it may spread to the other joints of the hands and feet and major joints like knees.

In the initial stages, between the attacks the patient may feel fine without any pain and swelling in the joints. After a few years, patients may get very frequent attacks. Excess uric acid in the blood is either due to excess synthesis of uric acid or decreased excretion of uric acid through the kidneys. It may run in families. Excess alcohol intake and sometimes tablets like diuretics also can cause Gout. Uric acid may also get accumulated in places other than joints, for e.g. ear (under the skin).They appear like little white nodules called Tophi. Gout is usually associated with obesity, hypertension, diabetes and high cholesterol .An untreated gout can cause kidney failure or the kidney failure patient per se can get gout due to accumulation of excess uric acid in the blood.

There is another type of arthritis associated with high uric acid – Psoriatic arthritis. This high uric acid in Psoriatic arthritis usually will not cause gout. The routine laboratory tests for diagnosing gout are estimation of serum uric acid, examination of joint fluid for uric acid crystals and radiographs of involved joints. The medications available for gout are pain killer [NSAIDS], Colchicine, Allopurinol, Probenecid, Febuxostat and occasionally steroids.

The important things to remember in the diet are avoid or reduce the amount of Alcohol intake [3-4 units / day for men, 3-2 units/ day for women], reduce the intake of foods rich in purine for e.g. Spinach, cauliflower, cabbage, mushrooms, beans, red meat and animal internal organs.

JIA (Juvenile Idiopathic Arthritis)

JIA(Juvenile Idiopathic Arthritis): It causes pain and swelling of joints in children. The symptoms are fever, joint pains and swellings, early morning stiffness in the joints and sometimes skin rash. There are different varieties of JIA, only a qualified Rheumatologist will be able to differentiate appropriately. Some children may get inflammation in the eye(Uveitis). The Rheumatologist may suggest the following tests: ANA, RF, ESR, CRP, CCP and Radiographs etc. The therapies for JIA include anti inflammatory pain killers, Corticosteroids, Methotrexare ,Sulfasalazine, Leflunomide and Biologics(Enbrel, Actemra and Abatacept).

Scleroderma

Scleroderma means hard skin. The skin becomes hard on the face, neck, trunk and limbs. Even the skin around mouth becomes tight causing difficulty in opening the mouth. It is of two types-limited and diffuse Scleroderma. It may affect other internal organs like heart, lungs, kidneys and Gut. The fingers may turn blue in cold weather (Raynaud’s). Patients may notice hard calcific deposits under the skin. Some patients notice heart burn(acid reflex). The Rheumatologist may order some special tests like ANA, Scl-70 and anticentromere antibody etc. to confirm the diagnosis.

Sjogren’s Syndrome

It is an inflammatory disorder affecting primarily salivary and lacrimal glands. The common symptoms are dry eyes, dry mouth, dental caries, dry skin and fatigue. Some patients may have coexistence of other autoimmune diseases like Rheumatoid arthritis and Lupus. The Rheumatologist may order some special tests which include ESR, ANA, SS-A, SS-B, Schirmer’s test(eye test) and salivary gland biopsy to confirm the diagnosis