What type of arthritis do you have?

 Did you know there is more than one type of arthritis? In fact, there are more than 100 types of arthritis. The prognosis is different for each type.

The term "arthritis" has been used as an umbrella term to describe a wide variety of rheumatic diseases, including the most common type, Osteoarthritis.  Most people at some point in their lives will experience Osteoarthritis. It is a result of barriers around the joint wearing away, usually due to age, injury, or excessive pressure placed on the joint (due to activity or weight), and is localized to the place of wear.  Typically when a person says "arthritis" they are referring to this type.

Being lumped with “arthritis,” other immune system related arthritis such as Rheumatoid arthritis (RA) does not get the attention it deserves.

Miss K 30 year old IT professional recently diagnosed with RA told me, ‘’Soon after diagnosis I realized that no one understood what Rheumatoid Arthritis was, most people only heard the word “arthritis” and would respond with “you are too young to have arthritis” or  ‘’take ayurvedic treatment” or “diet and exercise will help’’.

Rheumatoid arthritis is a serious disease that is misunderstood by most people, including many professionals and medical personnel. RA is type of autoimmune diseases. It causes damage not only to joints but also affects internal organs like lungs and heart.

 After explaining to a young patient that he did have RA, he asked me ‘’ I don’t understand why such a common problem like ‘arthritis’ can cause so severe symptoms? I feel more tired than my 70 years old grandfather who actually has arthritis’’.

Since each type of arthritis is different, each type calls for a different approach to treatment. That means an accurate diagnosis is crucial for anyone who has arthritis. With the proper diagnosis, you'll know what causes the pain. Then, you can be sure you're taking the proper steps to relieve the pain and continue to be active.

Simply stating, "I have arthritis," isn't enough.  Knowing the type of arthritis you have is the key to understand your illness and treatment.

As shown in the above pictures Rheumatoid arthritis is a progressive disease. Joints may look normal in the early stages. With recent advances in the treatment it is possible to halt disease progression. Majority of patients with arthritis can lead a normal life if treated appropriately.

Common symptoms of Rheumatoid arthritis are –

• Constant or recurring pains in 1 or more joints pain
• Stiffness on getting up after a period of inactivity or in the morning
• Swelling in one or more joints
• Joint pains affecting night sleep
• Fatigue /difficulty in performing routine activities

The most common joints involved are the hands, wrists and feet. The stiffness in the morning generally lasts longer than 45 minutes.

Rheumatoid arthritis and heart disease

 Patients with rheumatoid arthritis (RA) die at a younger age. Do you know what is the commonest cause of death in patients with RA? The incidence of heart attacks is much higher in patients with RA. Just like high cholesterol, diabetes and hypertension - RA is a separate risk factor for heart disease.

It is important for patients with RA to make lifestyle changes to reduce risk of heart attacks.  Measures like quitting smoking, weight reduction, lowering cholesterol and blood pressure could help to reduce the risk.

Current evidence:

RA sufferers are far more likely to die from heart attacks and strokes, a major study has recently revealed. Those with RA are 40% at higher risk of atrial fibrillation and 30% higher risk of strokes than the general public.

The risk of heart attack for RA patients is comparable to those with type 2 diabetes, according to the conclusions of two studies presented at the Annual Congress of the European League Against Rheumatism. 

Patients with untreated or poorly controlled RA are at higher risk of getting heart attacks and early death. Early treatment with disease modifying anti-rheumatic drugs (DMARDs) aiming for complete control of disease activity within the first year of disease is required. Appropriate treatment of RA can protect patients from developing heart problems and such therapy to be commenced early in the disease.

Advise your RA patients to take following ‘self-management’ steps

These changes can reduce your risk of heart disease and give you a greater sense of well-being.

1.      Quit smoking.

2.      Decrease sugar and salt intake.

3.      Avoid processed foods containing trans fats. Use polyunsaturated vegetable-based oils like olive oil when cooking.

4.      Be active often. Research shows that 30 minutes of exercise five days a week can lower blood pressure, cholesterol levels and risk of heart attacks.

5.      Being overweight and obese are major risk factors heart disease. Losing weight can reduce the risk.

Action from doctors:

1.   Annual tests for measuring heart attack risk is mandatory for all RA patients. Regular monitoring of for hypertension, dyslipidemia and diabetes is recommended. 

2.   Lifestyle recommendations (on areas including diet, exercise, smoking cessation and stress management) should be given to all patients with RA.

3.   Early and optimal treatment of RA with DMARDs is essential to reduce inflammatory load.

 

Osteoporosis - The Silent Disease

 What is Osteoporosis?

Osteoporosis is a disease of the bones. It happens when the body fails to form enough new bone or lose too much bone or both. As a result, your bones become weak and may break from a minor fall or in serious cases even bumping into furniture leads to a fracture.

Osteoporosis is often called “the silent disease” because bone loss usually occurs gradually over the years without symptoms. Many people aren't aware that they have osteoporosis until they either have a bone densitometry test (DEXA) or have a minor fall which causes a bone to break. Often, this “fragility fracture” (a fracture resulting from a mild fall from standing height) is the first sign of osteoporosis.

When someone is diagnosed with osteoporosis, it is important to investigate for causes of osteoporosis other than aging.

What are the symptoms of osteoporosis?

It is very important to be aware that there are no symptoms in the early stages of bone loss. But once bones have been weakened by osteoporosis, you may have signs and symptoms that include:

·       Back pain, caused by a fractured or collapsed vertebra

·       Loss of height over time

·       A stooped posture

·       A bone fracture that occurs much more easily than expected

 

1 minute screening test for osteoporosis

1. Do you have a family member diagnosed with osteoporosis or fracture after a minor fall?
2. Have you ever had a fracture after a minor fall?
3. Have you taken steroid tablets for more than 3 months?
4. Have you lost height?
5. Does your upper back look more rounded than normal?
6. Do you weight <50kg?
7. Do you regularly drink excess alcohol?
8. Do you smoke regularly?
9. Did you undergo menopause before the age of 45?
10. Have your periods stopped for 12 months or more (other than because of pregnancy)?

 This could be osteoporosis. Consult a Rheumatologist. Delay can cause fracture and disability.

Five simple steps for bone health and osteoporosis prevention –

1. Get your daily recommended amount of calcium and vitamin D.

2. Be physically active every day. Improve strength and balance.

3. Avoid smoking and excessive alcohol.

4. Discuss with a specialist about bone health.

5. Have a bone density test and take medication when appropriate. Testing is a simple, painless procedure.

Complications of rheumatoid arthritis

 Rheumatoid Arthritis (RA) is a disease of young adults. Regrettably, RA has very little identity of its own. Anything with “arthritis” is considered to be linked with old age. Adding the prefix “rheumatoid” frequently adds little additional impact. The average individual has very little knowledge of rheumatic diseases. Many patients face complications of rheumatoid arthritis due to late diagnosis and high delay in the treatment initiation.

Joint damage

RA has potential to cause progressive and permanent damage.

Problems that can affect the joints include:

·       damage to nearby bone and cartilage (a tough, flexible material that covers the surface of joints)

·       damage to nearby tendons (flexible tissue that attach muscle to bone), which could cause them to break (rupture)

·       deformities in joints leading to change in normal shape and appearance

Many patients need surgical treatment to relieve pain and improve function loss caused by untreated disease.

Inflammation in internal organs

RA is not a disease of only joints. It can affect other organs like eye, lungs and heart.

Lungs – inflammation of the lungs or lung lining can lead to pleurisy or Interstitial lung diseases/pulmonary fibrosis, which can cause chest pain, a persistent cough and shortness of breath.

Heart – inflammation of the tissue around the heart can lead to pericarditis, which causes chest pain.

Eyes – inflammation of the eyes can lead to redness, pain, dryness and reduced vision. It can cause scleritis or Sjögren's syndrome.

Blood vessels – inflammation of the blood vessels (vasculitis) is a life-threatening condition.  It can affect blood flow to your body's organs and tissues.

However, with early treatment, inflammation in other parts of the body from rheumatoid arthritis is less likely.

Cardiovascular disease

If you have rheumatoid arthritis, you're at a higher risk of developing cardiovascular disease (CVD). Patients with rheumatoid arthritis (RA) die at a younger age. The incidence of heart attacks is much higher in patients with RA. Just like high cholesterol, diabetes and hypertension - RA is a separate risk factor for heart disease. The risk of heart attack for RA patients is comparable to those with type 2 diabetes.

 Effects on the Skin

You might develop lumps of soft tissue called rheumatoid nodules. They usually appear on your skin, especially on the elbows, forearms, heels, or fingers. Sometimes, inflammation of blood vessels -vasculitis - shows up as spots on the skin which may even cause deep ulcers on the skin.

 Osteoporosis (weak bones)

Rheumatoid arthritis itself can increase your risk of osteoporosis — a condition that weakens your bones and makes them more prone to fracture. In addition to rheumatoid arthritis, increasing age and certain medications like steroids can also make your bones weak.

Carpal tunnel syndrome

Carpal tunnel syndrome describes a condition in which a nerve that passes through your wrist’s bony tunnel gets compressed. The inflammation from active rheumatoid arthritis at the wrist can compress the nerve causing carpal tunnel syndrome. You may experience numbness or tingling sensation in your hand and fingers.

 

What Can I Do To Reduce My Risk of Developing Complications?

 

1.   If you have developed RA related complications you might need different doctors and different treatments to control your RA. Always discuss new symptoms with your doctor.

 

2.   Patients with untreated or poorly controlled RA are at higher risk of getting complications and internal organ involvement. Early treatment with disease modifying anti-rheumatic drugs (DMARDs) aiming for complete control of disease activity within the first year of disease is required.

 

3.   Following changes may help to reduce your risk of heart disease and give you a greater sense of well-being.

 

4.   Quit smoking.

 

5.   Decrease sugar and salt intake.

 

6.   Avoid processed foods containing trans fats.

 

7.   Be active often. Research shows that 30 minutes of exercise five days a week can lower blood pressure, cholesterol levels and risk of heart attacks.

 

8.   Being overweight and obese are major risk factors heart disease. Losing weight can reduce the risk.

 

9.   Appropriate treatment of RA can protect patients from developing heart problems and such therapy to be commenced early in the disease.

 

10.  Do not stop medications abruptly. It is important to continue medications even when your arthritis symptoms are under control. Regular medications with appropriate monitoring helps to prevent RA related complications in other organs.

 

11.  Do not miss your follow up appointment. Regular follow up with rheumatologist can help to spot potential complications at an early stage.

 

12. Pay attention your bone health. Regular calcium and vitamin D supplements can help to make your bones strong and prevent osteoporosis. You may need tests like DEXA scan to measure osteoporosis.

7 Common Rheumatoid Arthritis Medication Mistakes

 

Taking medications regularly and following correct instructions is very important for people with rheumatoid arthritis (RA). It is the responsibility of the patients to know their medications well and avoid making mistakes, which can have serious consequences.  

Mistake No. 1: You take Methotrexate daily instead of once a week

Methotrexate, the most commonly prescribed drug for RA, is usually taken weekly.  Sometimes, it is prescribed twice a week. It should be taken one day a week - on the same day each week (e.g., every Saturday). It is not taken daily like many medications. Methotrexate tablets are available in different strengths like 2.5, 5, 7.5, 10, 15, 20 and 25 mg. The usual starting dose for adults with RA is 15 mg once a week. The total dose of methotrexate can be increased to up to 25 mgs each week, if needed.

Too often we come across patients who mistakenly take methotrexate daily rather than weekly. That specific mistake can result in serious side effects related to toxicity. Errors can occur at the pharmacy, too, where mislabelling may direct a patient to take methotrexate daily versus weekly. Know that methotrexate for RA is a weekly drug.

Mistake No. 2: You forget to take folic acid tablets

Taking folic acid regularly is important to prevent side effects from methotrexate. Usually, folic acid is prescribed five days a week. Please note folic acid and methotrexate are completely different drugs. Brand name of these drugs could sound similar (e.g. Folvite/Folimax and Folitrax)

Mistake No. 3: You continue medications even during infection.

If you catch an infection which requires you to take antibiotics it is advised to withhold medications like methotrexate for 2 weeks and inform your rheumatologist.

Mistake No. 4: You stop medications abruptly

Keep taking your medications for the full time of treatment, even if you begin to feel better after a few days. Do not miss any doses. Sudden discontinuation of certain medications may pose a life-threatening situation.

Common reasons to stop medications –

1.   ‘I was worried about side effects’  

2.   ‘My parents/relatives suggested me to switch to alternative therapy’

3.   ‘I thought my body will get addicted to medications’

4.   ‘I was feeling fine’

 

Mistake No. 5: You alter the dose or treatment regime against medical advice.

It is important to follow all the instruction of the doctor. Many patients try to minimize drug intake by either taking tablets alternate days or half doses. Suboptimal treatment can cause flare up of disease. You may not be aware that certain tablets like sulfasalazine should not be broken. You should swallow Sulfasalazine enteric-coated tablet whole. Do not crush, break, or chew it. This is because they are specially coated to pass through your stomach before they are absorbed. Breaking the tablet could interfere with the special coating.

Mistake No. 6: You don’t tell all your doctors about everything you are taking

All your doctors should know what medications and supplements you are taking. People with RA typically have more than one doctor on their healthcare team. It is important for each of your doctors to have a complete and current medication list for you. Keeping all your doctors informed about your medications will help to prevent drug interactions. Do not neglect to provide each doctor with your full list. It’s your responsibility.

Mistake No. 7: You don’t inform your rheumatologist information related to your pregnancy or breastfeeding.

You should consult with your rheumatologist if you are planning to get pregnant. Planning ahead is the key. Some of the drugs used to treat RA can be continued while trying to conceive or even during the pregnancy. Certain medications like methotrexate and leflunomide should be stopped well in advance before you conceive.

Although you may be concerned about the possible harmful effects of taking RA drugs while pregnant, it is important to remember that uncontrolled arthritis during pregnancy can also have adverse effects on your baby such as low birth weight. 

My Takeaway Advice

·       Learn about each medication that you are taking.

·       Don’t deviate from the prescribed regimen.

·       Do not stop medications abruptly.

·       Share with rheumatologist if you are planning to get pregnant or taking alternative therapy.

 

 

Understanding Gout: The Disease of Kings

Gout is a very painful form of arthritis that has been recognised since ancient times.

1.   Symptoms of gout

Gout symptoms usually start suddenly without any warning. Severe pain, swelling and redness in the big toe is typical for gout. Overlying skin is often red and shiny.  It often involves only a single joint.

Common sites include: Big toe (75%), ankle and knee.

Pain reaches a peak within just 6–24 hrs. The symptoms usually do not last more than 2 weeks. Often the patients are unable to walk, wear socks or even touch bed sheets during flare-ups due to severe pain.

2.   Triggers for gout attack

Attacks are often spontaneous but may be triggered by direct trauma to a joint, stress, surgery, alcohol, high protein intake or dehydration.

3.   Risk factors for gout

Age – The risk of gout increases with age.

Gender – It is more common in men. Gout occurs rarely in young females (due the ability of oestrogen to eliminate uric acid via urine).

Diet - An increased risk is associated with a high red meat diet and a higher consumption of seafood, Excess alcohol intake, protein supplements like protein milk shakes, whey protein.

Drugs – Blood pressure medications like diuretics are considered to be the most common modifiable risk factors for gout especially in the elderly and in women.

Other medical diseases - metabolic syndrome, Obesity, Renal insufficiency increases risk of gout.

4.   Concentrate on changing lifestyle, not just on diet

Most people are not aware that just avoiding “trigger foods” won’t cure the problem.

Dieting reduces the UA level by about 10%.  If you are overweight, work hard on weight reduction. Weight loss must be gradual as crash dieting can bring on attacks. Cutting calorie intake with steady weight loss can reduce the number of attacks and significantly decrease the health risks that go with it. Don’t forget that alcohol and sugary soft drinks contain lot of calories.

5.   Treatment - If you start on treatment – stick to it even if your uric acid has come down to normal range or the gout will return. Many people take medications only for few days during the symptomatic period. It is important to continue uric acid lowering therapy even when you don’t have any symptoms. Medications help to prevent next attack of gout and complications of high uric acid such as kidney stones.

RA factor (Rheumatoid factor) Test

RA factor is a protein (antibody) that is measurable in the blood with a routine blood test. A positive RA factor test means that level of rheumatoid factor in patient’s blood is high. A positive RA factor test is mainly used as a supportive tool in making diagnosis of rheumatoid arthritis.

What is RA Factor?

Our immune system produces healthy proteins (antibodies) that fight off infections caused by bacteria and viruses. Sometimes, bad antibodies are produced by the immune system which can attack healthy tissue. RA factor is a bad antibody protein produced by patient’s immune system. 

What Causes RA Factor?

It is unknown what triggers our immune system to produce rheumatoid factor. It is thought to be a combination of genetics and other external risk factors. 

What Do RA factor Test Results Mean?

RA factor test is used by doctors to help in diagnosing rheumatoid arthritis. Approximately 70% of rheumatoid arthritis patients test positive for RA factor.

A negative RA factor test does not rule out diagnosis of rheumatoid arthritis. In fact, there is no single test to diagnose rheumatoid arthritis. The diagnosis is made from a combination physical symptoms and medical history supported by various blood tests such as RA factor, anti-CCP antibodies and elevated inflammatory markers. Newer tests like anti-CCP antibodies are much more specific for rheumatoid arthritis.

Patients who test negative for RA factor but have signs and symptoms may still be diagnosed with rheumatoid arthritis. This is seen in around 30% patients with rheumatoid arthritis (seronegative). 

Why bother testing for RA factor?

Rheumatoid arthritis affects different patients in different ways. Rheumatoid arthritis patients with a positive RA factor test have the potential for a more aggressive disease course. Keep in mind this isn’t always the case. If RA factor is tested and symptoms are detected early, a diagnosis can be quickly reached. Treatment should be started as soon as possible to joint damage. 

Do I need to check RA factor again?

The level of RA factor can fluctuate during the course of disease but it does not correlate with disease activity and it does not normalise with treatment. If you have rheumatoid arthritis, it is not necessary to monitor the level RA factor. Inflammatory markers such as ESR and CRP are often elevated during active disease and can be good markers to monitor treatment response.

For more information please visit www.punerheumatologist.com