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

Rheumatoid arthritis and pregnancy

• In the past there were concerns that RA might affect the ability to conceive. But with recent advances it is clear that if the disease is well controlled, most women with RA can have an enjoyable and successful pregnancy. 
• The risk of foetal loss or genetic abnormalities for women with RA is not significantly greater than for any other pregnant women.
• Planning ahead is the key. Before you try to conceive, it’s important that you discuss with your rheumatologist.
• It is recommended to become pregnant when the disease is not active.
• All women who are planning to get pregnant should take folic acid supplements daily. 
• Many patients may not need RA medications during the pregnancy if their disease is not active. The pain and swelling associated with RA is much improved during pregnancy in up to 75% women.
• Some of the drugs used to treat RA can be continued while trying to conceive or even during the pregnancy. It is advisable to consult with your rheumatologist before you stop any drugs.
• Certain medications like methotrexate and leflunomide should be stopped well in advance. There are medications like sulfasalazine, hydroxychloroquine and steroids are safe during pregnancy and breast feeding.
• Although you may be concerned about the possible harmful effects of taking RA drugs, it is important to remember that uncontrolled arthritis during pregnancy can also have adverse effects on your baby such as low birth weight. 

HLA B27 test and ankylosing spondylitis Facts

1.   HLA B27 (human leukocyte antigen) is not a disease. It is a gene in your body.

2.   A positive HLA B27 test does not mean you have a disease. If you look at the whole population the majority of people carrying this gene will not develop ankylosing spondylitis. The usefulness of the test depends on the context that it is ordered in. History and examination is really useful.

3.   HLA-B27 is a normal genetic variant. HLA B27 can be positive in upto 8% of normal population.

4.   HLA B27 positivity is associated with a variety of diseases like ankylosing spondylitis, psoriasis, inflammatory bowel disease, reactive arthritis etc.

5.   If your HLA B27 test is positive usually there is no need to have this test again. It does not disappear even after treatment.

6.   Around 80 to 90% of patients with ankylosing spondylitis tests positive for HLA-B27.

7.   If you look indiscriminately at the whole population, only 10-15% of those with this HLA-B27 gene will end up developing ankylosing spondylitis or another type of spondyloarthritis.

8.   History suggestive of inflammatory back pain should prompt a doctor to order the HLA-B27 test. In this context, a positive HLA B27 test is useful in making the diagnosis.

9.   Please note a negative HLA-B27 test does not completely rule out the diagnosis of ankylosisng spondylitis. Around 10-20% of patients with proven ankylosing spondylitis will test negative for HLA B27.

10. Treatment depends on the final diagnosis and severity of the disease.

Symptoms of inflammatory back pain –

#1. Starts before the age of 40 years

#2. Comes on slowly over time

#3. Worse in the mornings and evening

#4. Stiffness in the mornings or after period of inactivity

#5. Improves with exercise and worse with rest

#6. Can often cause pain in the buttocks

For more information please visit punerheumatologist.com 

I have been diagnosed to have Rheumatoid arthritis. What next?

To fight Rheumatoid Arthritis (RA), you have to understand the condition inside and out. Try to learn everything you can about this disease. It makes a huge difference if your initial experience of care is positive. As they say a good beginning is half the battle won! Similarly, a correct diagnosis is the most important step.

1. Regular Blood Tests For Monitoring – You will be requested to have regular blood tests. This helps doctors to identify if you are developing any side effects related to medications. Also, certain blood tests are requested to understand the response to treatment. Here are some commonly requested monitoring blood tests - CBC (Complete Blood Count), SGPT (liver function test) and ESR, CRP (inflammatory markers).

2. Quit smoking  – Get advice and support on how to quit. Having Rheumatoid arthritis puts patients at increased risk of heart disease and smoking further increases this risk. Evidence shows that Rheumatoid arthritis treatment is less effective in people who continue to smoke.

3. Build support – Patients living with RA should discuss with family and friends the impact RA is having on their working life, emotional and mental health.

4. Access to the multidisciplinary team – To help manage your RA you should have the opportunity to see specialist professionals including a rheumatologist, physiotherapist, dietician and psychologist if required.

5. Get involved– Try to get involved in your treatment. Show interest in understanding medications and symptoms. Learn more about your disease by joining patient support group, reading information booklets, online forums or any other educational opportunities.

6. Access to a specialist – You should know how to get access to your doctor when you need it, for instance when experiencing side effects to medications or for help if you flare.

7. Exercise – Ask your physiotherapist about an individual exercise programme designed for you. Exercise is essential and plays a key role in controlling the symptoms of RA including fatigue, pain, and referred pain. It’s also important to maintain a generally healthy lifestyle including healthy diet and appropriate weight.

8. Pregnancy – Get information and specialist care if you are planning to have a baby. Your RA will need to be more tightly controlled and monitored during family planning for both prospective mothers and fathers.

In addition, the following are highly recommended for people living with RA

·         Have your blood cholesterol and sugar measured.

·         Have your blood pressure measured and recorded and set a personal target that is right for you.

·         Have your eyes checked – yes RA can affect eyes as well.

·         Limit sugar and salt intake in your diet.

      For more info please visit punerheumatologist.com