Rheumatoid Arthritis
Rheumatoid Hand
Rheumatoid Hand
Rheumatoid Knee
Rheumatoid Knee
Rheumatoid Foot
Rheumatoid Foot
Rheumatoid arthritis (RA) affects about 0.92% of adult population in India. It a systemic autoimmune disease which leads to swelling (inflammation) of various joints. The swelling destroys joints from within and causes permanent deformities. Effective treatments are now available for this common disease. Early diagnosis and aggressive therapy can usually prevent permanent disability. This, unfortunately, does not happen in many cases. There are about 20-40 new cases per Lac population each year and the disease occurs more frequently in females. The onset can be after delivery although the disease remains silent during pregnancy. Stress and environmental triggers can precipitate onset of the disease. About 5% of first degree relatives are at risk of developing RA. Cigarette smoking, coffee and oral contraceptive pills appear to increase risk of development of RA. Early diagnosis is the key to prevent deformities with appropriate management. Delay in diagnosis is the main cause of functional disability and reduced quality of life.

Mechanism
The T lymphocytes (a type of white blood cells) release cellular toxins (cytokines) and degradative enzymes which damage the joints. They also stimulate B lymphocytes to produce auto-antibodies. The process is highly complex and beyond the scope of present write up. Extensive information on this subject has led to successful development of various effective new drugs for this dreaded disease.

Symptoms
Swelling of 3 or more joints, involvement of small joints of hands and wrists, symmetry of joint involvement and morning stiffness lasting for over an hour are main features of the disease according to earlier criteria laid down by American College of Rheumatology. These have recently been modified to add more weightage to involvement of small joints of hand and values of some blood tests such as Rheumatoid Factor (RF- RA Factor is an incorrect term) and Anti-cyclic Citrullinated Peptide Antibodies (ACPA).

The disease usually starts insidiously with involvement of few joints and affects more number of joints later on. RA can sometimes start and remain confined to a single joint such as knee. Some generalized features such as feverishness, weakness, fatigue, malaise, loss of appetite and loss of hair may also accompany. Anxiety, depression, helplessness and loss of confidence are usually observed in chronic cases. The joints are progressively damaged in untreated or inadequately treated cases and develop various deformities such as deviated fingers, swan neck fingers, subluxed fingers, hammer toes, flat feet and fixed contractures of large joints. Many diseases can mimic RA. An expert rheumatologist is needed to establish diagnosis and plan customized therapy for every patient.

Involvement of other systems

Rheumatoid VasculitisRheumatoid Vasculitis Uncontrolled RA is now recognized to reduce lifespan by about 7 years due to involvement of blood vessels. RA can involve various systems in our body. Male patients and those with positive rheumatoid factor are more likely to develop extra-articular features. Some of these problems can also develop due to intercurrent infections and cancers. Thorough investigations are, therefore, essential in such cases.
 Common problems are given in the following table:

1 Bones Osteoporosis (Weak bones with increased fracture risk).
2 Muscles Wasting and weakness.
3 Eyes Dryness, pain and redness, ulceration and perforation.
4 Lungs Pleural effusion (fluid around lungs), Interstitial pneumonia and fibrosis.
5 Mucosa Dry mouth, vaginal dryness.
6 Heart Effusion (fluid around heart), swelling of heart (myocarditis).
7 Nodules Painless nodules on back of forearm and other areas. Can occur in lungs and other organs too.
8 Blood Anemia, reduced white cells and platelets.
9 Blood Vessels Arteriosclerosis – thickening and stiffness of vessels. Higher risk of heart attack and strokes. More severe heart disease. Early death.
10 Vasculitis Swelling of blood vessels. Nonhealing skin ulcers and infections. Neuropathy.
11 Nerves Neuropathy
12 Kidneys Glomerulonephritis and interstitial nephritis.
13 Psychological Anxiety, depression.
14 Infections High risk.
15 Cancers Lymphoproliferative – high risk.
16 Others Hoarse voice, ringing in ears, amyloid.
17 Drugs Many systemic adverse events.
Investigations
Erythrocyte sedimentation rate (ESR) and C-reactive proteins (CRP) are the blood tests that indicate inflammation. RF and ACPA indicate immune dysfunction and higher levels increase possibility of RA. RF positivity does not automatically mean RA as 3% normal population (especially aged) is RF positive. RF positivity is seen in many other conditions such as diabetes, liver disease, cancer, TB and AIDS. Diagnosis of RA is clinical and presence of joint swelling (synovitis) is essential for diagnosis. Other blood tests are required for assessment of systemic involvement (liver, kidneys, etc) and monitoring of adverse drug events. X-rays of joints may indicate destruction and bone loss. Ultrasound and magnetic resonance examination of joints can detect joint involvement at a very early stage.
Rheum Arhritis Erosions
Rheum. Arhritis Erosions
Knee Erosion
Knee Erosion
Osteopenia Wrist
Osteopenia Wrist
12Early RA
All cases of swelling of more than one joint must be seen by a rheumatologist preferably within 6 weeks as joint damage can be prevented by aggressive therapy at this stage.  Female sex, higher number of involved joints, RF/ACPA positivity, high ESR/CRP levels indicate diagnosis of RA and predict severe disease. RA of less than 2 year duration is known as early disease whereas duration of less than 3 months indicates very early disease.

Assessment
Disease assessment in RA is extremely important for knowing the severity and activity of disease. This also helps in planning and monitoring therapy. Various disease activity scores such as DAS-28 (28 joints examined for swelling and tenderness) and CDAI (clinical disease activity score-this does not require any blood tests) have now been validated for evaluation of RA. Pain, fatigue, quality of life and other assessments are required to be carried out in clinical research. A simple health assessment questionnaire has also been devised for patients of RA. American College of Rheumatology and European League against Rheumatism have developed criteria for disease remission which indicate success of treatment and help modifications in therapy.
Treatment

Hand after treatmentSignificant progress has been made recently in drug management of this disabling disease. Many drugs, if used appropriately, can slow down the disease progression. Although there is no cure at present, scientists are aiming at complete remission of disease activity and halting or reverting the process of joint damage. The aim of therapy is to relieve pain and stiffness, to control the disease and to avert possible disease complications. Pain and inflammation is managed with paracetamol, non-steroidal anti-inflammatory drugs (ibuprofen, piroxicam, indomethacin, etc.) and glucocorticoids. These drugs are used as “bridge” therapy until disease modifying anti-rheumatic drugs (DMARDs) take over disease control. DMARDs usually require 2-6 months for maximum benefit. Painkillers and glucocorticoids (steroids) can then be reduced or stopped completely according to patient response. DMARDs commonly used are chloroquin (250 mg once daily), hydroxychloroquin (200-400 mg once daily-preferably at night), methotrexate (10-25 mg oral/subcutaneous injection once weekly) and leflunomide (10-20 mg once daily). All these drugs can cause adverse effects in few patients and must be monitored by a rheumatologist. New biologic agents (etanercept, infliximab, abatacept, rituximab, etc.) have shown dramatic effects in methotrexate non-responsive cases. Though effective, they are expensive and most of Indian patients do not afford them.  Many new drugs are in pipeline and coming years will see a revolution in management of RA. Drug compliance as per rheumatological advice is extremely important. It is observed that 50% of uncontrolled patients are non-compliant. Lifetime use of DMARDs is recommended at present though their dosages can be reduced after achieving adequate control of disease activity
Life Style
Healthy living and positive thinking are extremely important for all patients of RA. One must understand the disease and learn to live with it. Active life-style, regular exercise(aerobic – walking, swimming, Yoga), weight control, adequate rest, avoidance of smoking as well alcohol, and nutritious food (proteins, calories and calcium) habits are essentials of self care. Role of a particular diet has no scientific proof as yet. Physiotherapy (range of motion and strengthening exercises)-under guidance of a physiotherapist- is used to maintain joint shape and function. Splints, gadgets and other appliances compensate for joint deformities. Application of heat, cold or an ointment can relieve pain in some cases. Overexertion should be avoided. Adequate rest is essential during disease flares. RA is a chronic disease and can lead to anxiety and depression. Support groups can be of great help in these situations.
Surgery
RA affects many joints at the same time. Drug treatment, therefore, is the mainstay of treatment. Joint replacement or other operations are indicated in deformed joint with functional impairment. Knee or hip replacement, ankle or wrist fusions are some of the surgeries required for deformed joints. Surgery is usually expensive. It is not the final answer and drugs must be continued even after a successful surgery.

 
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