WHAT IS RHEUMATOID ARTHRITIS (RA)?  Rheumatoid arthritis is an inflammatory, autoimmune disease.  It usually strikes between the ages of 25-50 years, but can occur in children.  The disease effects more than 1% of the tropical population.  The presentation of the disease increases with age 5% in females and 2% in males at age 55 years.  Women have the disease three times more than men.  The disease has a hereditary tendency but may skip generations.  The onset of Rheumatoid arthritis varies but it may develop within weeks or months.  It usually affects joints symmetrically on both sides of the body.  The affected joints develop Pain, Redness, Warmth, Swelling and Loss of function.  The joint involvement may migrate from one joint to another, leaving residual damage.  The joints involved are usually the small joints of the hand & feet, elbow, shoulder, ankles & knees.  The disease can affect the entire system, with feeling of sickness, weight loss and fever.  It causes prolonged stiffness, specially in the morning or after rest.  The disease may cause major fatigue.

 Rheumatoid arthritis is caused due to various environmental triggers in genetically predisposed individuals.  The environmental triggers may be Infections, Hormonal influence, (Harris, 1993) Neuro-endocrine disturbance and Smoking. (Silman, 1996).  Bacterial Infections due to Streptococcal, Atypical mycobacteria, and Proteus, while viral infections due to Ebstein Barr virus, Rubella, Parvovirus, and Retrovirus have been attributed.  For reasons not fully understood the immune system of the body attacks the tissue surrounding the joints leading to infiltration of T-Lymphocytes and Plasma cells.  This is followed by proliferation of the synovial lining and formation of new blood vessels and seaweed like fronds and folds. This proliferation leads to the formation of ‘Pannus’ by covering of the cartilage and juxta-articular bony surface. The proliferation is first seen at the joint margins.  Due to this attack the joint lining or ‘synovium' becomes inflamed and enlarged and produces large quantities of synovial fluid.  This leads to swollen, sore and stiff joints.

 If left untreated, this process damages the joint cartilage and erodes the bones, leading to joint destruction and deformity.

 The diagnosis of rheumatoid arthritis is essentially based on the clinical findings. As per the recommendations of the American Rheumatism Association (Arnett et al, 1988), the following diagnostic criteria are made. 1. Presence of morning stiffness of at least one hour for more than six weeks. 2. Arthritis of at least 3 joints with soft tissue swellings for mare than 6 weeks. 3. Arthritis of hands, at least one swollen area in wrist or Meta-Carpo-Phalangeal or Proximal InterPhalagial Joint for more than 6 weeks. 4. Symmetric arthritis of more than 6 weeks. 5. Presence of Rheumatoid nodules as diagnosed by a physician. 6. Presence of raised titre of Rheumatoid factor 7. Presence of Radiological changes The presence of at least four of the above is considered diagnostic of Rheumatoid Arthritis but the points to be noted are:  Rheumatoid factor alone is no indicator of the presence or absence of the disease. A raised titre indicates a poor prognosis while more than 40% patients remain sero-negative throughout their life.  Diagnosis made on X-rays is already too late since joint damage has already set in.  Early diagnosis and aggressive management is the rule today, in order to prevent residual damage that takes about three months to occur. Further it takes most of the disease modifying drugs about six weeks to start working, so waiting six weeks for initiation of therapy may not be justified.  X-rays, laboratory tests, etc. are done to monitor the progress of the disease and effects of treatment.
WHAT ARE THE FOODS RESTRICTIONS?   There is no clear evidence for any food restrictions. Food like rice, wheat, lentils, fruits, curd, buttermilk, red meat, have been linked to the disease but there is no clear evidence for this.   Weight loss in obese patients is advised. Acidity, Flatulence & upset stomach are not related to the disease.

WHAT ARE THE EFFECTS OF WEATHER?    There are no long-term effects of weather. Many people feel worse in cold and humid weather, and comfortable in dry and crisp conditions. Winters or cold cause pain & stiffness of affected joints, but does not increase the disease.

DOES IT RUN IN FAMILIES?   Genetic predisposition has been seen but the disease often skips every other generation. Since we hope to find good cure for the disease, do not be afraid that you may pass it on to your children.

SHOULD PREGNANCY BE AVOIDED?   In 75% of mothers, RA improves during Pregnancy. Those women taking DMARDs, and are planning pregnancy, must consult their Doctor, because most DMARDs are potentially teratogenic.

WHAT IS THE DIFFERENT CAUSES OF ARTHRITIS? The Greek word ‘Arthro’ means joint while ‘itis’ means swollen. Arthritis may be found in common viral fever, malaria or Typhoid etc. Other common causes are Rheumatoid Arthritis, Gout, Ankylosing Spondylitis, Systemic Lupus Erythematosis (SLE), Psoriasis, etc. Children may get Juvenile Rheumatoid Arthritis (JRA) and Juvenile Idiopathic Arthritis (JIA). The commonest type of arthritis is Osteoarthritis. The differences between Rheumatoid Arthritis and Osteoarthritis are:-



 

An inflammatory, autoimmune disease Usually strikes between 25-50 years of age


A degenerative disease of the cushioning cartilage

 

Usually affects after 40 years of age Usually develops slowly over many years

 

May develop within weeks or months Usually affects symmetrically on both sides of the body


Affects isolated joints or on one side of the body


Causes Pain, Redness, & Swelling of affected joints

Usually does not cause redness and warmth of the joints


This process may migrate from one joint to another
 

Does not migrate Most commonly affects weight bearing joints (E.g. knees and hips)


Affects many joints, usually small joints of the hand and feet, may include elbow, shoulder, ankles & knees


The disease can affect the entire system


Discomfort is usually related to the affected joint


Prolonged stiffness, specially in the morning


Brief periods of stiffness are seen Rarely causes fatigue


Causes major fatigue

WHAT IS THE TREATMENT FO RHEUMATOID ARTHRITIS? The treatment comprises of mainly the following aspects:           Early diagnosis Aggressive approach Joint protection Pain relief Disease modification Regular follow-up Damage repair Counter Disability Family Counselling Patient support - only an early and accurate diagnosis will prevent joint damage - early and aggressive treatment is aimed at to obtain good joint salvage - joints have to be protected against damage when they are inflamed - physiotherapy and pain-killers and anti- inflammatory drugs - DMARDs-Disease Modifying Anti-Rheumatoid Drugs are essential for treatment - to monitor and modify the results and adverse effects of the treatment - repair of damaged joints by various methods - help overcome the disabilities caused by the joint damage - family should be educated about the needs of the patient - Physically & Psychosocially help the patient to cope with the disease

ROLE OF EXERCISE IN RHEUMATOID ARTHRITIS: Exercise is very important in RA: The advantages are: Proper exercise relieves pain, Increase blood supply to the joints, Increases bone mineralisation and strength Improve joint function, and decreases stiffness. Rules of Exercise: Rest is advocated when the joints are hot & inflamed, Exercise should be carried out under proper advise & guidance.

MEDICATION IN RHEUMATOID ARTHRITIS: 1. PAIN KILLERS & ANTIINFLAMMATORY DRUGS     They are prescribed for pain relief and to decrease the inflammation. They improve the quality of life. They have potentially serious side affects like Gastrointestinal Ulcers and Kidney Damage. They should not be used indiscriminately & Over the Counter use should be avoided

2. STEROIDS       They are strong Anti-inflammatory agents, and also decrease pain. They have major Gastro-intestinal side effects and also cause bone degeneration. If used locally in the form of injections the side affects are minimised. They give excellent symptomatic relief but do not stop the disease process They have a rebound phenomenon when stopped & should be slowly tapered off. They are known as the double-edged sward of Rheumatology and should be used only under Medical Guidance.

3. DMARDs: DISEASE MODIFYING ANTI-RHEUMATOID DRUGS    They are essential in the treatment of Rheumatoid Arthritis They take time to start their effect They are potentially toxic which can be prevented and treated by proper follow-up and management

 

They cannot be removed by Dialysis – specific washout procedure is followed.. They should not be stopped without proper medical advice as the sub-clinical levels exist for years and they have potential adverse effects.


They should not be taken by pregnant ladies, or breast-feeding mothers.

4. FOOD SUPPLIMENTS:  Calcium, Vitamins, Joint regenerators, Anti-oxidants, and other substances are given to facilitate treatment and prevent damages. 5. WHY SHOULD I TAKE TREATMENT AND IS IT EXPENSIVE? Treatment is a must since Rheumatoid arthritis is a Progressive Degenerative Disease that causes: Discomfort Disability Deformity Death - in the form of pain, - in the incapacitation to do work, - in the form of disfigured destructed joints, - if not treated it shortens life spans for about 10-15 years.

The cost of treatment is very low if weighed against the advantages of treatment. The disease causes major economic loss because of loss of productivity of the disabled person. Further the loss due to dependent on others and useful man-hour lost in caring for the disabled. There is a definite loss due to disease anxiety leading to family tensions and low productivity.

FOR FURTHER ADVISE AND CLARIFICATIONS PLEASE CONTACT: DR.ANISH AGGARWAL MBBS (AFMC), MD, PGD-PCR (England) Consultant Rheumatologist Ph: 9810073795 Pushpanjali Medical Centre Every Friday 4-7pm

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