FAQ's on Rheumatology

Q- What causes rheumatic diseases?

Ans- Rheumatic diseases are generally believed to be caused by a combination of genetic and environmental factors. In other words, you may be born with a susceptibility to a disease, but it may take something in your environment to get the disease started. Some of these factors have been identified. For example, in osteoarthritis, inherited cartilage weakness or excessive stress on the joint from repeated injury may play a role. In rheumatoid arthritis, juvenile idiopathic arthritis, and lupus, patients may have a variation in a gene that codes for an enzyme called protein tyrosine phosphatase nonreceptor 22 (PTPN22).
Certain viruses may trigger disease in genetically susceptible people. For example, scientists have found a connection between Epstein-Barr virus and lupus. There are likely many genes and combinations of genes that predispose people to rheumatic diseases, and many different environmental factors that trigger them.

Gender is another factor in some rheumatic diseases. Lupus, rheumatoid arthritis, scleroderma, and fibromyalgia are more common among women. This indicates that hormones or other male-female differences may play a role in the development of these ¬conditions.

Q- Who is affected by rheumatic diseases?

Ans- Approximately 4-6 out of 10 consultations with a family physician are for a musculo[skeletal complaint. Rheumatic ¬ diseases are a more frequent cause of activity limitation than heart disease, cancer, or diabetes.

Rheumatic diseases affect people of all races and ages. Some rheumatic conditions are more common among certain populations. For example:

·         Rheumatoid arthritis occurs two to three times more often in women than in men.

·         Scleroderma is more common in women than in men.

·         Nine out of 10 people who have lupus are women.

·         Nine out of 10 people who have fibromyalgia are women.

·         Gout is more common in men than in women. After menopause, the incidence of gout for women begins to rise.

·         Systemic lupus erythematosus is more common in women than in men, and it occurs more often in African Americans and Hispanics than in Caucasians.

Q- How are rheumatic diseases diagnosed?

Ans- Diagnosing rheumatic diseases requires a systematic approach in evaluating the symptoms and signs. A general practitioner or family doctor may be able to recognise the presence of a rheumatic disease and should then refer the patient to a rheumatologist (a doctor who specializes in treating arthritis and other rheumatic diseases).

Common Signs and Symptoms of Arthritis

·         swelling in one or more joints

·         stiffness around the joints that lasts for at least 1 hour in the early morning

·         constant or recurring pain or tenderness in a joint

·         difficulty using or moving a joint normally

·         warmth and redness in a joint

Common laboratory tests and procedures include the ¬following:

Antinuclear antibody (ANA) – This test checks blood levels of antibodies that are often present in people who have connective tissue diseases or other autoimmune disorders, such as lupus. Because the antibodies react with material in the cell’s nucleus (control center), they are referred to as anti¬nuclear antibodies. There are also tests for individual types of ANAs that may be more specific to people with certain autoimmune disorders. ANAs are also sometimes found in people who do not have an autoimmune disorder. (In such cases, the result is referred to as a “false positive.”) Therefore, having ANAs in the blood does not necessarily mean that a person has a disease and it is important to analyse the result in the light of the patients’ symptoms.

CCP (or anti-CCP) – This test checks blood levels of antibodies to citrulline, a protein that can be detected in up to 70 percent of people in the early stages of rheumatoid arthritis. Because the presence of anti-CCPs is associated with more aggressive disease, the test can also be useful in helping doctors plan treatment.

C-reactive protein test – This nonspecific test is used to detect generalized inflammation. Levels of the protein are often increased in patients with active disease such as rheumatoid arthritis or any other disease that causes inflammation.

Complement – This test measures the level of complement, a group of proteins in the blood. Complement helps destroy germs and other foreign substances that enter the body. A low blood level of complement is common in people who have active lupus.

Complete blood count (CBC) – This test determines the number of white blood cells, red blood cells, and platelets present in a sample of blood. Some rheumatic conditions or drugs used to treat arthritis are associated with a low white blood count (leucopenia), low red blood count (anemia), or low platelet count (thrombocytopenia).

Creatinine – This blood test measures the level of creatinine, a breakdown product of creatinine, which is an important component of muscle. Creatinine is excreted from the body entirely by the kidneys, and the level remains constant and normal when kidney function is normal. This test is commonly used to diagnose and monitor kidney disease in patients who have a rheumatic condition such as lupus.

Erythrocyte sedimentation rate (or ESR) – This blood test is used to detect inflammation in the body. High ESR, indicates the presence of inflammation, and is seen in many forms of arthritis, such as rheumatoid arthritis and ankylosing spondylitis. High ESR is also typical of many of the immunologic connective tissue diseases, such as lupus, scleroderma and Polymyalgia rheumatica. However, the ESR may also be elevated in the presence of other conditions such as some infections and malignancy.

Haematocrit (PCV, packed cell volume) – This test and the test for hemoglobin (a substance in the red blood cells that carries oxygen throughout the body) measure the number of red blood cells present in a sample of blood. A decrease in the number of red blood cells (anemia) is common in people who have inflammatory arthritis or another rheumatic disease. Rheumatoid factor – This test detects the presence of rheumatoid factor, an antibody found in the blood of most (but not all) people who have rheumatoid arthritis. In rheumatoid arthritis, it may be associated with more aggressive disease. Rheumatoid factor may be found in many diseases besides rheumatoid arthritis and sometimes in people without health problems.

Synovial fluid examination – Synovial fluid may be examined for white blood cells (found in patients with rheumatoid arthritis and infections), bacteria or viruses (found in patients with infectious arthritis), or crystals in the joint (found in patients with gout or other types of crystal-induced arthritis). To obtain a specimen, the doctor injects a local anesthetic, then inserts a -needle into the joint to withdraw the synovial fluid into a syringe. The procedure is called arthrocentesis or joint aspiration.

Urinalysis – In this test, a urine sample is studied for protein, red blood cells, white blood cells, and bacteria. These abnormalities may indicate kidney disease, which may be seen in lupus as well as several rheumatic conditions. Some medications used to treat arthritis also can cause abnormal findings on urinalysis.

X Rays and Other Imaging Procedures
To see what the joint looks like inside, the doctor may order x rays or other imaging procedures. X rays provide an image of the bones, but they do not show cartilage, muscles, and ligaments. Other noninvasive imaging methods such as computed tomography (CT or CAT scan), magnetic resonance imaging (MRI), and arthrography show the whole joint. The doctor also may look for damage to a joint by using an arthroscope: a small, flexible tube which is inserted through a small incision at the joint. The arthroscope transmits the image from inside the joint to a video screen.

Q- What are the treatments?

Ans- There is no single treatment for rheumatic diseases and this would depend upon the individual disease or condition and the problems caused, in a given patient. The treatment options may therefore include:

General Measures: General measures as part of the treatment for rheumatic diseases may include (where appropriate) rest, exercise, proper diet, and joint protection measures. Joint protection may require the use of assistive devices, such as splints or braces. In severe cases, surgery may be necessary.

Medications
A variety of medications are used to treat rheumatic diseases. The type of medication depends on the rheumatic disease and on the individual patient. The medications used to treat most rheumatic diseases do not provide a cure,but can control the disease and prevent or limit further complications and/or joint damage. Infections in a joint can often be completely treated by appropriate medication. Another exception is Gout, which is virtually curable, if treated properly.

Following are some of the types of medications commonly used in the treatment of rheumatic diseases.

Analgesics – Pure analgesics (or pain relievers) include oral medicines such as Paracetamol or Tramadol and can be used to reduce the pain caused by many rheumatic conditions. In addition to oral medicines, analgesics may also be used as topical preparations; These creams or ointments are rubbed into the skin over sore muscles or joints and relieve pain through one or more active ingredients. These are the most common:

·         Counterirritants – These ingredients, such as menthol, oil of wintergreen, eucalyptus oil, or camphor, work by irritating the nerve endings in the skin. This distracts the brain from the deeper source of pain.

·         Salicylates – This ingredient works like aspirin, by blocking chemicals in the body that contribute to pain.

·         Capsaicin – This natural ingredient found in cayenne peppers is an effective pain reliever by blocking the pain sensing nerve endings.

Nonsteroidal anti-inflammatory drugs (NSAIDS)– This large class of medications is useful against both pain and inflammation of joint diseases. Though they are non-specific and do not act as disease modifying drugs, they are commonly used for symptomatic benefit in addition to other specific medication. Some NSDAIDs are: Ibuprofen, Diclofenac, Naproxen etc. There is a group of NSAIDs called Cox-II inhibitors that are considered to be easier on the stomach and they include: Etoricoxib and Celecoxib.

All NSAIDs work similarly: by blocking substances called prostaglandins that contribute to inflammation and pain. Due to their anti-prostaglandin effects, NSAIDs can cause stomach irritation or can affect kidney function. Therefore they must be used with appropriate caution and an understanding of the benefits and potential risks.

Disease-modifying antirheumatic drugs (DMARDs) – A family of medicines that are used to treat inflammatory arthritis like rheumatoid arthritis and ankylosing spondylitis, DMARDs work by acting upon the mechanisms that cause the inflammation and therefore modify the disease and stop/limit the effects or damage by the disease. DMARDs typically require regular blood tests to monitor possible side effects and with proper monitoring can be continued for prolonged periods, for their beneficial effects. Though DMARDs may help to retard or even stop joint damage from progressing, they cannot change joint damage that has already occurred- therefore, it is imperative that these drugs are started sooner rather than later.

Some of the commonly used DMARDs are Methotrexate, Hydroxychloroquine, Sulfasalazine, Leflunomide, Azathiaprine, Cyclophosphamide.

Biologic response modifiers – Amongst the DMARDs, Biologic response modifiers, or Biologics, are a new family of genetically engineered drugs that block specific molecular pathways of the immune system that are involved in the inflammatory process. Thus, they actually ‘target’ the disease mechanism and can be very effective. They are often prescribed in combination with DMARDs such as methotrexate. They may make an individual more prone to some types of infection and their cost can be a limitation as well. The Biologics currently available in India are: Etanercept, Infliximab, Abatacept, Tocilizumab and Rituximab.

Corticosteroids– Corticosteroids, such as prednisolone, dexamethasone, betamethasone, and methyl-prednisolone, can be used to treat many rheumatic conditions, because they decrease inflammation and suppress the immune system. The dosage of these medications as well as their method of administration may vary depending on the condition being treated. Corticosteroids can be given by mouth, in creams applied to the skin, intravenously, or by injection directly into the affected joint(s). Short-term side effects of corticosteroids include swelling, increased appetite, weight gain, and emotional ups and downs. These side effects generally stop when the drug is stopped. It can be dangerous to stop taking corticosteroids suddenly, so it is very important that the doctor and patient work together when changing the corticosteroid dose. Side effects that may occur after long-term use of corticosteroids include stretch marks, excessive hair growth, osteoporosis, high blood pressure, damage to the arteries, high blood glucose, infections, and cataracts.

Hyaluronic acid substitutes – Hyaluronic acid products, such as Hyalgan and Synvisc, mimic a naturally occurring body substance that serves to lubricate joints and is believed to be deficient in joints with osteoarthritis. Depending on the particular product, patients receive a series of three to five injections, which are administered directly into the affected knee(s) or hip(s) to help provide temporary relief of pain and flexible joint movement.

Splints and Braces - Splints and braces are used to support weakened joints or allow them to rest. Some prevent the joint from moving; others allow some movement. A splint or brace should be used only when recommended by a doctor or therapist, who will explain to the patient when and for how long the device should be worn. The doctor or therapist also will demonstrate the correct way to put it on and will ensure that it fits properly. The incorrect use of a splint or brace can cause joint damage, stiffness, and pain.

Assistive Devices - A person with arthritis can use many kinds of devices to ease the pain. For example, using a cane when walking can reduce some of the weight placed on a knee or hip affected by arthritis. A shoe insert (orthotic) can ease the pain of walking caused by arthritis of the foot or knee. Other devices can help with activities such as opening jars, closing zippers, and holding pencils.

Surgery - Surgery may be required to repair damage to a joint after injury or to restore function or relieve pain in a joint damaged by arthritis. Many types of surgery are performed for arthritis. These include:

·         Arthroscopic surgery – surgery to view the joint using a thin lighted scope inserted through a small incision over the joint. If repair is needed, tools may be inserted through additional small incisions.

·         Bone fusion – surgery in which joint surfaces are removed from the ends of two bones that form a joint. The bones are then held together with screws until they grow together forming one rigid unit.

·         Osteotomy – a surgery in which a section of bone is removed to improve the positioning of a joint.

·         Arthroplasty – also known as total joint replacement. This procedure removes and replaces the damaged joint with an artificial one.

Q- What can be done to help?

Ans- Many people find that having arthritis or another rheumatic disease limits their activities. When people can no longer participate in some of their favorite activities, their overall well-being can be affected. Even when arthritis impairs only one joint, a person may have to change many daily activities to reduce pain and protect that joint from further damage. When a condition affects the entire body, as it often does with rheumatoid arthritis, lupus, or fibromyalgia, many daily activities have to be changed to deal with pain, fatigue, and other symptoms.

Changes in the home may help a person with chronic arth¬ritis continue to live safely, productively, and with less pain. People with arthritis may become weak, lose their balance, or fall. In the bathroom, installing grab bars in the tub or shower and by the toilet, placing a secure seat in the tub, and raising the height of the toilet seat can help. Special kitchen utensils can accommodate hands affected by arthritis to make meal preparation easier. An occupational therapist can help people who have rheumatic conditions to identify and make adjustments in their homes to create a safer, more comfortable, and more efficient environment.

Friends and family members can help a patient with a rheumatic condition by learning about that condition and understanding how it affects the patient’s life. Friends and family can provide emotional and physical assistance. Their support, as well as support from other people who have the same disease, can make it easier to cope

Q- Where can people find more information about arthritis and rheumatic diseases?

Ans- Patient educational leaflets published by the Indian Rheumatology Association (IRA) are available and can also be downloaded from the IRA website- www.indianrheumatology.org