Narayana Health Care

In simple terms Arthritis means inflammation of joints. Inflammation is characterised by pain, swelling, redness, and local warmth. Apart from Osteoarthritis, which is a non inflammatory cause of joint pain, most of the diseases that occur due to arthritis are caused by autoimmunity. Autoimmunity is an unstoppable disease process that is caused by the cells and chemicals of our normal immune system, who keep on attacking and damaging our own joints. These autoimmune damage causing arthritis is broadly called RHEUMATOLOGICAL DISEASES and the hallmark of them is RHEUMATOID ARTHRITIS. The Rheumatological diseases do not spare any age group. They can start at the age of 2 years and even may occur for the first time in a patient aged 80 years too. There are more than 300 disease types under the domain of RHEUMATOLOGY .

TYPES:

We would tabulate a few for easier understanding.

Sl	Name of the Disease	Age	Symptoms				Diagnostic Strategy
1	Rheumatoid Arthritis	20-70 years	Pain & Swelling of small joints of				Classic symptoms + Raised ESR, CRP
			hands with early morning stiffness				and Positive Rheumatoid Factor or
			and may affect larger joints such as				Anti CCP Ab
			knees, elbows and shoulders and if
			untreated may cause deformity of the
			hands.
2	Ankylosing Spondylosis	15–40	Usually males are affected.  Pain				X  ray  of  Sacroiliac  Joints  shows
		Years	located at lower  back  region that				Inflammation + A genetic Test called
			increases at second half of the night				HLA B27 which is positive in 90% of
			or after prolonged rest and improves				patients. ESR and CRP values may be
			with activity. Often associated with				very high.
			pain and swelling of some large joints
			and some may complain of red eyes.
3	Fibromyalgia	20-50 years	Almost females are affected and they				No  diagnostic  test  available  as
			mostly complain of aches and pains				almost   all   reports   is   normal.
			all over the body. Often associated				Diagnosed by clinical eye .
			with	Depression,	low	mood,
			unrefreshed sleep and migraine like
			headache.
4	Systemic Lupus Erythematosus	2-40 years	A   multiorgan   disease   that   is				Clinical picture is often classic. Blood
	[SLE]		characterised  by  facial  rash,  sun				tests like ANA, Anti ds DNA Antibody
			exposed rashes, joint pain, anaemia,				is positive. Treated with long term
			kidney dysfunction, lung and heart				steroids.
			problems.
5	Reactive Arthritis	16-50years	Pain and swelling of one or two large				No  specific  diagnostic  tests  are
			joints  especially  knees  and ankles				available. ESR and CRP value may be
			that  develop  within  3  days  to  3				high. Some patients have HLA B27
			months  after  a  viral  or  bacterial				genetic test POSITIVE
			infection and is self limiting
6	Gout	50years	Common in elderly males and can be				Blood levels of uric acid DO NOT help
		and above	acute or chronic. Acute gout affects				in diagnosis and it may be normal
			the ball of the great toe which may				during the attack. Aspiration of joint
			become extremely swollen, red and				Fluid	and	examination	under
			painful and can bring in fever				microscope can visualise uric acid
							crystal.

WHO ARE AT THE RISK?

In fact all the rheumatological diseases are caused by more than one gene. In fact 100 of genes are responsible for the disease and the simple arithmetic of parents having the disease will result in the same in the offspring does not apply here. But diseases like Ankylosing Spondylosis, Psoriatic Arthritis and Rheumatoid Arthritis often run in the family.

People who smoke or eat high protein food especially rich in saturated fats and smoked foods develop devastating consequences of a well-established disease characterized by excessive pain, poor response to the treatment and accelerated joint destruction and early development of deformities.

TREATMENT

The most important part of the treatment is physical therapy and dynamic exercise. The fluid or liquid that is present at the joint space is normal circulated throughout the day and fresh joint fluid is formed from the ultra filtration of the blood. The more a person is active, there is more circulation and the damaging chemicals are washed out of the joints. This causes reduced destruction of the joints.

The most effective medicine is suppressing any form of autoimmune inflammation is steroids. Steroids act rapidly at the site of damage and can give dramatic relief to pain. In most of the rheumatological diseases steroids are used for short duration and at low doses. High doses of steroids are used in rheumatological emergencies. Chronic use of steroids may cause high blood pressure, development or worsening of diabetes, stomach ulcers, osteoporosis of bones, swelling of the body etc.

The next group of drugs are classic pain killers also known as NSAIDs. They are used for short duration but diseases like Ankylosing Spondylosis need long term treatment with NSAIDs, Adverse effects are stomach ulcer, kidney damage and cardiac problems.

The next set of drugs is called Disease Modifying Anti Rheumatoid Drugs or DMARDS. Methotrexate [with Folic Acid], Sulfasalazine, Hydroxychloroquine Sulfate, Minocycline and Leflunomide are together called Synthetic DMARDs [sDMARD]. They modify the disease and prevent progression of the disease. They are used in variable combinations in different Rheumatological disorders. They have their own battery of adverse effects and hence periodic monitoring of Haemoglobin, Blood Counts, Liver and Kidney Function is necessary.

The most advanced group of medicines are called Biological DMARDs or only Biologicals. They are costly highly proficient injections that exclusively target and suppress the offending chemicals that damage the joint. They can result is excellent response to the treatment and people benefit significant with such shots. Once again they have a unique school of adverse effects which is characterised by development of serious infection such as Tuberculosis, Hepatitis or some neurological damage. It is prudent to rule out any latent tuberculosis, Hepatitis or HIV infection prior to initiation of the drug. Further, it also important to vaccinate the patient against common vaccine preventable diseases before starting this therapy.

CONCLUSION

With rapid and continual up gradation of medial knowledge most of the Rheumatological disorders can be addressed well. The crux of the treatment lies in early detection. Most of the Rheumatological disorders do not come with all the specific clinical symptoms and neither there are any confirmatory diagnostic tests. Hence early and correct diagnosis depends on the clinical eye of the treating doctors. It is always beneficial to catch them young and hit them hard before any damage is accrued. Life expectancy is hardly shortened and quality of life is usually preserved with proper management program.

Dr. Tanoy Bose

Consultant – Arthritis: Rheumatology: Internal Medicine

NH Rabindranath Tagore International Institute of Cardiacsciences, Mukundapur &

NH Rabindranath Tagore Surgical Centre, Hiland Park