Rheumatoid Arthritis Treatment

The word “arth” means joint and the word “itis” means inflammation. Hence “arthritis” means “inflammation in the joints”. In various languages and communities it is known differently.

Some of the commonly used names are “Sandhi – vaat”. In Marathi it is quite often referred to as “Aam – Vaat”. In the North and North western part of India it is also known as “Gathiya” and so on.

Because this disease is characterized by pains and swelling in multiple joints, it is often referred to as “polyarticular” (“poly” means multiple usually more than 5 and “articular” meaning related to joints).

Quite typically, Rheumatoid Arthritis is characterized by a symmetrical involvement of the joints: if the left wrist is involved then the right wrist will also be or if the right knee is affected then there will be affection of the left knee as well.

One more important feature of Rheumatoid Arthritis is that both small and large joints are involved. This means the finger joints as well as the larger joints such as knees etc. Contrast this with “Spondyloarthropathy” or “Ankylosing spondylitis“, where the disease is usually asymmetric and involves only the larger joints.

Additionally the spine is spared in RA except for the cervical spine meaning the neck region.

Rheumatoid arthritis is a “systemic disease” meaning it affects the entire body. It is incorrect to assume that only the joints are involved. Rheumatoid Arthritis can affect the eyes and the lungs as well.

People with uncontrolled arthritis are known to have a shorter life span than the average life span of the population. This is because the chronic inflammation also affects the blood vessels, and thereon, the heart. Hence it is imperative to treat this disease as aggressively as you would any other systemic illness.

Untreated arthritis leads to permanent joint damage and deformities. Joint damage is permanent. It cannot be reversed. What is lost is lost. You can only try and prevent further damage in the joint by controlling the inflammation with anti-rheumatic drugs, known as DMARDS (disease modifying anti-rheumatic drugs).

It is known that if untreated for 6 months, 80 percent of patients begin to show signs of cartilage affection and joint damage. It is also an established fact that if treatment is begun within the first 6 weeks then the patient stands a chance of remission, which means a “cure”. Even if that does not happen and medications need to be continued, joint damage will be prevented and a good quality of life will be ensured.

Please consult a rheumatologist as early as possible and have this illness treated appropriately. Most patients consult an orthopedic surgeon for this problem. Orthopedic surgeons are ‘surgeons’ and are not trained to understand this particular disease in its totality. Their training is in surgery, and they treat fractures or conduct joint replacements etc. They are not trained to treat Rheumatic diseases, which is a different specialty altogether.

Rheumatologists are physicians who specialize in Rheumatology AFTER their MD in medicine or pediatrics in case of pediatric rheumatology.

Diagnosing Rheumatoid Arthritis

The diagnosis of Rheumatoid Arthritis is essentially a clinical diagnosis based on symptoms, signs and a thorough clinical examination by a Rheumatologist. There are no tests to diagnose arthritis, though there are certain tests which support in establishing the diagnosis of Rheumatoid Arthritis.

For example let us take Rheumatoid factor (RF). This test is erroneously referred to as a “RA test”. This is a misnomer. There is no such thing as a RA test. Some laboratories issue reports which refer to this as RA test, which is wrong.

Now let us talk about this test. This test, even in cases of Rheumatoid Arthritis, is positive in about 66% of patients. Effectively this means that 33% of patients who do have RA will not be diagnosed if you rely on this test. Even patients who have an aggressive disease can have a negative rheumatoid factor(Sero negative RA).

On the other hand this test can be positive in other conditions as well so relying solely on this test can lead to a wrong diagnosis.

Cyclic Citrullinated Peptide (Anti CCP, sometimes referred to by a few as ACPA): This is a more specific test for Rheumatoid Arthritis meaning if this test is positive there is a significant possibility that you do have Rheumatoid Arthritis. Again, the titres are important. But more importantly, if this test is negative it still does not mean you do not have Rheumatoid Arthritis.

So what is the outcome? Does one not treat the patient because the test is negative? Can we allow their joints to get damaged because the test is negative? The question is: are we treating a patient or a blood report?

On the other hand, we see a lot of patients being treated with anti-rheumatic drugs by orthopedic surgeons when they do not have Rheumatoid Arthritis at all. The patient has joint pains and so starts treatment. What is important here is to diagnose correctly, and treat on time, or else there will be complications on both sides.

Complications:

Rheumatoid Arthritis can affect the eyes and cause dry eyes and dry mouth often referred to as Sicca symptoms or Secondary Sjogrens syndrome. Over a period of time untreated dry eyes can even lead to ulcers over the cornea and then blindness. As mentioned earlier Rheumatoid Arthritis can also cause Interstitial Lung disease (ILD) where there is inflammation in the connective tissue of the lungs causing damage in the lungs over time.

Long standing Rheumatoid Arthritis can affect the blood vessels and cause inflammation of the blood vessels leading to their rupture and thus cause open ulcers. This is called “Rheumatoid Vasculitis” and is a marker of poor prognosis.

Again as mentioned earlier Rheumatoid Arthritis patients tend to get cardiovascular complications with an increased tendency towards heart attacks.

There are many more, but those mentioned above are meant just to highlight the fact that vasculitis is a systemic disease affecting multiple organs when untreated.

Rheumatoid Arthritis Treatment:

1) Disease modifying anti-rheumatic drugs (DMARDS):

These are not painkillers or steroids but anti-rheumatic drugs meant to control the inflammatory process itself. They are slow acting drugs and take a minimum of 6 to 8 weeks to show any benefit. The patient will feel relief only when the inflammatory process itself is controlled. However these have to be carefully chosen on a case by case basis and after screening the patients to gauge THEIR ability to tolerate these drugs.E.g. a patient with allergy to sulfa cannot be given the anti-rheumatic drug sulfasalazine.

Similarly, a patient planning pregnancy in the near future cannot be given drugs like Methotrexate and leflunomide. The commonly used DMARDs in arthritis treatment are Methotrexate, leflunomide, Sulfasalazine and hydroxychloroquin. In some cases, cyclosporine is given when the above are not suitable.  Each of these drugs has been dealt with separately in the drugs section.

Beyond these drugs there are are biological agents which are extremely powerful anti-rheumatic drugs. These drugs have brought about a revolution in the treatment of Rheumatoid Arthritis. However these drugs come with their own set of conditions.

a) They are extremely expensive. This puts them beyond the reach of the majority of middle class patients, much less the lower class.

b) These drugs are extremely powerful immunosuppressants. Given the level of hygiene in our country and the number of infections that our country is endemic for, these drugs will need to be used very cautiously after carefully screening each patient for any underlying infection right from head to toe.

2) Non-steroidal anti-inflammatory agents (NSAIDs): Commonly called painkillers however not all painkillers are anti-inflammatory. These have a short lived but important role in the initial relief of pain. As mentioned above, DMARDS take 6-8 weeks to act at the least. Hence to tide over this initial period one would need to use these drugs for a short while. However these are not anti-rheumatic drugs and cannot be continued indefinitely as they will then lead to side effects. NSAIDS have been dealt with separately in the drugs section.

3) Steroids: ‘Steroid’ has become a taboo word for all the wrong reasons. When used by the wrong people in the wrong condition in the wrong dose for a wrong period of time, they can definitely cause side-effects and problems. But remember, steroids were meant to be lifesaving drugs and not meant to cause side effects. The only reason they now have a ‘bad’ image is because they have been used in the wrong indications.

Extensive research has been carried out on the benefits and side effects of steroids and the conclusion is that steroids when used in low doses along with adequate doses of a combination of DMARDs, it achieves almost the same result as that of biological drugs which most people in our country still cannot afford. Additionally if used in doses of less than 7.5 mg per day, the incidence of side effects is significantly reduced, though not totally absent.

More on this topic is written under a separate chapter on steroids.

4) Exercise: Regular exercise is a must, a fact almost no one pays much attention to. We hear excuses and more excuses to avoid exercise. This issue is discussed in detail on this site.

Remember, if you do not treat Rheumatoid Arthritis on time you will miss the boat. This disease will keep progressing and affect so many functions of our body that it takes the very joy out of living. Once that happens, life becomes an endless misery.  So start arthritis treatment early and control the disease aggressively. AS are weak already and such activities may result in fractures.