rheumatology

A Pain in the Hands, Wrists, Ankles and Feet: a Q&A on Rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory disorder that affects 1.3 million Americans; women three times more often than men. A disorder of the small joints in the hands and wrists, ankles and feet, RA is currently incurable.

Unlike osteoarthritis, a joint disorder caused by “wear and tear,” RA is primarily the result of inflammation of the synovial membrane, a soft tissue found on the inner layer of affected joints. The condition produces fluid build-up and swelling that results in pain, bone erosion, joint deformity and disability.

Older drugs and newer biologics can offer effective treatment, especially if they are started early. Arnold Ceponis, MD, PhD, a rheumatologist at UC San Diego Health System, says that standard x-rays and blood tests, in conjunction with newer imaging tools, can help to diagnose RA earlier. We asked Ceponis when people should become concerned that their aches and pains are something more worrisome than just telltale signs of aging.

Q: Is rheumatoid arthritis strictly inflammation of the joints?

A: RA is an auto-immune disorder in which one’s own immune system attacks healthy tissue causing chronic inflammation and destruction of joint cartilage and bone. If not properly treated, the damage to the joints can be severe and irreversible. RA often occurs in periodic flares of disease activity.

Fortunately, remission is possible. RA is a “systemic disease,” which means that in addition to causing joint problems, it affects the entire body. The results can be fatigue, dry eyes and mouth, nodules under the skin and eye inflammation. Chronic inflammation caused by RA can accelerate atherosclerotic damage of blood vessels and therefore significantly increase risk of heart disease, such as myocardial infarction. Having untreated or undertreated RA is somewhat similar to having untreated high blood pressure or high blood sugar levels from poorly controlled diabetes.

Q: Why do some RA patients receive ultrasound?

A: In addition to earlier diagnosis, joint examination by ultrasound during a regular office visit can help to individualize treatment. Newer generation ultrasound systems are equipped with tools that can numerically measure the amount of the blood flow within the joint and therefore can objectively measure joint inflammation.

For example, it’s not uncommon using ultrasound to find signs of active joint inflammation in patients who are only partially treated, but thought to have good disease control because there was little or no pain or swelling. Conversely, ultrasound can help to look in more detail into a source of the joint pain that might present as arthritis, but the actual reason for symptoms could be musculoskeletal pain due to sports or overuse injuries, tendinitis or a torn rotator cuff in the shoulder.

Q: What drugs are best for treating rheumatoid arthritis?

A: Most RA patients can successfully be treated with older disease-modifying drugs, such as methotrexate, leflunomide, sulfasalazine and/or hydroxychloroquine. If these traditional disease-modifying drugs aren’t sufficient, I usually prescribe biological medications, such as TNF-inhibitors or medications that modify function of specific immune cells. This strategy targets different aspects of joint inflammation, not only to improve disease symptoms, but also to halt disease progression. Although potential side effects from these treatment strategies can make individuals more prone to infection, these medications have good safety record and are usually well-tolerated.

Q: Can a patient alter the course of RA on their own?

A: I offer patients four steps: Stop smoking. Floss your teeth. Keep moving. Stay in touch with your rheumatologist.

As paradoxical as it sounds, there is strong scientific evidence to suggest that smoking is a risk factor for RA, and that poor dental hygiene can promote inflammation in the joints. It’s difficult to change habits, but stopping smoking can have multiple benefits, and it appears it can also decrease risk for RA. Certain bacteria in the mouth can trigger an immune response that causes a cross-reactivity and inflammation in the joints. Therefore, gum diseases like gingivitis and periodontitis can promote and make RA more difficult to treat. By maintaining a good oral hygiene, by flossing and brushing, you can actually help to take care of your arthritis.

Contrary to a belief that exercise is bad for your joints, studies suggest that moderate exercise can help to reduce inflammation in RA joints.

Last but not least, stay in touch with your rheumatologist. Recent studies have shown that if not treated or under treated, RA patients have a life expectancy 10 years shorter on average because of significantly increased risk of cardiovascular disease. What we also know is that treatment with methotrexate and/or TNF inhibitors may reverse that trend.

The worst reactions of people when I told them about my chronic illness...

I thought of a list for all chronic illness sufferers to edit.

1. You have crohn’s? You can be glad, you’ll be skinny your entire life.
2. But you don’t want to have children? I wouldn’t like to give one of my kids THESE diseases.
3. Arthritis? But you’re that young.
4. Are you sure you can eat this tomato?
5. But you can’t work like THIS?!
6. You don’t look sick - you’re just skinny as usual.
7. Go to a naturalpathic doctor. He can cure you.
8. You don’t want to be healthy…
9. It’s not good for you to take these medications: they can give you CANCER.

3

Kawasaki’s Disease

  • autoimmune vasculitic condition of unknown cause
  • mainly seen in children <5yrs old
  • raised temperature, lymphadenopathy
  • swelling and erythema of lips, hands and feet
  • as this resolves leads to skin peeling
  • also; classic “strawberry tongue”, conjunctivitis, cracking of lips
  • complication - coronary artery aneurysms  —> MI or rupture
  • management - IV immunoglobulin, aspirin therapy, ?pulsed steroids or anti-TNF

There are 4 main important causes of an acutely swollen joint:

  1. Crystal arthopathies (gout and pseudo-gout)
  2. Septic arthritis - infection in the joint
  3. Reactive arthritis - infection outside the joint but the immune system goes mental and attacks the joint
  4. Acute presentation of inflammatory arthropathies e.g. RA, psoriatic

Primary features are a painful, swollen, erythematous joint. In the infective types the patient may also have a high temperature and by systemically unwell. 

A Horse Among Zebras (A PMTH Monday Morning Report)

Not every patient encounter I had in Africa** was a sad one. There were tons of successes, too, and I hope to share more like the one below in the coming days/weeks. 


On rounds in the hospital I worked in in Africa, patients weren’t really assigned to docs. Whoever got to their bed first in the morning rounded on them. As a result, we cross-consulted each other fairly frequently when we felt out of our depth. Since the overwhelming majority of our patients were admitted for infectious diseases (many of them considered zebras in the US), weird bugs and tropical illnesses were always top on our differentials. 

Sometimes it caused us to forget that horses make hoofbeats, too. 

Keep reading

Even Short Courses of Steroids Linked To Bone Death

Even short courses of glucocorticoids in conditions such as lupus, rheumatoid arthritis, and many other diseases can be associated with the development of osteonecrosis, a researcher cautioned here.

For instance, exposure to these drugs for less than 30 days was associated with an odds ratio of 3.8 (95% CI 2.1 to 6.8) for osteonecrosis compared with no exposure, Steven C. Vlad, MD, of Boston University School of Medicine, reported at the annual meeting of the American College of Rheumatology.

And for patients who used glucocorticoids for more than a year, the odds ratio rose to 212.2 (95% CI 8.9 to >999.9), he said in a plenary session at the meeting.

'Chronic glucocorticoid use has long been recognized as a risk factor for osteonecrosis, but it has not been established whether short-term use also can be risky and if the risk persists after treatment ceases,' Vlad said.”

http://www.medpagetoday.com/MeetingCoverage/ACR/29537?pfc=40&spc=238

lightriot asked:

I am a 19 year old pre-med student in Florida who was just diagnosed with rheumatoid arthritis and lupus. Through this whole experience I've began to wonder, is medical school physically something that someone with such conditions should attempt? Med school of course is a grueling experience and I wonder if it would be more detrimental to my health than beneficial. I'm not making any quick decisions; I am sure that with treatment and time my health will change and I will experience ups & downs, but it is something that's been on my mind quite a bit and was looking for an honest opinion from someone who has some experience under their belt :)

Wow, spinlights, that’s a really rough pair of conditions to be dealing with! I hope you’ve got a good rheumatologist working with you.

Excellent question. As you might/might not be already aware, RA and lupus are two very difficult conditions to treat/manage, especially if you have to be on immune-modulating medications which then increase your risks for infection. So just thinking about the number of infectious diseases that you’ll be exposed to as a med student and resident (even if you eventually go into a specialty that minimizes contact with patients, such as pathology or radiology); and thinking about the physical stress of on-call nights and long operations and mental stretching for exams — yeah, you’re going to be putting your health at risk, more than the average/immunocompetent med student.

But, on the other hand, I’d hate to scare you off from pursuing medicine as a career. Careful infectious-exposure procedures could keep your reasonably safe. And imagine how your patients would benefit from seeing a doctor who is also a patient — a doctor who knows the nitty-gritty reality of managing chronic illness, taking medications, getting lab tests, having flare-ups and relapses, dealing with the hope and depression and uncertainty. Your personal health issues could make you into a powerhouse of empathy and insight for your patients. So keep that angle in mind too.

I’d love to hear more from you as you continue your journey. I think a blog about a pre-med/med student who is also dealing with chronic disease would be very fascinating —- future “book” material, even! Good luck.

***Pending Cranquis-Mails: 26***

Clinical practitioners not adhering to guidelines for osteoarthritis. Most therapeutic interventions are primarily aimed at reducing pain and improving joint function by using therapies that target symptoms, BUT DO NOT facilitate improvement in joint structure or long-term betterment of the disease.

That little excerpt explains a lot about problems with health in the United States. The doctors KNOW what will help, but they prescribe drugs they know only mask symptoms. Yes, patients usually DEMAND relief NOW, but the truly professional thing to do is to follow the guidelines and convince the patient that this approach is far better than palliative drugs.

Doctors who knuckle under to their patients’ demands have given up the right to refer to themselves as a professional. Instead, they have become little more than drug pushers, distributing substances that are often more potent than the drugs available “on the street”.

Maybe we could release some of the pressure on doctors if we stopped reading and watching ads about drugs. That just isn’t going to happen. Sad, huh?