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Rheumatoid Arthritis

What is Rheumatoid Arthritis?

Rheumatoid Arthritis (RA) is a chronic, painful and disabling autoimmune disease affecting 1% of the Indian population. It can affect any joint in the body. It causes swelling and damage to the cartilage and bone around the joint. It is a systemic disease which means that it can affect the whole body and internal organs (although this is not the case for everyone with RA) such as the lungs, heart and eyes. This disease affects people of any age including children and is three times more common in female than males.

What causes it ?

“Why me?” is a common question by someone who develops rheumatoid arthritis. The exact answer for this question is not known. Smoking, both active and passive, is undoubtedly a very important cause. In the last decade research has shown that lot of genes are associated with rheumatoid arthritis and RA may run in families.

What are the symptoms?

  • Joint swelling
  • Pain
  • Morning joint stiffness
  • Poor sleep
  • Fatigue

The diagnosis of early RA is very difficult. If you have these symptoms you should contact your rheumatologist immediately. Swelling of many joints along with stiffness in the joints, particularly in the morning hours is a very trouble some for these patients.

What happens to joints in rheumatoid arthritis?

In Rheumatoid arthritis the ones own immune system fights against its own joints. This results in swelling and later resulting in the damage of the joints.
Normally the synovium (green) which lines a joint is very thin . In rheumatoid arthritis this lining becomes thick and starts destroying the cartilage which lines the ends of bone. The defects in cartilage caused by these cells is called erosions If this process is not controlled early it results in destruction of the joint.

Organs other than joints can be affected in rheumatoid
Other parts of the body can get affected: (not affected in everyone with RA)

  • Eyes - dryness, redness
  • Lungs - fluid, breathlessness (rare)
  • Skin - nodules, ulcers
  • Heart - heart attack
  • Blood - anaemia

How is Rheumatoid arthritis diagnosed?

There is no single diagnostic test that you can take which can give you an immediate definite diagnosis. It is a ‘clinical’ diagnosis, which means that apart from taking a detailed history and examining you doctor has to do a few blood tests and X-rays before making a diagnosis.  Most important of these are:

  • History of symptoms
  • Signs of swollen joints
  • Pain on squeezing knuckles
  • Raised inflammatory markers in a blood test (CRP + ESR)
  • Presence of Rheumatoid Factor (though about 30% of people with RA do not have Rheumatoid Factor)

What is the importance of seeing a specialist?

Arthritis can be manifestation of more than 150 different diseases. The list of conditions vary from mild viral infection to joint destroying rheumatoid and gout to  dangerous, potentially lethal diseases like SLE and Vasculitis. Each of this disease has different treatment based on the seriousness of the condition. Some of these have exactly opposite treatments. The bottom line is that “All the arthritis are not rheumatoid”. A specialist can make correct diagnosis and give you right treatment. Failure to make a right diagnosis may cost you your joint or even life.

Importance of early diagnosis and treatment?

In rheumatoid arthritis cartilage is being destroyed. Delay in initiating appropriate treatment can result in destruction of cartilage. It has been shown in latest research that more than 80% of patient develops erosions (defects in cartilage) by the end of one year. Once the cartilage is destroyed it can not be regenerated fully.  So in rheumatoid “time is cartilage”. So, it is essential not only to make a right diagnosis but also to start treatment as early as possible.

Importance of treating even if it is late
Even after many years of disease the rheumatoid patients have ongoing pain, swelling and destruction in their joints.  More over in late stages of disease there is more chance that other organs in your body may get affected. So it is essential that you get right treatment even if it is late. Bottom line is “It is better to be late than never.”

What is the treatment of rheumatoid arthritis?

The understanding of rheumatoid arthritis has improved vastly in last 10 years, and there are now many effective treatments available. Most of it is cheap and is affordable to most of Indians. With these drugs majority of patients get good relief and joint damage can be prevented. The initial treatment options are DMARDS (Disease Modifying Anti-Rheumatic Drugs). The most important of these drugs is Methotrexate. Once these drugs fail, which happens only in a few patients, newer agents like Biologicals( Eg: Infliximab, RItuximab) are used.

Are steroids mainstay in modern medicine?

It is a misconception that management of RA is with steroids. Till 1980s steroids where the first line treatment in rheumatoid arthritis. Thanks to modern day management strategies the use of steroids in RA has decreased tremendously. If we use the right drug in correct doses the use of steroid can be easily avoided.

Can a rheumatoid arthritis patient have a normal life?

If the disease is diagnosed early and controlled well with drugs, these patients can have a normal life as any other individual.

What are biological medicines for rheumatoid arthritis?

Biologics are new class of drugs that have been used for more than one decade. As already told rheumatoid arthritis is  an autoimmune disease which means the immune system attacks the person. Some time back we used to suppress the whole of the immune system to protect the joint as we did not have methods to block harmful molecules alone. The problem with this approach was that the as we have suppressed the whole of the immune system there is higher risk of infection. By the advent biological it has become possible to block the specific molecules responsible for the inflammation of the joints.   For example TNF is a molecule which is responsible for inflammation of the joint. By giving Anti TNF molecules we can eliminate the effects of the TNF alone and the rest of the immune system is free to fight against the infection. Currently there are 5 biologic medicines available in India. Advent of biologic medicines is a major advancement in the field of rheumatology and the work in this direction is still ongoing so that better and better biologics are being developed.