How does ankylosing spondylitis cause osteoarthritis of the hip? — the Pacman game

May 15, 2016

I’m sure all of you know that Ankylosing spondylitis (AS) is an autoimmune disease, which means that the body’s immune system considers its own joints as foreign & attacks them. We have not been able to pinpoint the exact reason for this.
If this immune attack is not controlled in time, it ends up destroying the joints; especially the hips. This is known as osteoarthritis of the hips. Ankylosing spondylitis is a unique disease as it causes destruction of the bones in the hip & at the same time it leads to excessive bone formation in the spine (syndesmophytes). So what starts as backache can well end up as deformities & disability.

But then, how does AS cause destruction of the hips?
Hip joint is lined by a thin membrane called the synovial membrane from the inside. The immune attack is targeted towards the synovial membrane. The synovial membrane swells up due to the attack. This inflamed synovium is like the pacman. Remember the pacman game?… pacman eats away all the dots. In a similar fashion, the pannus eats the cartilage & the bones around it. When it eats the bones, the same is known as erosion. Apart from the hips, these erosions are also seen in the sacroiliac joints. Destruction of the cartilage & the bone ultimately leads to osteoarthritis.

 

Rheumatoid_Arthritis_Knee_Joint

 

pacman

The Pacman game.. Pacman keeps eating the dots…just like the inflamed synovium keeps eating the cartilage & the bones. Note how the AS Pacman has destroyed the hip bones (above) & the sacroiliac joint (SI joint) (below).

 

Ankylosing_Spondylitis_CT_Scan

Can the hip osteoarthritis be prevented?
Yes, very much so. Seeing a Rheumatologist at the earliest & starting definitive treatment at the earliest can definitely tame this pacman & prevent osteoarthritis.


How to make the most out of your rheumatologists visits

May 5, 2016


This is definitely one of the best ways to understand the ailment in its entirety. However, given the long queues at our clinic, time is becoming a scarce resource. We need to listen to the patients so that we understand the intricacies of the disease & also not miss out on anything.
However, you can help us in this endeavor to listen to every important point of yours with these smart tips.
 
1. Always remember that if you organize everything before the visit, you can make the most out of it.
2. For the first visit, a neatly written description of your history with specific details of hospitalizations & important reports. This is especially helpful especially if there are multiple files.
3. List of all medications including alternative therapy ones.
4. Share details of your family history – these details can help reach a diagnosis. It also helps understand the risk of developing a disease.
5. Always enlist your concerns & particular questions- you will be focused & happy at the end that all your questions were answered.
6. For the follow up visits- discuss your life (personal, professional, family) goals. This helps us understand & plan therapy accordingly. Make your Rheumatologist a partner in achieving the goals.
7. For the follow up visits- discuss any major life decisions you are planning to take especially if the reason is related to the ailment.
8. Before leaving the clinic always check that you have understood all the medicines.
9. Ask for any warning signals that you should watch out for & report immediately.


An Individual Is Much Bigger Than His/ Her Disease

January 3, 2016

Yesterday, I met one of my regular known patients who had come with sweets to announce a new arrival in his family. Why known? …. Because he has taught me an important lesson. AN INDIVIDUAL IS MUCH BIGGER THAN HIS/ HER DISEASE. Now, what does that mean?

life goals blog

Samir, a young man in his early thirties consulted me almost 3 years back. He was suffering from Ankylosing spondylitis for 6-7 years. Apart from the disease details, I could make out that he had seen his life go tospy turvy in these years. Right from the first day, I realized that there was something different about him. Once the discussion about his Ankylosing spondylitis was over, he would make it a point to talk about his life, his goals & ambitions. In fact, I felt as if he was laying down a roadmap of what he wanted & asking me to help achieve that with the medications.

From his talks, I understood that he had a saree shop. He was unable to manage it due to his backache & his wife had to do the needful. His social & married life too was in bad shape due the persistent pain. Once as he was talking about his life, I asked him to take time out to put down his wishes & priorities on paper & bring it during his next visit.

This is what he had listed-
1) Conquer his pain & the disease
2) Get back to work. Manage the shop on his own
3) If possible, change the business into some other business that was more manageable. A saree business required one to travel to distant areas to buy sarees at a cheaper cost & for variety.
4) Once the financial situation improved, think of starting a family.

As I said, he had given me a roadmap to work on. We started the work together.
DMARDs were not helping him. We discussed about biologics. In India, biologics is never an easy thing as these are expenses out of pocket. He spoke to his wife, the seniors in the family, friends & mustered sufficient funds to start & sustain the treatment. I did my part & managed to provide the most from the company’s ‘Patient assistance Programme’.

As I think about it today, the rest is history. He did well with biologics. He achieved his first goal of conquering his pain & the disease in the subsequent months. He was managing his shop well. His profits improved. With these resources, he could manage the biologics on his own. After a year, he decided to shift over to a DTP business. He undertook a part time course to learn DTP. A DTP business does not require traveling or lifting weights. His plan was clear. Once the business was set, he would employ the staff & get the work done. This was clearly a good decision given his condition. His DTP business stabilized over a period of time.

Yesterday, he was at the clinic not for a consultation but to announce a new arrival. I was moved. He had indeed come a long way. Though this would sound like a fairy tale, but it isn’t. There were many obstacles particularly with the finances for the biologics. But, since he had mentioned his priorities & made me a partner not just in achieving remission but also in his life related goals, our path was clear.

Please understand that you are not the same as your disease. You are not ‘a case of Ankylosing spondylitis’. That is so not right. Your life is much bigger & you should not forget your professional, personal, social, marital life. Talk about your goals, aspirations with your Rheumatologist. Apart from ensuring that your disease goes in remission, we can plan & help you achieve these goals.


Is Rheumatoid Arthritis a lifestyle disease?

January 1, 2016

Time & again, rheumatoid arthritis gets labeled as a lifestyle disease. In fact, just came across an article that blames genes, stress & poor sleep for causation of Rheumatoid arthritis.

 

By definition, lifestyle disease is a disease caused by the way a person or a group of people live. Lifestyle diseases include Type II diabetes, hypertension (high blood pressure), dyslipidemia (high cholesterol), obesity. The definition also includes diseases associated with alcohol, tobacco & drug abuse.

 

Rheumatoid arthritis is an autoimmune disease. Normally, body’s immune system is designed to fight microorganisms causing infections. Due to various reasons, the immune system may start considering its own body organs as foreign and attacks it. This self intolerance is known as autoimmunity. In Rheumatoid Arthritis, synovium (inner lining of the synovial joints) is considered by the immune system as foreign & bears the brunt of the attack. The immune attack causes pain & swelling of the joints.

 

As we have seen, one’s lifestyle has nothing to do with the immune attack & is not causative. It is a great injustice to patients with Rheumatoid arthritis to get blamed for their lifestyle & be at the receiving end of unnecessary advice.


Low Starch Diet for Ankylosing Spondylitis: Part 2 – The Scientific Evidence

November 2, 2014

We have already seen (in the last blog) the theoretical possibility of a ‘Low starch diet’ being beneficial for Ankylosing Spondylitis. Let us now see whether it really works in real life & whether there is sound medical evidence to support it.

Today’s medicine works on the basis of evidence. If a new medicine/ intervention is thought to be useful, it is tested in clinical trials. A group of patients is given the standard treatment & placebo (an inert substance that has no effect on disease activity) while another comparable group is given the standard treatment & the experimental therapy/ intervention. A ‘double blinded study’ that ensures that neither the investigator nor the patient knows whether he is taking the experimental drug or placebo is ideal to avoid any bias; both on the investigator or the patient front. This is not possible for studies with dietary modifications as blinding is not possible & bias tends to creep in.

As against medicines, it is very difficult to keep an exact track of the diet of any patient for obvious reasons. It is extremely difficult to ensure that a patient sticks to a particular diet in the long run throughout the study period.

These two factors make studies based on dietary interventions difficult to conduct as well as interpret.

For the reasons mentioned, there are hardly any studies about ‘low starch diet’ in Ankylosing spondylitis. In 1996, Dr. Ebringer discussed the disease activity trend of one of his patients following the diet for a long period (1983- 1995). His ESR showed a continuously decreasing trend. In another study (mentioned widely on the internet with no reliable data available on any of the medical literature sites) 36 patients received Dr. Ebringer’s diet & showed considerable improvement in symptoms. These two studies would be highly inadequate for any definite conclusions.

So, as we have seen, the utility of ‘low starch diet’ in Ankylosing spondylitis is not yet proven scientifically.

One way of looking at things would be to give it a try & see whether it works. However it has to be weighed against the risks involved in pursuing such a diet.

In the next blogpost, let us look at what a ‘low starch diet’ includes/ excludes & the possible health hazards of such a diet.


“Low starch diet’ for ankylosing Spondylitis

October 25, 2014

Many patients keep asking me about the role of ‘Low starch diet’ to control Ankylosing Spondylitis. This has been a hot topic of discussion on most Ankylosing spondylitis groups on social media & many confirming the good results of a low starch diet.

The original idea of a ‘low starch diet for Ankylosing Spondylitis’ comes from Dr. Alan Ebringer, Prof of Immunology at King’s College London. He found high levels of a gut pathogen called Klebsiella Pneumoniae in stool samples of patients with Ankylosing spondylitis. He also found high levels of antibodies to klebsiella in the blood of patients with Ankylosing spondylitis. These findings indicated the presence of the bacteria in the gut of patients with Ankylosing spondylitis & the body’s immune reaction to it.

These findings evoked further research & Dr. Alan’s further research showed that K. pneumoniae was isolated more frequently during the active phase of Ankylosing Spondylitis & clinical relapse was preceded by appearance of the bacteria in fecal samples. This meant that Klebsiella Pnemoniae was somehow related to inflammation of Ankylosing Spondylitis.

Dr. Alan’s research continued & he went on to show that there are similarities in structure of the HLA-B27 molecule & enzyme Pullulanase produced by the Klebsiella bacteria. There is also similarity between the enzyme & type I, III & IV collagens found in joints & other organs. This gave rise to the ‘Molecular mimicry theory’. The human immunity recognizes Klebsiella as foreign & attacks it. However, since HLA-B27 & collagens have similar structure, they get attacked to. This may be responsible for the inflammation in joints & other structures like the eyes in Ankylosing spondylitis.

One can infer from the proposed ‘molecular mimicry theory’ that by reducing the klebsiella bacteria in the gut, one can reduce the inflammation associated with Ankylosing spondylitis.

Various studies have shown that the gut bacteria including klebsiella grow on undigested starch in the gut. Hence a reduction in starch in the diet may help reduce the klebsiella bacteria in the gut. Klebsiella bacteria is well adapted to the human gut & produces the Pullulanase enzyme that can break down the starch, derive nutrition & thrive in the gut.

The rationale of the ‘low starch diet’ is to cut down on the starch, make life difficult for the klebsiella bacteria. This may indirectly help control the Ankylosing spondylitis.

This is the exact basis of the ‘low starch diet’ for Ankylosing Spondylitis.

Now that we know the basis of the theory, we also need to look at the following points—
1. What is a ‘low starch diet’?
2. Are there any studies conducted in patients with Ankylosing spondylitis to prove the benefits of ‘low starch diet’?
3. If the concept looks so convincing, why do Rheumatologists not recommend it on a regular basis?

I would be answering these questions in the subsequent blog posts. These posts are coming soon & follow my blog so that you don’t miss out on any of those useful posts.

References: Erbinger A, Wilson C. J Med Microbiol 2000; 49: 305-311 http://jmm.sgmjournals.org/content/49/4/305.abstract


RAers, can you prevent Rheumatoid Arthritis in your children?

September 7, 2014

Doc, I have had rheumatoid arthritis (RA) since last 10 yrs. I know this terrible disease inside out. It has ruined my life. I do not want my daughter to suffer from this. Can I do anything to prevent rheumatoid arthritis in her? Does science have any answer? Are there any meds/ strategies to prevent rheumatoid arthritis?

The words of my patient are still echoing in my mind. ‘Does science have an answer?’ For a long time, we were grappling with the best strategy to control RA. Hence, majority of the research was directed at this.

However, importance of the ‘pre-RA’ phase has been understood. ‘Pre-RA phase’ is the phase before the symptoms of RA actually appear. This phase is important from the preventive perspective.

We do know about a few proven strategies to prevent RA.

These include:

1) Smoking cessation — The risk of developing RA is about two times higher for male smokers than for nonsmokers. For women, the risk for smokers is approximately 1.3 times greater than for non-smokers. (We have seen this in detail previously)

2) Dental hygiene—Periodontal disease is a proven risk factor for RA. (We have discussed this previously on the blog)

3) Optimal body weight. This is a recent finding. We would soon have a dedicated blog post for this. As of now, aim at a healthy body weight to reduce chances of developing RA.

4) Adequate vitamin D intake.

A study specifically looking at the various risk factors for evolution of RA in those with family history is underway & should provide further insight.

So, RAers; your daughters need not suffer the way you did. We do have these definite, easy strategies to prevent RA in those genetically predisposed.


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