Why is one screened for tuberculosis prior to starting TNF blockers?

March 12, 2017

Tuberculosis (TB) is an infection caused by bacteria. It most commonly affects the lungs. When a patient of pulmonary TB coughs, the bacteria are discharged in the air. If someone inhales these bacteria, they then find a way into the lungs. Once in the lungs- the bacteria face the following-

  • The bacteria are killed by body’s immune system. They are destroyed & cannot harm the body.
  • They lodge in the body, overcome the immune system & cause an active infection- tuberculosis.
  • The immune system does not kill them but instead jails them (literally; it forms a granuloma—a jail wherein the bacteria remain in dormant- inactive form). So the bacteria are in the body, but are jailed in dormant state & do not cause harm. Anything that frees them from the jail can make them active & lead to an infection.

The bacteria remain in the granuloma jail for years in a dormant phase. They are inactive & do not cause an active infection while in this phase. This is called ‘Latent TB’. The person does not have an active infection & does not spread it to anyone.

TNF alpha is a cytokine (chemical in the body) that is required for maintaining the integrity of the granuloma & also for other defence mechanisms that keep these bacteria dormant. TNF alpha blockers (Remicade, Infimab, Inflectra, Enbrel, Etacept, Intacept, Benepali, Humira, Exemptia, Cimzia, Simponi) are used to treat autoimmune ailments like rheumatoid arthritis, ankylosing spondylitis.

If we start TNF blockers in a person who has latent TB, the granulomas would open up, setting the dormant TB bacteria free & thus leading to active TB infection. This is called for reactivation of TB. This is why, one is always tested for active/ latent TB before TNF blockers are thought of. Active pulmonary TB can be diagnosed by examination & X-ray of the chest along with sputum test. TNF blockers are not given if one has active TB.

Tests for Latent Tb include Mantoux test & IGRA (Interferon gamma release assay commonly known as the TB gold test). A positive test (either) would suggest presence of latent TB.

In case of latent TB, one needs to be treated before TNF blockers can be given. The treatment recommendations vary from country to country. TNF blockers can be given after 1-2 months of this treatment.

Thus the chance of reactivation of TB with TNF blockers is real but can be minimised by proper testing & treatment for latent TB.


Ankylosing spondylitis update from American College of Rheumatology conference 2016

November 17, 2016


American College of Rheumatology conference is an annual event where experts, Rheumatologists & researchers meet & insights & advances in rheumatological ailments are discussed.

The important updates for AS warriors from the conference is the further research into newer treatment options.

  1. Secukinumab (Cosentyx): has already been approved by US FDA. Studies looking at long term effect (>1 year) were discussed & show good efficacy of the drug in AS.
  2. Tocilizumab (Xeljanz) : A new ray of hope for AS. It has already been approved for rheumatoid Arthritis. It was studied in 207 patients of AS & has shown promising results. However this is quite early. One would require many more studies & the FDA regulatory approval procedure for it to be used in AS. The results definitely look promising & is a ray of hope for AS.
  3. Ustekinumab- another new biologic being studied for AS. Early study shows promising results & is a drug to watch out for.

All in all, a lot of action in the AS treatment arena. With a lot of focus targeted at AS, we should expect more options to treat AS in near future. 


Can a positive HLA-B27 test turn negative later & vice versa?

August 7, 2016

hla b27

Has this happened to you? A negative HLA-B27 test turning positive later or vice versa?

Technically speaking, this can never happen. HLA-b27 is a genetic marker & just like a blood group it can never change. In that case, what can go wrong?

Let us now understand how the HLA-B27 gene is tested.

It is processed using three different methods

  • Microlymphocytotoxicity (MLCT)
  • Flowcytometry (FC)
  • DNA based typing using a Polymerase chain reaction based assays (PCR)

The methods are arranged in the order of their accuracy with PCR based method being the most accurate. A few patients that test negative with Flowcytometry method do turn out to be positive with the PCR method.

Flowcytometry can also give an ‘indeterminate’ (inconclusive) report that needs to be rechecked with a PCR based method. This is how the discrepancy in subsequent tests sets in.

So the next time to get your HLAB27 checked; do have a look at the method as well.

 

 

Image courtesy: Free Vectors via <a href=”http://www.vecteezy.com”>vecteezy.com</a&gt;


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.


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.


Lupus- the Pandora’s box: when all hell breaks loose

January 19, 2014

lupus pandora box

Lupus has long been represented by two mascots: wolf & the butterfly.
The word ‘Lupus’ (Lupus- wolf in Latin) was coined by a thirteenth century Physician Rogerius as the facial lesions in Lupus looked like wolf bites. The butterfly as a mascot has its origin in the butterfly shaped malar rash seen in SLE.

There have always been debates regarding the ideal mascot for lupus. The wolf is a sinister, cunning animal. It aptly represents what Lupus can do to a person & also represents the origin of the name. However, as a mascot, it has a negative impact.

As against this, butterfly is beautiful & represents vitality. Many have even compared the life history of a butterfly emerging from a cocoon to a Lupus patient emerging with flying colors from a flare.

As I was reading the journal Lupus the other day, a beautiful explanation held my attention. The author MJ Fritzler has highlighted the Greek mythological story of the Pandora’s box in an article.

According to the Greek mythology, Zeus, the father of the Gods & men, ordered Hephaestus, the God of craftsmanship to create Pandora, the first woman on earth. She was endowed with many gifts: clothed Athena, endowed with great beauty by Aphrodite, and eloquent speech by Hermes. After Prometheus stole fire from heaven, Pandora was given a beautiful container by Epiphemus. Pandora was given explicit instructions not to open the container under any circumstance. However, another of her God given traits, curiosity eventually got the better of her & she opened it only to find that all evil escaped & invaded the entire earth. Realizing her error, she tried to make amends by closing the container, but the entire contents had escaped, except for one thing- a winged creature with iridescent wings – the personification of Hope named Elpis.

This story would aptly describe what a Lupus patient goes through. Once diagnosed, it seems like the Pandora’s box is opened because ‘all evil’ seems to break loose. It is the butterfly that gives the hope.

Indeed, over the years, the butterfly has brought hope to lives of Lupus patients & the prognosis has improved significantly.

References:

Boltzer JW. Systemic lupus erythematosus. I. Historical aspects. MD State Med J 1983; 37:439

Lahita RG. Introduction. In: Lahita RG, ed. Systemic Lupus Erythematosus. New York: John Wiley and Sons. 1987; 1-3. (Fifth edition published 2010)

http://lupusadventurebetweenthelines.wordpress.com/2012/04/24/lupus-and-its-mascot-butterfly-or-wolf/

Reflections on Lupus 2013: butterflies, wolves and prophecies MJ Fritzler Lupus, October 2013; vol. 22, 11: pp. 1092-1101


Life of a #rheum patient: It is indeed a juggling act

December 29, 2013

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We always keep complaining that most studies about Rheumatoid Arthritis (RA) focus only on the objective measures of inflammation & other factors rheumatologists are interested in. They hardly ever look at what a patient goes through, physically & mentally due to RA. Caroline Flurey & colleagues have just published a study that looks at Rheumatoid Arthritis from the patient’s perspective.

The study consisted of interviews of patients with Rheumatoid Arthritis to understand how they manage their day-to-day life & cope with their ailment.

The results have been startling. For us Rheumatologists, they are an eye-opener; letting us a sneak preview of what a RAer goes through. As a RAer, I am sure you can identify yourself as you go through the study results.

Here is what the study revealed. I have also added links about remedial actions.

1) Most RAers experience RA as a constant background reality, often being aware of its presence & the limitations it brings. Life is all about micromanaging & macromanaging their symptoms & daily life so that it remains in the background & does not interfere much with daily life.

2) Learning & developing proper coping strategies (details in resources at the bottom of the post) can do a lot good & help keep RA in the background. The aim of any rheumatologist is to keep the RA in remission (background) & minimize the chances of a flare.

3) RA can be & is unpredictable. It can intrude into life in the form of a flare without any notice. A flare can reach a magnum proportion by the time one sits trying to make sense of the fluctuation.

4) Once in a flare, coping strategies do matter. Some try to regain control on their own, some seek medical help right away while some Leave it as the final option.

5) One of the best ways to better manage a flare is to keep a self-help plan ready in consultation with your Rheumie. We have discussed this in the past here on the blog. Let it roll as soon as a flare is recognised & seek a Rheumie appointment in the mean time.

All in all, life of a #rheum patient is indeed a juggling act with a need to balance every aspect of life so as to keep RA & its impact in the background.

DMARDs/ biologics, positive attitude & the right coping strategies help in this regard.

In case, RA tends to overpower & come to forefront in form of a flare, there is no need to panic. Roll out the ‘flare plan’ immediately & push RA in the background again.

Tame your RA

Resources:

1) Study- It’s like a juggling act: rheumatoid arthritis patient perspectives on daily life and flare while on current treatment regimes. Caroline A. Flurey & colleagues Rheumatology (2013) doi: 10.1093/rheumatology/ket416

2) How to plan a house cleaning job with RA?

3) How to arrange the kitchen if you have arthritis?

4) Tips for painless cooking.

image courtesy: http://www.openclipart.org


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