How does Ankylosing Spondylitis progress?

Whenever one speaks about Ankylosing spondylitis, I’m sure picture of a man with a hunchback & restricted mobility comes to your mind. This famous photograph from the ACR library clearly describes what a patient with Ankylosing spondylitis goes through in his life. Ever wondered what really happens behind the curtain?

Ankylosing spondylitis is a chronic inflammatory arthritis affecting the sacroiliac joints (joints beneath the buttocks), vertebral joints & the hips. The joints get inflamed & persistent inflammation in the long run leads to formation of new bone.

The inflammation is responsible for the pain & the bone formation leads to restriction in movements of the spine.

Let us have a look at a simple example to understand this. The spine is similar to multiple matchboxes hung by a set of flexible threads. The flexibility of the threads is responsible for the movements of the spine. However, if you put wax on the threads & let it set, the threads do not bend. This is exactly what happens with Ankylosing Spondylitis. The threads are akin to the ligaments of the vertebrae & the matchboxes to individual vertebrae. Once the threads become hardened by inflammation (wax) the mobility is lost.

final box

The hardened ligaments give the typical tram track or bamboo spine appearance on the X-Ray.

Ankylosing spondylitis progression xray 2

Ankylosing spondylitis progression xray final 1

Help us design the iOS Lupus app

It is almost a year since the Mumbai Arthritis Clinic App for android was launched. It has had a phenomenal response with more than 2000 downloads & 50 reviews.

It has been rated the best lupus app by Laptop magazine & an average score of 4.5 out of 5 on google play.

We would like to help more lupies with the app & are all set to launch an iOS version soon.
The app is designed around you & would like to have your suggestions for inclusion in the iOS version.

Have a quick look at the previous blogpost about the features of the android app.
Please help us design a better app for iOS.

It would have all the features included in the android app –
1) Help you manage appointments better.
2) Keep a track of your Lupus activity
3) Store your prescription & set medicine reminders
3) Make a note of questions you want to ask your Rheumatologist.
4) Store all the important snaps (eg. a rash that you have) for showing it to your Rheumatologist later.
5) A Lupus eBook.
6) Mail your Rheumatologist.

However, the best Lupus app can only be designed if I know what you want from it.
Kindly post your suggestions (however silly, weird they may sound) so that they can be incorporated in the app.

Looking forward to your suggestions for inclusion in the iOS app…
You may also tweet your suggestions using the hashtag #lupusiOS

Help me help this lady with Ankylosing spondylitis

It was a nice Wednesday afternoon. Saw this young lady with Ankylosing Spondylitis.

Reminded me of the typical Indian #rheum story.

She had been having symptoms since last 5 years. She had consulted an orthopedic surgeon for the same. She was diagnosed to have Ankylosing Spondylitis & was started on Sulphasalazine. She was 27 years old & the parents were eager to get her married. They found a groom in her hometown (Uttar Pradesh). It was a typical Indian village.

The parents did not reveal anything about the illness, medicines to the groom. The lady had a tough time after marriage. She had to manage household work with all the pain; more so since she was in a rural Indian setup where the newlywed is supposed to take care of all the work. Taking medicines daily was a big problem as the illness was never declared.

There was another major problem for her. The marriage plan was never discussed with any Doctor & they had never consulted a Rheumatologist. She was not even sure whether Sulphasalazine was safe in pregnancy. Contraception is never in the hands of rural women in India & she was no exception.

As days passed, the pain started becoming unbearable for her & started showing up in day-to-day life. The in laws & the husband soon realised that something was amiss. Due to the workload & stress, she was soon on the bed. The in laws felt cheated & sent her back to her parents.

And that is how they reached me, with anxiety & stress clearly showing in their face. This was some 3 months back. She saw me again this week. Ankylosing Spondylitis was now controlled, backache significantly reduced.

The next was the big question- what to do next? Should she go back to her in laws? If yes, what are they to be told…This caught me unprepared. Apart from the medical management, they also wanted me to help them reach a decision. ‘You must be seeing so many patients with such a problem- you help us take a decision’ they quipped.
Ankylosing Spondylitis being a chronic ailment, this decision is a tricky one.
• She is prone to have ups & downs, down the line. Would her family accept the future pain/ regular medicines?
• One thought was to call her husband/ in laws & counsel them about the disease. However, I was wondering whether they would really come all the way to discuss about her ailment.
• The other thought was to ask her to carry on with her life, concentrate on her health for the time being rather than the stress of going back to the in-laws, working hard in a hostile environment.
• At her in-laws’, she would be under pressure with regards to pregnancy & may find it tough to manage it with Ankylosing Spondylitis presently.
This patient has really caught me unprepared on the decision front. I thought I should be asking the #rheum community to help me out reach a solution for her & guide her.
• What is the best possible solution for her right now?
• What should the parents do prior to marriage as in this case.
Please post your opinion & help me help this lady!

Why are we Rheumatologists looking forward to Tofacitinib (Xeljanz) ?

Rheumatoid disease is a chronic disease predominantly involving the joints. We have come a long way as far as treatment & outcomes are concerned. We have been able to put life back into patient’s life.
However, not everyone is that lucky. We are still not able to achieve remission in each & every patient. Statistically, almost 20- 30% rheumatoid patients do not improve sufficiently with DMARDs & biologics. The retention rate of most biologics are low (retention rate is the proportion of patients continuing biologics on a long term basis). We have still not understood the rheumatoid pathogenesis completely. We have not yet located the master switch that can turn off the inflammation.

As Rheumatologists, we would like each & every patient to achieve remission & do well. That is precisely the reason why we are looking forward to further development in understanding of RA & new drugs to tame the inflammation.

Rheumatoid inflammation

Rheumatoid inflammation


In rheumatoid disease, immune cells in the synovium of the joints get activated. They secrete various chemicals called cytokines. These cytokines are absorbed in blood & circulate throughout the body. These in turn act on other immune cells; activate them. The activated immune cells start secreting more cytokines. Theses cytokines are responsible for the joint damage & other complications of Rheumatoid disease. So, our efforts are directed to block either these cytokines or the cells secreting them. This would not only reduce the chances of joint damage but also keep the inflammation in check by blocking activation of immune cells. We can block these cytokines & cells with DMARDs & biologics.

Let us consider an example to understand the rheumatoid inflammation & the mechanism of various medications. This is akin to the following plot.
Understand biologics, DMARDs & JAK inhibitors
There are 5 terrorists (cytokines ) who want to enter an island country (immune cell) to start a terrorist camp & train more terrorists (generate more cytokines). So, if they are able to enter this country, the number of terrorists will increase as also the chances of destructive activities. They can enter the country by air using multiple airlines ( Airline TNF- α, Airline IL-6, Airline B cell)

If a Rheumatologist is the police; using DMARDs is like using multiple contacts in various airlines asking them to block the entry to the terrorists. This may work if one has good contacts, but is not foolproof.

Biologics are more specific. They are like specific legal orders to specific airlines to block their entry. So if one blocks the TNF α Airline from carrying the terrorists, the island is safer. But then, this is not the only airline available. They can always take the other airlines & still manage to enter the country & succeed with their plans. The same way, a biologic works but then is not the final answer.

How about going a step further? One can also block their entry at the ports of entry. This will block the terrorists irrespective of the airline they use.
Blocking inflammation at cellular level

This is exactly where we are today.
We have taken the war against Rheumatoid to the ‘ port of entry- signal transduction’ level. Instead of blocking multiple different cytokines, we are now looking at blocking the cellular system that responds to multiple cytokines. This way, we can block the effect of multiple cytokines with a single medication & reduce activation of immune cells thus keeping the Rheumatoid inflammation under check.
Janus Kinase is an enzyme that works at the port of entry in the cell & helps the transduction of message (execution of the plot). We now have Tofacitinib (xeljanz), a Janus kinase blocker recently approved by FDA.

As we saw, this is clearly a step ahead in our battle against the Rheumatoid Disease. We would be looking how well this technological advance really translates in practice in the further blogposts.

History of Fibromyalgia – an infographic

History of Fibromaylgia

History of Fibromaylgia

Fibromyalgia is a chronic painful condition characterized by widespread pain in the body. Though it affects almost 2-3 % of the population, awareness in general is lacking.
It is a grossly under-diagnosed, under-treated condition.

Though described since the 1800s, definite classification criteria were established in 1990 & updated by the American College of Rheumatology (ACR) in 2010.

How does Rheumatoid arthritis affect the cervical spine (neck joints)?

Rheumatoid disease can affect the cervical spine (neck vertebrae) joints as any other joint. What makes the cervical spine joints different is the fact that the spinal cord is in close vicinity & any pressure on the same by the rheumatoid synovium or the bone can lead to paralysis.

To understand this, we should understand the anatomy of these vertebrae. The 1 st vertebra is called Atlas & the 2 nd vertebra is called the Axis. These are ring shaped circular bones. The axis has a vertical structure called the odontoid process (Dens). The atlas sits on top of the Axis & the odontoid process.

Cervical vetebrae anatomy

The space enclosed by the atlas has the odontoid process & the spinal cord within. The swollen rheumatoid synovium destroys the ligament (Transverse Ligament) that holds the odontoid process in its position. Once this ligament is damaged, the odontoid starts pressing against the spinal cord. The cord in turn has nerve fibres that control the movements of the limbs.

Rheumatoid affection of the cervical vetebrae

Early symptoms would include weakness in the limbs, neckache, electric current like sensation when one bends the neck. This generally happens with chronic deformed Rheumatoid Arhtirits.

Prevention with tight control of Rheumatoid activity remains the best way to avoid this serious problem. However, once the dislocation occurs, surgery remains the best option to avoid damage to the spinal cord.

Rheumatoid Atlantoaxial dislocation surgery

Does One Need Anti Arthritis Meds After Knee Replacement Surgery (With Rheumatoid Arthitis) ?

TKR

Rheumatoid Arthritis (RA) is an inflammatory ailment that affects multiple joints. However, this is too simple a picture. RA has systemic manifestations & can involve other organs like eyes, lungs, nerves as well. In fact, we now call it Rheumatoid Disease as it is more than just arthritis.

Unchecked rheumatoid inflammation in the joints damages the joints (as seen previously on this blog). It can destroy the cartilage in the joints & leads to secondary osteoarthritis. This is common in the knee due to the weight bearing.

Surgical intervention like TKR (Total Knee replacement), THR (Total Hip replacement) are used to take care of the damaged joint. Once severely damaged, knee replacement surgery remains the best option. TKR, THR thus take care of the mechanical problem in the involved joint. It does not take care of the RA activity. Hence the surgery will have no implications on the inflammation in the other joints.

Hence, DMARDs (Anti Arthritis meds like Methotrtexate,Hydroxychloroquine, Leflunomide, Suphasalazine are a must even after surgery to take care of the other joints.

Allopathic anti arthritis drugs– bad cop or good cop?

cop

Whenever a patient with an autoimmune disease (Rheumatoid arthritis,Ankylosing spondylitis, Lupus) on DMARDs (Disease Modifying Anti rheumatic drugs like Methotrexate, Leflunomide) or biologics gets an infection, the DMARDs/ biologics are always blamed. The patient tends to get into a reflective mode thinking whether these drugs should have been prescribed in the first place.

What exactly happens in an autoimmune ailment is that the self immunity, that is actually meant to protect the body; instead starts attacking the body joints & organs. It, in fact, starts behaving like a bad cop. The bad cops; instead of protecting the city, start robbing its own citizens.

DMARDs/ biologics suppress the immunity & do not let the immunity attack the self organs. This is akin to locking the bad cop for what he is doing (mind you there are not one but too many bad cops in autoimmune ailments). Now, when the city cops themselves are in jail, it is a difficult situation when real robbers actually arrive. There are not many good cops to protect it. Robbers then have an easy task set out.

This is exactly what happens when an infection strikes. The immunity that is suppressed by DMARDs/ biologics is not able to mount a strong response. However, as you must have understood, blaming them is not the solution.

It is always a tight rope walk for all the Rheumatologists to keep the disease activity under check with DMARDs/ biologics & avoid too much of an immunosupression at the same time.

So, when on DMARDs/ biologics:

1. In case of any fever/ infection, contact your Rheumatologist immediately.
2. In case of any fever/ infection, stop the DMARDs/ biologics immediately & seek Rheumatologist’s opinion.

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