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


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.

Time, tide & inflammation waits for nobody…

I recently blogged about the ‘drug free remission’ in Rheumatoid Arthritis.
Aggressive treatment with DMARDs, biologics & a targeted approach can help one achieve this.
But, is it really that simple? For the best results, what would one expect from Patients? Positive approach & compliance……
But, why am I thinking about all This?

Last week, I was going through my OPD appointment list. One of the names looked familiar; Mrs. K, but I could not recollect the patient.
A lady in wheel chair, with most of the joints swollen was brought in by 6 of her relatives! She was unable to walk on her own. As I went through her file, history unfolded.

I had seen her some two years back. A lively young lady, a doting mother had consulted me for her joint complaints. She did have rheumatoid arthritis & was started on DMARDs. She was given three DMARDs due to the high disease activity. However, unfortunately she continued to have persistent joint inflammation even after 6 months of therapy.

The inflammation then started interfering with her personal & family life as well. Frequent leaves were ruining her professional reputation, her son was doing badly at school & there were frustration & fights at home.

We were slowly moving towards a decision of starting biologics. The entire issue, need of biologics, effects, side effects were discussed. The family was alright with the idea of a more potent drug to control the inflammation, but wanted to wait for some more time. We waited for two months, DMARD doses further optimized; but in vain.
After three months, I discussed the issue again. However, they were scared by a pharmacist relative about the side effects of biologics.

That was the last I saw her then. Now, she started telling me what happened after the last meeting. She & her family were scared of the side effects of biologics, decided to try alternative medicine, stopped all her allopathic medicines. The Result? It was staring at me……

A crucial mistake of stopping all DMARDs at a crucial juncture had done a lot of damage. Her knees were badly damaged & hands were deformed. Time, tide & inflammation does not wait for anyone…..uncontrolled inflammation had inflicted enough of damage already & quite a bit was irreversible.

Suppose you are caught in a similar situation wherein you have to decide regarding a biologic/ new therapy advised by your Doctor, how would you go about?

Decision making made easy

Decision making made easy for patients

A few points to remember —

1) When you go for a second opinion, if the second consultant confirms the proposed line of treatment, go back to your primary consultant who already knows you & your disease. The second doctor would take some time to understand your arthritis & establish his own treatment strategy.

2) Use the internet, get more information. Be judicious in the choice of sites. You can also use the social media to connect with specialists & other patients to learn from their advice, experience.

3) Never stop the ongoing treatment in the mean time. Never go for the radical option of stopping all the medicines without medical advice.

4) Always know when to put a ‘stop- loss’ order. What is this ‘stop loss order’? It simply means that, you should know when to stop wasting time in taking crucial decisions. Your decision & the plan should not take more than 4- 6 weeks (preferably).

Let us not realize that ‘Time, tide & inflammation does not wait for anyone’ the hard way.

Rheumatoid Arthritis: The journey from ‘no treatment’ to ‘drug free remission’

Not bothered about me crying in pain,
That Physician with great name & fame,
Gave the disease he cannot cure,
A name!

Is this what Rheumatoid Arthritis treatment all about?
Are Rheumatologists just giving name to a disease for which they do not have any treatment & cure?
Mind you, these lines were penned almost 150 years back.

We have come a long way since then.
In the early years, symptomatic therapy (pain control & patient’s feeling of well being) was all that was available. We had aspirin & steroids. Slowly multiple other anti inflammatory meds became available; but the treatment concept remained the same.

Slowly, the destructive potential of rheumatoid arthritis was realised. This stimulated the search for means to modify the disease course. This is when DMARDs (Disease Modifying Anti Rheumatic drugs) came into the picture. Armed with evidence, Rheumatologist shifted gears from the ‘conservative wait & watch’ approach to the much more aggressive ‘early diagnosis, early aggressive targeted treatment’. This literally translated into ‘will not tolerate any harm’ approach. Biologics came in handy for Rheumatologists to achieve this goal.

The change in mindset coupled with effective medicines enabled us to aim for remission in a disease that was thought to be the one without effective treatment.  Recent studies have already shown that even ‘drug free remission’ is possible.

The existence of ‘drug free remission’ was discussed at length at this year’s American College of Rheumatology Conference. Doubts about its real world definition, longetivity, recurrence of RA definitely do exist.

Nevertheless, we have come a long way; from ‘no effective treatment’ to ‘drug free remission’ Collateral damage in the form of cardiovascular events, osteoporosis is also well recognised & prevention strategies are getting refined. Patients be rest assured that better things are in store for them.

Few years from now & you may find me tweeting & blogging about sustained drug free remission. All the very best & wish everyone remission……

A stitch in time saves nine…How early is early in Rheumatoid Arthritis?

Rheumatoid arthritis is a chronic autoimmune arthritis with destructive potential. It not only destroys joints but can also play havoc with one’s personal life, family life & career. As Rheumatologists, we have learnt over the last decade that the only way to conquer this deadly disease is to treat early & aggressively with DMARDs.

However, how early is early enough?

We are very much interested in knowing how early we should be treating RA with DMARDs for the best results. This period is the ‘window of opportunity’. Once missed, the prognosis would change drastically. Initially, this was thought to be 2 years from the onset of symptoms. Later, it was thought that diagnosis & treatment with DMARDs within 6 months from the onset of symptoms should be good enough to take care of the disease.

Michel PM van der Linden studied this ‘window of opportunity’ at the Leiden Early Arthritis Clinic. His group studied 1674 patients with RA over a period of 6 years for the level of improvement with DMARDs & joint destruction. They found that contrary to popular belief, 6 months is too long a period to be considered as the window of opportunity. 12 weeks was found to be the critical period. A delay of more than 12 weeks would mean a lesser chance of achieving a drug free remission & 1.3 times higher risk of joint destruction in the long run. What was very striking was the fact that the effect of the delay could not be nullified by a more potent medication strategy later. Treatment started in this phase had the best chance of inducing remission & reset the disease. The effect was seen for anti CCP positive as well as negative patients.

What this means is that any delay of more than 3 months form the onset of symptoms to the start of DMARDs would mean poor outcome in the long run. Where can this delay occur?
1) Patients taking time to seek help.
2) Time taken at the Family physicians level in diagnosing & referring patients to a Rheumatologists.
3) Time taken at the Rheumatologist level in getting an appointment.

The average delay in UK, Canada & the Netherlands was found to be 23 weeks, 17 weeks & 18.4 weeks respectively. A survey in the UK found that delay at the patient level was the main cause of delay. Hence, an earnest request from my side to anybody suffering from joint pain – please seek a Rheumatologist’s help at the earliest. You can take this quiz to know if you have early arthritis. Please do not underestimate any joint pain or swelling as a part of ageing or as rheumatism that would settle on its own. Seek an expert help & that could mean a whole new life for you in the long run!

1)van der Linden, M. P. M., le Cessie, S., Raza, K., van der Woude, D., Knevel, R., Huizinga, T. W. J. and van der Helm-van Mil, A. H. M. (2010), Long-term impact of delay in assessment of patients with early arthritis. Arthritis & Rheumatism, 62: 3537–3546. doi: 10.1002/art.27692
2)Bykerk, V. and Emery, P. (2010), Delay in receiving rheumatology care leads to long-term harm. Arthritis & Rheumatism, 62: 3519–3521. doi: 10.1002/art.27691
3)Kumar K et al Delay in presentation to Primary care physician is the main reason why patients with Rheumatoid arthritis are seen late by Rheumatologists. Rheumatology (oxford) 2007;46:1438-40
4)Feldman DE et al Rapidity of rheumatology consultation for people in an early inflammatory arthritis cohort. Ann Rheum Dis 2009;68:1790-1.