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.

Advertisements

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

December 29, 2013

c6

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


Steroids for Rheumatoid Arthritis: Misconceptions & the reality

December 21, 2013

Steroids……

More bad than good comes to one’s mind when steroids are mentioned, isn’t it? Steroids (Glucocorticoids) have been equated with all that allopathy has to offer for its arthritis patients. It is thought that each & every patient consulting a Rheumatologist would be on long-term steroids irrespective of his diagnosis & would invariably end up with side effects.

Glucocorticoids (popularly known as steroids) were discovered by Scientist Hench. It was a path-breaking discovery & Hench was awarded the Nobel Prize for this in 1950.
Steroids when introduced were used for Rheumatoid Arthritis (RA). As expected they had miraculous results. It was thought that a cure for Rheumatoid Arthritis was in the making. Variable doses were given for variable duration as everyone was on a learning curve. Soon, the side effects were realised. Search began for better medications. This resulted in the development of DMARDs & later biologics that have revolutionized the treatment & outcome of Rheumatoid Arthritis. Not just new drugs, but treatment strategies such as ‘treat to target’ were developed to ensure remission in RA.

So then, if not for steroids, how is RA treated now?
RA is now treated with a target of remission (absolute control of arthritis) right from day 1. Patients are started on DMARDs; generally a combination with Methotrexate as the anchor drug. The DMARD doses are stepped up with the aim of achieving remission asap. If the patient fails to show a good response by six months, biologics come into the picture.
What about steroids in that case? What is its role? Steroids are given to begin with as a bridge till the time DMARDs have their effect. This would mean a small dose of steroid for 4-6 weeks.

However, there a few situations in which steroids have to be given in the long run. These include
1) Rheumatoid Arthritis related Interstitial Lung Disease
2) Rheumatoid vasculitis – this can present as vasculitic ulcers
3) Rheumatoid Arthritis related mononeuritis multiplex (damage to multiple peripheral nerves)
4) Rheumatoid Arthritis related scleromalacia (an eye complication)
5) An occasional patient who has persistent active arthritis despite DMARDs & cannot afford biologics.
All in all, steroids have a well-defined role & use as far as Rheumatoid Arthritis is concerned & one does not have to be on long-term steroids unless for some specific indications.


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

March 24, 2013

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.


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

February 3, 2013

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


History Of Rheumatoid Arthritis- an infographic

January 27, 2013

History of Rheumatoid Arthritis


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

January 20, 2013

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.


%d bloggers like this: