A Family Doctor's Tale - RHEUMATOID ARTHRITIS

DOC I HAVE RHEUMATOID ARTHRITIS

Rheumatoid arthitis can be a very depressing illness. My first serious case of rheumatoid arthritis was a young female who has just graduated from Nanyang University some time in the 1970's. Her blood tests confirmed her symptoms and signs of joint swelling and pain. Unfortunately at that time the only  effective treatment were NSAID( non steroidal anti inflammatory drug).If that does not relieve the pain, then steroids are added with its side effects of gastritis and water retention. Then diuretics and antacids have to be given. In the meantime the disease continued to its attack on her bones and organs such as kidney. Eventually she was put on methothrexate but by that time her joints were completely deformed and the career of a young graduate was gone.
Another patient  was luckier because she got the disease during the discovery of new treatment. She was initially treated with steroids with improvement. Then some relative recommended treatment with natural herbs in India. After a few months of worsening arthritis , she returned to Singapore and was started with methothrexate with improvement. She was able to walk without pain and continued her career as a teacher. 
Another patient comes weekly for her methothrexate injection at my clinic for control of her condition.

Rheumatoid arthritis is a systemic autoimmune disease that can cause chronic inflammation of the joints and other areas of the body. Patients with autoimmune diseases have antibodies in their blood that target their own body tissues .


Rheumatoid Arthritis is one of the most common form of inflammatory arthritis.
It most commonly occurs between the 25 and 50 years.
However it can occur at any age.
 Females are 3 times more likely to get Rheumatoid Arthritis than males.


Most common symptoms are pain, swelling, stiffness, warmth and sometimes redness of the joints.
 Rheumatoid Arthritis is suspected when there are:
1. Swelling in the joints especially those of the hands,elbows,knees,ankles and feet.
2. Stiffness in the joints in the mornings which can last more than an hour or after prolonged rest
3.redness and warmth in one's joints
4.Persistent pain or tenderness in a joint for more than a month
5.Inability to move or use a joint normally
6. Unexplained weight loss and appetite, fatigue, or weakness  together with joint pains


Abnormal blood antibodies can be found in patients with rheumatoid arthritis.
1.A blood antibody called "rheumatoid factor" can be found in 80% of patients. 
2.Another antibody called "the antinuclear antibody" (ANA) is also frequently found in patients with rheumatoid arthritis.
3.Another blood test that is used to measure the degree of inflammation present in the body is the C-reactive protein.
4.A blood test called the erythyrocyte sedimentation rate (ESR) is a measure of how fast red blood cells fall to the bottom of a test tube. The sedimentation rate is used as a crude measure of the inflammation of the joints.
The rheumatoid factor, ANA, ESR, and C-reactive protein tests can also be abnormal in other systemic autoimmune and inflammatory conditions. Together with the symptoms they may confirm a diagnosis of
Rheumatoid Arthritis


 Rheumatoid Arthritis may start gradually or with a sudden and severe attack.
 It usually attacks many joints at one time.

  Rheumatoid arthritis is a chronic disease, characterized by periods of disease flares and remissions.
 
In rheumatoid arthritis, multiple joints are usually affected in a symmetrical pattern.
It most commonly affects the hands and feet,often in a systemic pattern(both right and left joints are affected). 
Other joints affected are the elbow,knees,and ankles. Less common are shoulder,hip and spine.


Rheumatoid Arthritis can result in joint deformities and disability especially in untreated severe cases.

Daily activities such as bathing,dressing, walking and even writing may be difficult.

Besides the joints, Rheumatoid Arthritis may sometimes affect other organs such as the eyes,lungs,skin,intestines,nerves and bone marrow.

Mild fever, fatigue, loss of appetite and loss of weight may be present.

Severe Rheumatoid Arthritis is associated with an increased risk of mortality.


There is no known cure for rheumatoid arthritis.
Therefore the purpose of treatment is to:
1. improve functions and
2. reduce pain and discomfort.


Treatment of Rheumatoid Arthritis can be broadly classified into:
1. Non-drug therapy:
      Weight loss is an effective way to reduce the stress on the joints and minimize the pain
      Walking sticks are useful ways to offload the stress on the affected weight bearing joints such as hips or knee. The walking aids should be used on the opposite side. It can be in the form of a sturdy umbrella instead of a crutch.

      Hot packs are useful aids in the morning to soften a stiff arthritic joint whereas braces and knee guards are useful supports to give some comfort to the knee.

      Exercises that improve strength, agility and flexibilty are useful to minimise the disability of Rheumatoid Arthritis. A range of motion exercises is useful to keep the joints supple and mobile.

      Water based exercises are a good alternative form of aerobic workout by patients afflicted by Rheumatoid Arthritis. The warm water especially is a good medium for joint mobility and together with the buoyancy of water it helps to minimize the body weight impact on the joints.
     
2. Drug therapy
      There are 2 main types of drugs:
       1. symptom modifying helps to alleviate the symptoms but do not change the natural history of the conditions. Eamples are Non-steroidal Anti-inflamatory Drugs(NSAIDS) like diclofenac.

       2. disease modifying drugs such as steroids, methothrexate, sulphasalazine, redaura, hydroxychloroquine have been shown to slow down the damage caused by Rheumatoid Arthritis.

 It is important that the disease should be controlled before irreversible joint damage occurs.

 Newer "second-line" drugs for the treatment of rheumatoid arthritis include leflunomide (Arava), and the "biologic" medications etanercept (Enbrel), infliximab (Remicade), anakinra (Kineret), and adalimumab (Humira).


The treatment of rheumatoid arthritis optimally involves a combination of patient education, rest and exercise, joint protection, medications, and occasionally surgery. 

Early treatment of rheumatoid arthritis results in better outcomes.