Dr. Theo on Arthritis Continued
RHEUMATOID ARTHRITIS (RA)
Rheumatoid arthritis (RA) is an autoimmune disease brought about
when the body has, for unknown reasons, turned on itself. In RA, the immune
system starts attacking body tissues as if they were foreign invaders. In its
mildest form, rheumatoid arthritis is characterized by joint discomfort caused
when the joint lining, especially the part that meets the cartilage, becomes inflamed.
In its most serious form, RA can cause painfully deformed joints and harm organ
system.
Some experts believe that RA is brought about by a bacterial
infection in the joints, but it might also be triggered by a virus in those who
are genetically susceptible. People with a family history of RA have a much higher risk of RA. A recent
study suggests that the disease's origin may be related to the body's attack on
a carbohydrate chain in the joint cartilage, not on proteins, as had been
previously been theorized.
Over time, the chronic inflammation of RA makes the joint lining
thick and overgrown. This overgrown lining may then start to invade the
cartilage, other joint supporting tissues, and even the bone, causing small
erosions in the bone and weakening the entire joint structure. Eventually, the
weakened joint becomes more and more painful and less able to perform. Under
pressure, it may even become dislocated and deformed.
Usually appearing in the same joint on both sides of the body
(both hands, for example), RA hits suddenly. The joints become swollen, tender,
and inflamed; there may also be fever, weight loss, and a general feeling of
sickness, soreness, stiffness, and aching. The eyes and mouth may dry out if
the tear and salivary glands become involved: People with RA generally have
stiffness in their joints that lasts for an hour or more when they wake up in
the morning. The pain and stiffness are often better after movement.
RA affects more than 2.5 million people in the United States,
striking women three times as often as men. Onset is typically between the ages
of 20 and 40, although older persons and children are also victims. Joint
inflammation is chronic and can be mild to severe, with occasional attacks or
"flares." The disease may get progressively worse over time and lead
to severe deformities in the joints.
The treatment for RA is designed to alleviate pain, reduce
inflammation, stop or slow joint damage, and improve overall body functioning.
In the past, treatment was started with mostly mild drugs; the more potent (and
potentially more hazardous) disease modifying drugs (or DMARDs) were reserved
for the time when the disease started to cause joint destruction. The trend
over the past few years, however, has been to start with more aggressive
treatment immediately rather than wait for joint destruction to become apparent
Some rheumatoid arthritis sufferers can have rapid progression of the disease.
In just a year they can have such severe damage to one or two joints that they
require joint replacement surgery. This is why it's critical to get a diagnosis
of RA early, have a consultation with a rheumatologist, and start prescription
medicine immediately.
Aspirin and NSAIDs are used to control pain in RA, but these drugs
do not slow the progression of the joint destruction. Immunosuppressive
medications such as methotrexate, sulfasalazine, leflunomide (Arava®)
hydroxychloroquine, azothioprin (Imuran), and cyclosporin may help slow the
joint destruction associated with RA. Three new biologic medicines known as
tumor necrosis factor inhibitors have been approved for use in RA: etanercept
(Enbrel), infliximab (Remicade) and adiliniumab (Humira). Another new
medication called anakinra (Kineret®), which works by blocking the activity of
a natural inflammatory agent in your body called interleukin-l, is now
available. These medications have had a major impact on controlling pain, joint
swelling, and joint destruction due to RA. Exercise and therapy can help reduce
joint soreness and swelling, alleviate pain, and increase joint mobility.
Surgery is an option in the case of severe damage to the hips or knees and
sometimes the shoulder when it can make the difference between dependence and
independence.
Unfortunately, there have not been any large, controlled studies
on the use of glucosamine, chondroitin, or ASU on rheumatoid arthritis
sufferers. From a theoretical standpoint, some of the mechanisms of action of
these supplements would suggest that they should benefit The supplements can
inhibit the enzymes that break down cartilage as well as the negative effects
of IL-l, chemicals that are produced both in osteoarthritis and even more so in
rheumatoid arthritis. Furthermore, many people with RA also have osteoarthritis
and can benefit from the use of the supplements. Since every case of RA is
different, it is important to discuss the use of these supplements with your
rheumatologist.
INFECTIOUS ARTHRITIS
Can arthritis be brought about by germs? Absolutely. Many forms of
bacteria. viruses, and fungi can cause infectious arthritis, which is
frequently characterized by loss of joint function, fever, and inflammation of
one or more joints, and (occasionally) chills. The knee joint is most commonly
involved (50 percent of the cases), followed by the hip, shoulder, wrist, and
ankle. Infectious arthritis can generally be cured if caught early enough. In
practice, any bacterium, virus, or fungus that produces disease can prompt this
infectious form of arthritis, and there are many ways that the infecting agent
can enter the body: trauma. surgery, inserting a needle into a joint, abscess
or bone infection near the joint, animal bites, insect bites (see the
discussion of Lyme disease that follows), and even thorns. Chronic alcoholics
and drug abusers are at high risk for infectious arthritis, as are those
suffering from diabetes, sickle cell anemia, kidney disease, and certain forms
of cancer. A less obvious cause of joint infection is bacteria that travels
through the bloodstream from a distant site in the body and settles in a joint.
Infections almost anywhere in the body can move to the joints, including
infections that begin in the lungs, urinary tract, and skin. Remember that any
medical procedure involving a joint can lead to infection and infectious
arthritis. Many joint infections are complications of surgery on the joints;
very rarely does an injection into the joint space actually lead to an
infection.
The body responds to the infection by mobilizing the immune system
and engaging in a fierce battle with the infectious agent. The joint becomes
the battleground. Like all battlegrounds, the joint suffers, becoming inflamed
and painful as the body releases enzymes that inadvertently degrade the
cartilage as they seek to destroy the invaders.
The goal in treating infectious arthritis is first to eliminate
the infection, then handle the arthritis itself. Treatment depends upon what
caused it in the first place: antibiotics are prescribed for bacterial causes,
while NSAIDs are the medicine of choice for viral causes. If the cause is a
bacterial infection, infected joints should be drained in order to limit
destruction to the joint due to the active infection and inflammation. Physical
therapy may then be used to build up muscle strength and relieve joint stiffness.
LYME DISEASE
A bacterial illness caused by a spirochete, Lyme disease is spread
by bites from infected deer ticks. The illness gets its name from Old Lyme,
Connecticut, where the first cases were recognized in 1975. Today it is the
most common tick-transmitted disease in the United States. It's most common in
the northeastern region, but cases have been reported in every state and also
in other countries.
Lyme disease usually, though not always, starts with a
characteristic "bull's-eye" rash at the site of the tick bite. This
is followed by flu-like symptoms, including fever, muscle and joint pain, and
headaches. When Lyme disease patients are treated promptly with antibiotics,
the illness usually goes away with no lasting effects. Unfortunately, because
the bull's-eye rash isn't always present and because the other symptoms can
sometimes be quite mild, some patients don't know they have the disease and go
untreated. These people can end up with late-stage nerve and heart problems-and
also with arthritis, usually in the knees. In fact, the first cases of Lyme
disease were initially diagnosed as rheumatoid arthritis because the patients
all suddenly had swollen, painful knee joints. It was only when doctors
realized that a cluster of rheumatoid arthritis cases in one place at one time
was unlikely that they realized there was an infection involved.
As with other forms of infectious arthritis, treatment for
late-stage Lyme disease usually involves antibiotics to treat the infection;
and NSAIDs and possibly surgery to treat the affected joints.
FIBROMYALGIA
Characterized by widespread, sometimes incapacitating pain,
fibromyalgia produces stiffness and weakness of the muscular areas of the lower
back, hips, thighs, neck, shoulder, chest, or arms, accompanied by muscle
spasms ("charley horses") in any of those areas. Patients often tell
their doctors: "I hurt allover." The symptoms of fibromyalgia are
quite similar to those of chronic fatigue syndrome (CFS), which explains why
doctors have had a hard time distinguishing between the two. But in recent
years, researchers have discovered that the diagnosis of fibromyalgia is based
on pain or tenderness in at least 11 of 18 specific points of the body.
Formerly referred to as fibrosis, because it was thought to be an
inflammation of the muscles, fibromyalgia literally means "muscle
pain." Recent controlled studies, however, show no evidence of inflamed
muscles in patients with fibromyalgia. Researchers now think that fibromyalgia
is secondary to abnormal pain perception. In controlled studies, patients with
fibromyalgia perceived stimuli as painful at lower levels than did controls.
When the brain activity of patients with fibromyalgia was compared to that of
controls, people with fibromyalgia had more brain activity in response to the
same stimuli: In other words, someone with fibromyalgia is very sensitive to
pain. Things that someone without fibromyalgia doesn't perceive as painful are
definitely painful to people with fibromyalgia. Why this is so is still a
mystery.
Women between the ages of 35 and 60 are the most likely victims of
fibromyalgia, with the highest incidence occurring just before menopause. No
specific cause has been pinpointed. Fibromyalgia is often misdiagnosed because
most of its symptoms are similar to those found in other conditions.
Treatment of fibromyalgia includes alleviating chronic pain and
sleep disturbances, as well as dealing with the depression that often
accompanies a chronic disease. Water exercises, biofeedback, and relaxation
techniques are all helpful. Although aspirin and NSAIDs are usually prescribed
to relieve the pain, they don't always do the job. That's why muscle relaxants
or local anesthetics are sometimes injected into the painful areas to quickly
relax the muscle and alleviate pain. In addition, medications that act on the
central nervous system, most notably the prescription drugs amitriptyline
(Elavil®) and cyclobenzaprine (Flexeril®, have been shown to help sleep
disturbance and improve pain. SSRI antidepressants such as fluoxetine (Prozac®)
also seem to help with pain due to fibromyalgia, even if the patient isn't
depressed. Fibromyalgia is a very difficult disease, both to have and to treat.
The good news is that although the joints may be painful, the disease does not
cause deformity or deterioration.
PSORIATIC ARTHRITIS
Psoriatic arthritis is an inherited disease that sometimes occurs
in people with the skin condition called psoriasis. The red, scaly patches of
psoriasis often appear on the neck. knees, and elbows; the nails may become
pitted. People with psoriatic arthritis usually have stiffness in their joints
in .the morning that lasts at least 30 minutes. Psoriatic arthritis often
affects the back. It also often affects the end joints of the fingers or toes,
causing them to become so swollen that they're often referred to as
"sausage digits." Despite the swelling, affected joints tend to be
less tender than with other arthritis conditions, so patients with psoriatic
arthritis may develop joint deformity without a significant amount of pain.
Although swollen joints in the extremities are the most common
symptom of psoriatic arthritis, the diagnosis can't be made unless the patient
also has skin and nail involvement consistent with psoriasis. Sometimes,
however, patients with psoriatic arthritis have only nail lesions or such mild
skin lesions that they don't even know they have psoriasis.
Psoriatic arthritis usually appears when its victims are between
the ages of 20 and 30, although it may occur at any age. It affects men and
women .equally, and occurs in 5 to 8 percent of those who have psoriasis.
Treatment regimens include NSAIDs to reduce the inflammation, exercises to
improve joint mobility, and immunosuppressive drugs such as methotrexate or cyclosporin,
which can slow the rate of joint destruction. The new biologic medications
etanercept and infliximab have been approved for the treatment of psoriatic
arthritis and can be very effective at both clearing up the skin lesions and
treating the arthritis.
Continue reading Dr. Theo on arthritis...
