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Useful laboratory tests for patients with recent onset inflammatory polyarthritis may include complete blood count, erythrocyte sedimentation rate, rheumatoid factor test, aspartate aminotransferase (AST) test, creatinine level and urinalysis. Erythrocyte sedimentation rate is an inexpensive measure of disease activity in those with rheumatoid arthritis; however, the test is not diagnostic and rates are not elevated in all patients affected. A positive test result for rheumatoid factor is helpful but not essential to confirm the clinical impression of rheumatoid arthritis in the setting of symmetrical inflammatory polyarthritis. If the arthritis has lasted more than a year, the physician should consider taking radiographs of the hands and feet.
 
The importance of diagnosing rheumatoid arthritis cannot be overemphasized - early intervention with DMARDs has been shown to improve long-term outcomes,and once joint damage has occurred erosion and joint instability are irreversible. If rheumatoid arthritis is mild and in its early stages many rheumatologists favour using hydroxychloroquine because it is safe and convenient. If control is suboptimal after 6 months, additional DMARDs are often prescribed. A recent study reported some efficacy with minocycline for patients with early seropositive rheumatoid arthritis. However, long-term efficacy data for patients treated with minocycline are not available, and radiographs show that damage progresses at the same rate as in placebo-treated patients.
 
If a patient has moderate or severe rheumatoid arthritis, especially if the rheumatoid factor is positive, injectable gold or methotrexate may be the preferred DMARD. Gold treatment has the important advantage of offering the potential for disease remission, but methotrexate is more convenient and better tolerated. Sulfasalazine is safe as a second-line agent and can be used in combination with methotrexate and other DMARDs. Many new DMARDs are becoming available.
 
There is frequently a delay between the presentation of polyarthritis and the confirmed diagnosis, and there is always a delay before a prescribed DMARD has the expected benefit. When optimal DMARD therapy or a combination of DMARDs does not control synovitis, low-dose prednisone can provide symptom relief, acceptable low toxicity and joint protection. Bisphosphonate, either cyclical tidronate or daily alendronate, reduces the risk of steroid-induced osteoporosis and should be prescribed prophylactically when the daily dose of prednisone is 7.5 mg or more.
 
Patients with active rheumatoid arthritis should be assessed by a rheumatologist on a regular basis, and clinical and laboratory evaluations should be repeated to measure the efficacy and toxicity of treatment. The aim of therapy is to minimize pain, stiffness and joint swelling; retard joint damage; and reduce future disability.
 
In patients who are under 50 years of age with joint pain and swelling lasting longer than 6-8 weeks the diagnoses to be considered include rheumatoid arthritis, psoriatic arthritis, other seronegative spondyloarthropathies and SLE. In patients over 50 years of age,crystal-induced synovitis should also be considered. Osteoarthritis may also cause considerable inflammation in the affected joints. For most of these conditions specific therapies aimed at controlling inflammation, preserving range of motion in the joint and preventing joint damage are successful in decreasing morbidity and improving quality of life.
 
The patient with symptoms in many joints requires a detailed history and physical examination. If there is morning stiffness lasting more than 30 minutes or stiffness after sitting, the joint complaints are likely to be caused by inflammation; a convincing history of joint swelling confirms the presence of inflammation . The physician should record the onset and progression of symptoms and the distribution of joints affected.
 
A history of psoriasis in the patient or a family member is an important clue to the possibility of psoriatic arthritis. The physician should also inquire about a history of iritis or inflammatory bowel disease, both of which are associated with seronegative spondyloarthropathies.
 
 A recent episode of infectious diarrhea or genitourinary infection are clues to possible Reiter's syndrome. Does the patient have symptoms suggestive of SLE (e.g., photosensitive or malar rash, alopecia or pleurisy)? Is there a past history of acute episodes of arthritis or gout? Are the joints tender or swollen? Is movement limited? The choice of laboratory tests that may help depend on the differential diagnosis.
 
Patients must be made aware of the need for monitoring. The incidence of serious side effects is markedly reduced with regular monitoring, because adverse effects are more likely to be discovered before serious or irreversible consequences arise. Despite the long list of side effects, which often intimidates patients, long-term series of rheumatoid arthritis patients treated with DMARDs  have found that serious side effects are rare.
 
When counselling a patient who expresses concern about potential side effects, it is also important to remind him or her of the consequences of the alternative; doing nothing will result in irreversible disability, progressive joint damage and premature death. It is also important to recognize that information on the use of antirheumatic drugs in other fields of medicine may not be applicable to patients with rheumatic diseases. Drugs such as methotrexate and cyclosporine,  which are used in cancer therapy and transplant programs respectively, are used in lower doses for rheumatoid arthritis, and the incidence of adverse events is lower.
 
Persistence in the use of DMARDs is of great importance. DMARDs are used to treat incurable, chronic diseases where treatment will be lifelong and the number of available options is limited.
 
Typically a patient with rheumatoid arthritis will use a succession of DMARDs over the years. After an initial response, a drug is often eventually discontinued, either because of adverse side effects or loss of effect. To ensure the best result, it is important to give each drug a full trial, namely, the maximum dose for sufficient time, before declaring it not efficacious. In addition, there are a number of strategies for dealing with common side effects. Rather than stopping treatment, the patient may be referred to a rheumatologist, or one can be consulted by the physician, regarding the management of persistent side effects.
 
The use of a combination of DMARDs is now widely practised. Some rheumatologists advocate the use of combination therapy from the onset of disease for early control, with a subsequent gradual withdrawal of therapy, as necessary to maintain control. Others prefer the opposite strategy: successively adding DMARDs to agents to which the patient has shown a partial response. Proponents of the latter view believe it prevents unnecessary exposure to potentially toxic drugs of patients who may respond to single therapy. This approach may also be more acceptable to patients.
 
 Commonly used combinations include hydroxychloroquine with most DMARDs, especially methotrexate or intramuscular gold; sulfasalazine and methotrexate with or without hydroxychloroquine; and cyclosporine and methotrexate.

The treatment of early rheumatoid arthritis is now recognized as crucial to long-term outcome, and the selection of agents is a complex task owing to the rapidly increasing number of treatments available, alone or in combination. When possible, a rheumatologist should be involved in this decision-making process.
 
There is no consensus as to the order in which DMARDs should be chosen for the treatment of rheumatoid arthritis or other inflammatory arthritides. Choice must be tailored to the patient's profile and preference, disease activity and prognostic markers of disease severity.
 
The use of corticosteroids results in rapid, potent and reliable suppression of inflammation. This explains their wide use for the inflammatory manifestations of rheumatic diseases and for systemic vasculitis. However, their effect in suppressing the synovitis in rheumatoid arthritis is not sustained and requires a progressive increase in dosage to maintain the benefit.
 
The precise role of orally administered corticosteroids in rheumatoid arthritis remains controversial. Short courses of low-dose steroids can be useful as "bridging therapy" to control symptoms while waiting for DMARDs to take effect or to control severe flare-ups. Patients can decrease the dose as soon as symptoms are under control. The injection of steroids into the most affected joints can often alleviate the need for oral steroids (at the rate of 1-2 large joints every 2-6 weeks). Intramuscular injections of corticosteroids are advocated by some to prevent difficulties in tapering off the dose of oral corticosteroids.
 
The use of an alternate-day regimen is associated with a lower incidence of some of the side effects  Maintenance of control of the disease can be a problem. Switching from daily to an alternate-day regimen must be done gradually (by tapering off the dose on alternate days down to zero) to prevent both adrenal insufficiency and exacerbation of the disease. Administration of the dose in the evening, a divided dose and the use of longer acting forms are associated with greater adrenal suppression.
 
It is useful to think of corticosteroid administration in 3 broad ranges: low dose (i.e., the equivalent of orally administered prednisone, 15 mg daily or less), as used in the treatment of polymyalgia rheumatica, active arthritis and mildly active systemic lupus erythematosus; moderate dose (i.e., 15-25 mg daily); and high dose (i.e., 25-60 mg daily), as used in the treatment of acute manifestations of systemic vasculitis and the more severe manifestations of systemic lupus erythematosus.
 
Unfortunately,RA has the reputation that it is incurable-that nothing can be done. RA is currently incurable,it certainly is treatable-at any stage-early the easier,and better. Health care systems are changing. The old system wherein physicians made all the decisions is slowly disappearing. In the new system, patients,especially those with complex diseases,can be misunderstood, The choice and the responsibilities,are yours. It is your health,and no one else will pay as much attention to it,or will benefit from it as much as you.
 
If you have rheumatoid arthritis,you need to be proactive. You have to initiate contact with your health care providers and get along with them. The right diagnosis is the start. You will most certainly require the services of a rheumatologist  for treatment and monitoring of your disease. Most of all you need to become more educated about your disease The most important thing in management of the disease is to get it under control.
 
If the inflammation associated with RA is controlled,most of the other problems that occur as a result of the devastating effects of inflammation is gone or minimized. Don't accept you have to live with it,(always) you may have to live with it up to a certain point.but understand your treatment options and never accept treatments just because someone said it may work. They may not work for you.
 
Most RA patients get lost in a maze of treatmentment options (and unfounded opinions),valuable time and the opportunity to control the disease is lost.
 
It is your life and your disease. Make the decision to get the treatment you  need to get your disease under contol,and forget Uncle Jims's arthritis symptoms and treatment,or your friend's back problem treatments. The first step,is seeing a rheumatologist. Family doctor's are one of the most valuable people in this world,but a good doctor who have your sole interests will refer you to one.
 
The family doctor's training in rheumatology is a very,very low time (estimated at less than 1 %-if the option in taken)spent in rheumatology,and furthermore some do not take the rheumatology option offered at medical school. My family doctor admits it,and quickly refers when he is not quite sure. of any complex problems of the human body,that what he is trained to do. A most valuable physician,we can not afford to be without,but with limitations in regard to certain problems that may arise.
 
 

 

 
Dismantling The Treatment Pyramid:
 
Dismantling the treatment pyramid: those of you remember "Red Kelly" then coach of the Toronto Maple Leafs hockey club of the NHL who tried "pyramid power" to motivate his team.
 
It was a seventies fad based on vague interpretations of mysteries,such as using crystals to "realign your aura" The mix of specious reasoning and hokey data was enough to convince students and athletes to sit under pyramids as a way of increasing their prowess in studies and sport. The practise, fortunately, has gone the way of the "model-A Ford automobile",but the pyramid did have one serious application: as a symbol for rheumatoid arthrtis management
 
The "pyramid approach to treatment" is a visual for the administeration of sequentially more powerful interventions: The base of the pyramid is rest, physical therapy,ASA,and other NSAIDs. Next up are progressively stronger disease-modifying anti-rheumatic drugs (DMARDs-slow acting anti-rheumatic drugs-then referred to as SAARDs) capped,at the apex of the pyramid,by experimental drugs and procedures.
 
The pyramid approach has long been part of the fabric of rheumatology, certainly for as long as Dr. James F. Fries can remember. Fries is director of ARAMIS (Arthritis Rheumatism and Aging Medical Information System) based at Stanford University Medical Centre,where,for the past decades or so,he and his colleagues have been building databases on arthritis. Their research has contributed to a new understanding of RA,and a recognition that the pyramid approach to tretment was based on some false notions about the disease.
 
The first was the view that RA is a relatively mild disease,followed a leisurely course,that doesn't amount to much in most people,and often goes into remission by itself. Then there was the belief,Fries says "that ASA and NSAIDs wer very benign drugs,and that disease modifying drugs-like intramuscular gold and,even worse,methtrexate or azathioprine-were too dangerous in a benign disease." Incorrect,and wrong again. On the basis of such false premises says Fries,"we accepted the pyramid strategy".
 
In recent years,anumber of studies-many of them drawing on the remarkable ARAMIS database-have led to a very different conclusions. What they've learned has led to what Fries calls "a 180-degree change in the way we therapeutically approach RA",similar to the change in the way heart attack victimins are treated: Years ago,heart patients were prescribed six weeks of absolute bed rest,which seemed logical at the time. But outcomes took a leap foward when cardiologists started hauling their patients out of bed and up into treadmills and out running marathons. "Those of us who have seen both eras",Fries says,"realize we were flatly wrong in the way we approached coronary artery disease-and we were flatly wrong in RA. So,we're at a time when we made a 180-degree shift,in this case with the treatment pyramid".
 
"Initially,the pyramid approach was useful because at the base of the pyramid you had one drug,ASA " says Dr. Bill Benson a rheumatologist a St. Joseph's Hospital in Hamilton Ontario. "And then,of course,you went very quickly from ASA ti the disease-modifying drugs. Where things got complicated was in the "70s and "80s,when we had 13 other NSAIDs come into the market. It made the base of the the pyramid so deep that many physicians started to go with the concept that you just keep trying these non-steriodals,which would give you up to two or three years' worth of alternatives before you move on to a stronger, slow-acting,anti-rheumatic drug. And this led to immense,damaging delay in the management of RA."
 
At the same time,it was clear that NSAIDs weren't stopping the disease in most people,while the slower acting drugs showed greter potential to put the disease to rest,if not temporarily, and sometimes permanently. In addition, doctors were becoming aware,from clinical experience if not from academic studies,that DMARDs also worked best with early-stage RA-before it caused irreversible cartilage or bone damage.
 
 
A rheumatologist at the University of Birmingingham,England wrote in the British Journal of Clinical Practise in 1995,"There is now great deal of evidence that inflammatory arthritis is at its most active soon after onset: The conventional delay in therapy until disease becomes severe is therefore a missed opportunity. The appearance of erosions ( in cartilage and bone ) also peaks early in disease. A further stimulus for early therapy has come from evidence that systemic disease itself is harmful: For example,patients who maintain a high acute phase response over two years lose approximately 10 % of the bone from the hips". -Dr. Paul Emery.
 
"There was a feeling 20 years ago that you could sort of start anytime and these drugs would work and slow things down" Says rheumatologist  Dr.Benson from Hamilton,"so there was no particular rush, I think people appreciate now that,if you want to stop the disease,you have to treat early and slam the barn door before the horse gets out."
 
Since that realization,there have been a number of new ways of looking at RA management. Two researchers at the University of Washington were among the first to suggest (in the Journal of Rheumatolog  ,in 1989) "remodelling the pyramid". In its place,they propsed a "step-down bridge" approach to RA,in which treatment is initiated "with a combination of rapid-acting anti-inflammatory medications and slower-acting second-line drugs. this provides erly control of inflammation and a "bridge" until slower-acting medications can take effect". Medications are then sequentially withdrawn,in contrast to the traditional pyramid,in which they're sequentially added.
 
A year later in the early 1990s A researcher-rheumatologist Dr. Fries suggested a slightly different strategy. (saw-tooth) One of the problems with previous strategies,he said, was that patients didn't recieve DMARDs before they had "substantial erosive disease and disability. Such drugs have most typically first been prescribed six to eight years into the disease course;too little,too late,for too few".
 
That course was based on the assumption that NSAIDs were relatively harmless in terms of side effects compared to DMARDs. In fact,ARAMIS (data base) data showed that there's really little to choose between the two drugs in that regard. The data also provided a new view of oain relief. It was always ssumed that NSAIDs provided fast relief from the pain,while DMARDs worked on the underlying disease
 
While that's essentially true,Fries noted that "pain in RA is a consequence of the inflammatory process and of prior destructive eents in the joints". So, while NSAIDs provide day-to-day relief from the pain,the ultimate pain reliever is the best medication that best "reduces Inflammation and retards bone and cartilage destruction and prevents future pain".
 
An ARAMIS study that examined pain levels nine months after therapy began in some 10,000 courses of treatment with different agents found that pain relief from NSAIDs was "at best modest,while (treatments) with DMARDs were three times more substantial".
 
Fries also emphasizes that RA isn't benign as people used to think It does,in fact,increase moratality rates,a "long-established but neglected observation" that negates another frequent argument for the old therapeutic pyramid:"that drugs with the ( extremely rare ) potential for fatal reactions should not be used in a 'nonfatal" disease unless absoslute necessary."- which proved wrong.
 
Fries asserts that old rheumatologists' dominant therapeutic strategy "had been an illogical one,based upon premises that can now shown to be false,in which we treted patients symtomatically until their joints had sustained irreversable damage. Only then did we employ,slowly and ferfully,our most effective agents. We took a short-term view of analgesia in a long-term diseae. We accepted rather uncritically the view that NSAIDs were safe and DMARDs were dangerous. We allowed slow month-to-month deteriation to pass unobserved until the best point to change therapy had long passed. We are using new stratgy,rolted in the relevant clinical facts and dedicated to the improvement of long-term outcome".
 
The sawtooth strategy Fries initially proposed advocated the serial use of DMARDs,introducing one or more as the therapeutic benefit of the earlier drug is lost,but that strategy has yet  to prove more effective than the step-down approach. Since then,variations have been suggested ,with clinicians employing different tactics to affect patient outcomes; rheumatologist no longer talk about "reversing the pyramid".
 
Dr Keystone-researcher-rheumatologist generally starts patients on methotrexate: "It used to be be you started with gold and then went to chloroquine (replaced by plauenil),then you went maybe to azathioprine or sulfasalizine,and finally you think about a agent like methotrexate. "Even if their joint swelling remains the same,people feel better,they're less symptomaticc. And a proportion of people go into remission"
 
Fries in contrast starts patients with relativelu mild hydroxychloroquine ( an approach more common in U S than in Canada) Keystone generally starts patients on methotrexate
 
Keystone contends that Canadians "are more aggressive than Americans by far" in their treatment philosophy. As soon as we make a diagnosis,we put patients on DMARD, What's different is,we're using methotrexate earlier,and we're combining DMARDs earlier. So, in a sense,we are reversing,the pyramid,because we're not waiting to get to the top,we're starting DMARD from Day One".
 
Most present day rheumatologist follow and believe in Keystones' approach.