General

Sock's Treatment And Management Of Rheumatoid Arthritis Pages

Rheumatoid arthritis is an systemic autoimmune disorder of unknown cause characterized by symmetric,erosive synovitis,and more often,mutisystem involvement. Most patients exibit a chronic changeing course of disease that if left untreated may result in progressive joint destruction, deformity, disability, and possible premature death. RA is one of the most common and serious type of arthritis.

It affects all ages and races. RA affects approximetly 1% of the population and this low prevelance may mean that many health care professionals may have little experience in treating the disease successfully.

Some Facts About RA:
RA affects more than 2 million Americans.
Direct and indirect costs of RA reached $65 billion in 1992.
More than 75% of RA patients are women.
Peak onset is between age 20 and 45.

Osteooporosis is common in patients with RA.

RA can be difficult to diagnose early because it may begin gradually with subtle symptoms. Blood tests and X-rays may be normal initially. The disease varies among individuals with respect to symptoms,joints affected and the nature of other organs involved,such as the eyes,lungs,and blood. Other types of arthritis may mimac RA. There are mild,moderate,and severe types of RA. Skill,often-patience,and experience are essential to reach a precise diagnosis and to arrive at the appropriate treatment

Although we do not know the cause of rheumatoid arthritis,joint damage is caused by inflammation in the synovial membrane. This normally thin memberane becomes inflamed and thick,filled with cells called fibroblasts, lymphocytes,polymorphs, and macrophages. This thick,inflamed synovial membrane is called the pannus. The cells within the pannus becomes activated, and releases enzymes,and chemicals that both permanetly damage the cartilage and the bone,and also attract more cells into the inflamed tissue. In RA,this inflammatory process is like a one-way highway, the inflammation continue indefinitely causing more and more damage,leading to possible joint deformity and destruction if not controlled.

This inflammatory process is part of the body's immune system. The immune system is a natural defense against invaders such as bacteria, viruses,and even cancer. The cells of the immune system recognize,and respond to invaders either by making antibodies to combat invaders or by attacking invaders directly. Although the immune system is normally activated by a foreign agent,it can be activated to attack normal cells. In RA,for unknown reasons,the immune system becomes over-activated and causes marked inflammation in the synovial membrane. Many of the drugs used to fight RA have antibacterial and/or anti-immune system activity.

The damage to the joints caused by RA is thought to be caused by the interaction of many inflammatory cells and chemicals. Cytokines,like tumour necrosis factor,IL-ra alpha etc., are secreated by synovial fibroblasts and other cells resulting in pain,and inflammation TNF may also be responsible for influencing other inflammatory compounds including interleukins (IL-1), collagenase,and prostaglandins

Tumor necrosis factor (TNF-a) converting enzyme contributes to production of TNF-a in the synovial tissue of patients with RA,who have a excess of TNF. Biologic drugs such as Etanercept (Enbrel) and Infliximab (Remicade) have developed to combat TNF. Due to the high cost these drugs have mostly been used on patients who do not respond to conventional therapy. Leflunomide (Arava) is a new DMARD which suppresses cells that are rapidly dividing have also been recently developed. Recently another drug was approved by the (F.D.A.)Federal Drug Administration to combat another cytokine IL-1 also involved in the inflammatory process. There are currently many research projects going on to combat rheumatoid arthritis.

The major underlying feature of RA is inflammation. By controlling inflammation,not only can the symptoms of RA be alleviated,but permanent disability can be prevented or minimized.

The help of specifically trained health care workers in rheumatic diseases will help in the management and treatment of RA. The major aim of treating RA is to control the inflammation before erosive and destructive forcess come to play in the disease process.

If the ("fire") inflammation of RA is controlled,pain,and swelling will diminish, and damage and possible deformity will be limited. Limited from inflammation, the patient will be able to resume a more satisfying,and productive life-style.

The patient will have the greatest interest in getting the most effective treatment for RA disease control. To accomplish this goal,the arthritis must be diagnosed promptly,and its type determined. A knowledgeable,and compassionate physician who is able to select,modify,and recommend the most appropiate treatment is a essential component of the whole disease control process.

Patients must take resposibility for their own disease,and navigate through the health care system to ensure the disease gets the treatment it needs. The "window of opportunity" to control the disease,when the disease is more manageable (2 years-onset of disease)exists,but it is never to late,to initiate DMARD therapy.

Successful management of RA requires early diagnosis and aggressive treatment before functional impairement and irreversible joint damage has ocurred. Nonsteriodal anti-inflmmatory drugs such as ibuprofen may be used first,but all RA patients with persistentent swelling in the joints are candidates for treatment with disease-modifying drugs, These drugs include methotrexate, hydroxychloroquine, sulfasalzine, corticosteriods,and intramuscular and oral gold,d-penicillamine, minocycline, azathioprine,cyclosporine,leflunomide and etanercept.

Optimal treatment requires comprehensive coordinated care,patient education and the expertise of a number of providers.including rheumatoligists,primary care physicians,specialized nurses trained in rheumatic diseases,occupational, physical therapist,physiatrists,social workers, and orthopedic surgeons if required.

With the success of total joint replacement surgery (especially hip and knee) many patients with advanced disease have continued to be active and mobile.

RA has ben a primary focus of rheumatologic research. The chronic nature of RA and the diagnostic and treatment complexicity have made the specialized skills and training of a rheumatologist critically important in the care of people with RA. Expertise is needed to balance the risks and benefits of disease modifying drugs.

Complete remission is defined as the absence of 1) symptoms of active inflammatory joint pain (in contrast to mechanical joint pain). 2) morning stiffness. 3) fatigue. 4) synovitis on joint examination. 5) progression of radiographic damage on sequential radiographs. 6) elevated erthrocyte sedimintation rate or (ESR),or C-reactive protein (CRP) level.

If complete remission is not achieved,the management goals are to control disease activity,alleviate pain,maintain function for essential activities of daily living,and work,maximize quality of life,and slow the rate of joint damage. Complete remission is rare,but in happens in some patients. Partial remission is the likely outlook.

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 "zoot suit",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 treatment 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,nt-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.

The first step in the diagnosis of rheumatoid arthritis is a meeting between the doctor and the patient. The doctor reviews the history of symptoms, examines the joints for inflammation and deformity.

Inflammation can be detected by:

1) Tenderness with pressure over a joint.

2) Swelling.

3) Pain ( when the patient move the joint through a full range of movement,pain is experienced towards the end of the range ).

4) Redness or warmth,(redness is not a criteria for RA)

5 )The number and severity of inflamed joints,whether or not the inflammation is symmetrical,gives the doctor a sense of what type of arthritis is present.

The doctor will also examine the skin for rheumatoid nodules, and other parts of the body for inflammation. Certain blood and x-ray tests are often obtained. The diagnosis will be based on the pattern of symptoms, the distribution of the inflamed joints, and the blood and x-ray findings. Several visits may be necessary before the doctor can be certain of the diagnosis--(rheumatologist).

The distribution of joint inflammation is important to the doctor in making a diagnosis. In rheumatoid arthritis, the small joints of the hands, wrists, feet, and knees are typically inflamed in a symmetrical distribution (affecting both sides of the body). When only one or two joints are inflamed, the diagnosis of rheumatoid arthritis becomes more difficult. The doctor may then perform other tests to exclude arthritis due to infection or gout.

The detection of rheumatoid nodules , most often around the elbows and fingers, can suggest the diagnosis. Rheumatoid nodules are bumps,the size of corn to that of a small grape,that develop under the skin. the most typical location is on the forearm,just below the elbow. Pressure seems to trigger their development;habitually resting a forearm on the arm of a chair or on a table is thought to be a factor.

Less commonly,people develop nodules over the Achilles tendon (where the back of a high shoe or boot presses),or over knucles of fingers or toes where pressure is applied repeatedly. Nodules may be single or in clusters. Some can be moved about under the skin,while others seem stuck to the underlying bone. they aren't painful unless they are injured or infected.

They may be mistaken for other bumps including "tophi" (deposits of uric acid),seen in some with gout. Very uncommonly,rheumatoid nodules are present by themselves,without any evidence of RA. the exact cause is unknown but there must be some more cause then pressure.or injury,since less than 20 % of RA patients develop nodules. In some patients,treatment with methotrexate,even though it helps control joint inflammation,causes the nodules problem to get worse when one has it-doctors don't know why.

Since almost all patients with nodules have rheumatoid factor (RF) in their blood. ( Eighty percent of RA patient's have a positive RF,in their blood stream.) RF may be involved in "vasculitis" (inflammation of a small blood vessel) possibily triggered by local injury from pressure. The body may react locally to the vasculitis inflammation,and the attempt at healing may result in a lump of scar tissue below the skin in some patients. Nodules may eventually go away,but they often persist after all other evidence of Ra has been suppressed. They tend to exist in patients with more moderate-severe RA patients,but that is not a general rule. In most cases they do not cause trouble in the majority of patients who have it.

Abnormal blood antibodies can be found in patients with rheumatoid arthritis. A blood antibody called "rheumatoid factor" can be found in 80% of patients. Another antibody called "the antinuclear antibody" (ANA) is also frequently found in patients with rheumatoid arthritis. ANA testing is associated more with Lupus patient diagnosis.

A blood test called the sedimentation rate (sed rate) is a measure of how fast red blood cells fall to the bottom of a test tube. The sed rate is usually faster during disease flares, and slower during remissions. An elevated "sed rate" can be seen in other diseases.

Another blood test that is used to measure the degree of inflammation present in the body is the C-reactive protein.

The rheumatoid factor, ANA, sed rate, and C-reactive protein tests can also be abnormal in other systemic autoimmune conditions. Therefore, abnormalities in these blood tests alone,are not sufficient for a firm diagnosis of rheumatoid arthritis.

Joint x-rays may be normal or only show swelling of soft tissues early in the disease. As the disease progresses x-rays can show bony erosions typical of rheumatoid arthritis in the joints. Joint x-rays can also be helpful in monitoring the progression of disease and joint damage over time. Bone scanning, a radioactive test procedure, can demonstrate the inflamed joints.

The doctor may elect to perform an office procedure called arthrocentesis. In this procedure, a sterile needle and syringe are used to drain joint fluid out of the joint for study in the laboratory. Analysis of the joint fluid, in the laboratory, can help to exclude other causes of arthritis, such as infection and gout.

Arthrocentesis can also be helpful in relieving joint swelling and pain. Occasionally, cortisone medications are injected into the joint during the arthrocentesis in order to rapidly relieve joint inflammation and further reduce symptoms.