COMMON JOINT DISORDERS AT A GLANCE
RHEUMATOID ARTHRITIS It is more common in females than males, involvement of hand and foot joints, usually symmetric, is common, and can lead to severe deformities if not treated properly. Early recognition and aggressive treatment is crucial for preventing damage and deformities. Treatment is usually life-long and regular monitoring is therefore necessary for monitoring both efficacy and safety of drugs. Steroids are often used in early disease or special circumstances like pregnancy and lactation.
OSTEOARTHRITISIt is the most common type of joint disease worldwide which occurs in older persons, usually related to weight and lifestyle and mainly affects knee joints in India, Lifestyle changes, weight reduction and exercise are the mainstay of treatment and drugs only have a supportive role. Safer forms of painkillers are often required for pain control.
ANKYLOSING SPONDYLITIS It predominantly occurs in young males, mainly affects joints in the spine. Low backache and stiffness are main symptoms. NSAIDs (painkillers), if taken properly and under medical supervision are first line treatment, spinal exercises are must. Recently, biological treatment has revolutionized the treatment of this disease, but they are very expensive.
GOUTIt is caused by increased uric acid, predominantly occurs in males with obesity, hypertension, kidney disease or those taking regular alcohol and very rarely in postmenopausal females. Typically occurs in episodes (attacks), only one or two joints affected in each episode, most commonly great toe and ankle. Blood uric acid levels are not diagnostic. Long term disease is often associated with stones in kidney. Treatment of acute attacks is short term painkiller, steroid or colchicine. Drugs to reduce uric acid are of no use in acute attacks, they are only used if such attacks are very frequent and are then have to be taken life-long. Dietary and lifestyle changes are first line measures. Most patients with vague aches and pains which are persistent and with minor elevation of uric acid (especially females) do not have this disease and should not take unnecessary medication for uric acid.
SLEThis is one of the most severe types of arthritis which mainly affects women of childbearing age. It can involve any organ of the body including skin, kidney, brain, lung, heart, liver, eyes, joints, muscles, blood, etc. Confirmation of diagnosis is crucial and requires multiple tests. Frequent monitoring is essential, high dose steroid is usually needed to control the disease which, if untreated, may be life-threatening. Treatment is life-long and may require long term steroid.
REACTIVE ARTHRITISIt usually occurs in young males and is often preceded by urinary or GI infections. It has excellent outcome with complete resolution usually within 6 months. May occasionally involve skin, eyes, oral or genital mucosa.
JUVENILE ARTHRITISThese are a group of arthritis in children less than 16 yrs of age many subtypes like polyarticular, oligoarticlar, systemic onset etc. Early identification and aggressive treatment is needed to prevent joint damage. About 50-60% of children will continue to have arthritis even after reaching adulthood.
PSORIATIC ARTHRITISIt is arthritis in association with psoriasis (a skin disease) which may mimic rheumatoid arthritis or ankylosing spondylitis.
VASCULITIS like SLE , these are multisystem diseases, but much rarer, which are often fulminant but remain unrecognized because of different organ involvement and lack of awareness. These are primarily an immunological diseases of vessels, and can involve skin, joints, heart, lung, brain, kidney, eyes, nerves, limbs, etc. Different types of vasculitis affect different blood vessels in different parts of body. High dose steroid is often needed for control of disease which may lead to loss of organ or sometimes even life.
FIBROMYALGIA Unlike other diseases mentioned above, this is not primarily a joint disease but can lead to similar kind of pain and discomfort. It can cause pain in areas other than joints like muscle, skin, back, abdomen and head, and is often associated with disturbances in appetite, sleep, temperature and anxiety and/or depression. Treatment usually requires drugs used in other neuropsychiatric diseases like depression/anxiety/epilepsy/migraine and must be combined with regular exercise and de-stressing activities like morning walk, yog or meditation.
MYTHS AND FACTS OF RHEUMATOLOGY
Myth Joint pain, per se, is a specific disease known as arthritis.
Fact Joint pain, just like fever and jaundice, is a symptom, and not a disease. It can be due to different kinds of arthritis.
Myth Arthritis is incurable or there is no treatment for it.
Fact Although there is certainly no cure for the arthritis (just like there is no cure for hypertension or diabetes), there are specific anti-arthritis medications which can effectively control the disease.
Myth RA factor is diagnostic of rheumatoid arthritis.
Fact First, the correct term is rheumatoid factor (not RA factor). Second, it is certainly not diagnostic of RA though it is a very helpful test. Some patients of RA may have a negative test, while some normal individuals, especially elderly, can have a positive test despite no evidence of arthritis.
Myth A positive ANA test means SLE.
Fact ANA can be positive in other rheumatic conditions besides SLE and rarely in normal individuals as well.
Myth All patients of arthritis have to take regular painkillers indefinitely or lifelong.
Fact While some patients do have to take painkillers indefinitely, the majority of patients of arthritis do not need them after initial few years when their disease is well controlled by specific anti-rheumatic drugs known as DMARDs. Moreover, some patients have milder disease which can be treated with regular painkillers alone without any serious side effects.
Myth Painkillers are very dangerous drugs with all sorts of serious side effects and should be avoided at any cost.
Fact Painkillers have some minor, some major side effects , some predictable, some unpredictable side effects, like many other classes of drugs , but they are quite effective in rapid control of arthritis symptoms and are safe, if taken for short periods, with proper monitoring and especially in younger individuals.
Myth Most common side effect of painkillers is kidney dysfunction.
Fact Most common side effect of painkillers involves stomach including gastritis, ulcer or even bleeding from ulcer which is especially common in elderly people.
Myth Arthritis is a disease of elderly.
Fact While osteoarthritis, the most common type of arthritis world over, is definitely a disease of elderly, other types can affect individuals of any age including small children.
Myth Like painkillers, steroid is another drug with multitude of side effects, which should be avoided at all cost.
Fact While the first part is true (about side effects), sometimes it is the only drug which works like rapid control of aggressive disease in early phase of rheumatoid arthritis, pregnancy and coexistent liver or kidney diseases . Plus, diseases like SLE, Systemic Vasculitis and Myositis warrant the use of aggressive therapy including very high doses of steroid , sometimes for prolonged periods and even serious side effects of steroids have to be tolerated for brief periods . Thus, the use of either painkiller or steroid has to be decided based on the risk-benefit analysis. When benefit outweighs risk- it has to be used.
Myth Treatment of arthritis also requires strict dietary restrictions with prohibition of foods with high protein content like pulses, milk, egg, curd, cheese etc.
Fact Only gout, and no other arthritis, requires some dietary restriction alcohol and non-vegetarian food ,especially seafood (which have a high purine content) have to be avoided.
Myth In every case of joint pain, uric acid has to be measured.
Fact Again, only gout is caused by elevated levels of uric acid.
Myth If a patient using long term steroid develops an infection, steroid has to be stopped immediately.
Fact While it is true that long term steroid use predisposes to infections and may lead to delayed recovery, and it may be advisable to reduce the dose, it should never be stopped abruptly for two reasons. First, the disease may have a severe recurrence, and secondly, patient may develop severe crisis due to steroid deficiency.