What is Rheumatoid Arthritis?
Rheumatoid Arthritis is a common disease which attacks the lining of the S7 joints of the hands and feet, and spreading to affect larger joints. Later, local deformity can occur. In addition it can cause widespread interference in many other systems of the body apart from the joints, and these can probably become life-threatening.
It may occur in either sex, but women are usually affected more commonly. It is found at any age, from childhood (where called Still’s disease) to old age, and as old as 75 have been recorded in medical literature when the disease commenced.
However, the most probable and peak of onset is between 35 and 50 years. About 2 per cent of males and 5 per cent of females may be affected. As age progresses, this tendency increases, so that about 16 per cent of women over the age of 65 show evidence of the disease, either past or present. The cause of the disease is unknown.
Environmental factors such as climate have often been suggested, but the evidence has never been substantiated. Close relatives seem more likely to contract it. The old idea of “focal infection” (such as an infected tooth) has now been completely negated, and is no longer held as a possible cause.
The synovial lining of the joints produces a particular protein during the disease, and this can often be picked up in the blood serum of a patient. It is called “Rheumatoid Serum Factor” (RSF), and is presumptive evidence of the disease, if discovered, but it is not always reliable. It assists the doctor in arriving at a correct diagnosis.
Rheumatoid Arthritis Symptoms
Typically the disease commences insidiously. The joints of the fingers of the hands, wrists, then feet and ankles are affected. From these small joints, it may gradually spread to the larger joints, the ankle, knees, elbows and shoulders, and later the hips. Generally the back vertebral joints are not affected, except those in the neck (the cervical intervertebral joints) and most commonly the topmost one where the back joins to the head. The joints are affected in a symmetrical fashion, which means both hands, both feet etc occurring in unison.
Pain over the joints is the characteristic feature, and this is usually worse in the morning after a period of rest. Movement becomes painful, and even without movement there may be discomfort. The joints tend to swell, and nodules may occur under the skin over pressure bearing joints such as the elbows. This takes place in about 25 per cent of patients.
Where tendons pass through sheaths (as in the wrist), and where this is associated with nerves similarly encased in fixed, non-expandable sheaths, pressure symptoms may occur. This is a relatively common cause of “carpal tunnel syndrome.” The median nerve is compressed in the wrist, producing abnormal sensations in the hand, such as tingling, burning and pain. Relief of the pressure will quickly relieve the unpleasant symptoms. Weakness of the muscles involved may also occur. This situation (commonly called “entrapment neuropathy,” as the nerve is trapped) may also take place at the elbow and knee.
With the progression of time, the joints either gradually or rapidly deteriorate. Bone surfaces may become adversely affected and eroded, and this is often detected particularly in the small joints the fingers, on X-ray examination (an important diagnostic investigatory feature) as the condition continues and advances, reduced activity occurs. Deformity of the fingers, hands, feet and limbs takes place.
It is usually most present and worst in the hands, where a various patterns may develop. Sometimes in severe cases, the muscle tendons that to the various bones will rupture. This has the effect of further reducing the movement of certain parts (such as fingers)
Involvement of other organs.
Quite apart from the local effects on joints, the rheumatic process involves other organs. Often there is a general malaise; the person just does not feel well. Weight loss and vague general un-wellness increases and rises in temperature may occur. Inflammation of the walls of the blood vessels) may take place, and this can produce many widespread problems. A common local sign of this is the appearance of dark brown areas about 1-2 mm in diameter in the nail folds. Nerves may be adversely affected, and neuropathy can take place. This usually affects the lower limbs and may produce alterations in normal sensations (paracsthesia), burning and tingling, loss of sensation and muscle weakness.
The eyes may be affected (and this is relatively common). Fluid production will be reduced, the eye becoming dry and irritable. Almost without fall, anaemia develops. This may be due to a lack of iron absorption, or simply due to the chronic inflammation occurring throughout the body. Many patients are on aspirin or non-steroidal anti-inflammatory drug therapy, and this may produce hidden bleeding in the bowel, and in turn an anaemia that may be worsen as time advances.
Often the spleen enlarges, the lymph. glands of the body swell, the skin becomes pigmented, and the leg may ulcer.(a condition given the name of “Fatty’s syndrome”). Sometimes there can be excessive and cause muscle weakness, greater than would be expected from the arthritis itself. This is referred to as “rheumatic myopathy.” It is very likely to be seen in patients on steroid treatment.
When the disease starts to produce significant symptoms, most patients will seek medical therapy from the doctor, and this is the sensible approach. Several investigations are available that will assist the physician to make an accurate diagnosis. In advanced cases diagnosis is not hard. But in early it is possible for it to be confused with other disorders.
The Erythrocyte Sedimentation test is invariably carried out. This is a test is a useful guide to determine the progress of the disease and treatment. (The higher and persisting the figure, the worse the particular case.) Tests for “Rheumatoid Factor” are positive in about 80 per cent of cases (but negatives can happen)
Rheumatoid Arthritis Treatment
In recent years, considerable progress has been made in developing new drugs for the treatment of rheumatoid arthritis. Each year new ones come onto the medical scene and ach has a useful place in a portion of patients. Much depends on the severity of disease when treatment is initially detected. . At present, as the cause of the disease is unknown, there is no Treatment that will offer a total cure. Often therapy is “empirical,” a case of trial and error with the known available methods. Rest is necessary in acute cases in which pain and swelling (and possibly a tendency to deformity) have taken place. Some cases can produce acute symptoms in a very short span of time. Others will develop slowly.
Bed rest for the patient for a short time and rest of the affected joints may relieve pain, and prevent the development of early deformities. Splints and supports may be advised in conjunction with skilled physiotherapy if the case warrants it. However, this must not be overdone, for in itself it may produce muscle weakness and may be psychologically bad for the patient. So care and discretion are essential.
The Use of Medication
More commonly, a less acute situation will be encountered. The popular method of treatment is based on the relief of pain. Analgesics (pain-killers) are widely used. For many years (even decades) aspirin was the sheet anchor of therapy, but this has been replaced by a family of drugs collectively known as the NSAIDs short for non-steroidal anti-inflammatory drugs. (Steroidal drugs refer to cortisone-type drugs also used for arthritis, but only in exceptional circumstances.) The first non-steroidal came to light several years ago, but have now secured their place as the most widely prescribed form of medication.
Most arthritics will he familiar with the different generic and trade names, and many will have already tried various members of the family. Ubuprofen (“Brufen,” “Rheumacin”), ketoprofen (“Orudis”), Naproxen (“Naprosyn”) and fenoprofen are the well-known propionic derivatives. They give excellent results in many cases. Other NSAIDs include sulindac (“Clinoril”), piroxicam (“Peldene”), diclofenac (“Voltaren”), indomethacin (“Indocid”), which was one of the first anti-inflammatory. Probably the very first of the new breed, phenylbutazone, which appeared in the early 1950s, proved effective and carved a name for itself in therapy, but due to a 155 large number of unacceptable side effects, it is now rarely used for ordinary arthritis therapy.
Aspirin in its multiple forms is still used, and produces good results. Today, most prefer large-dose tablets, often “enteric coated.” This means they dissolve in the intestine rather than the stomach, and produce fewer adverse side effects. Aspirin in 600 mg strength forms includes “ASA Arthritis Strength,” “SRA,” “Ecotrin” and others.
The NSAIDs are effective in reducing pain and swelling in joints. However, most have some adverse side effects. Most cause stomach irritation and are notorious for producing nausea, vomiting and bleeding and sometimes ulcer formation and even stomach perforation. There is a very small risk of causing blood disorders. For these reasons, they are usually taken with food and closely monitored by the doctor. Checks should be made regularly to make certain there are no serious adverse effects.
There is almost a never-ending range of medications, and these will continue, for arthritis represents such a vast market, with millions of persons affected. The fenrnates, mefenarnic and fiufenamic acid, have their uses.
The chioroquine derivatives have been in use for some years, but they may produce side effects affecting the intestinal system, eye and hair (loss of pigment in some patients).
Penicillamine was introduced relatively recently, but due to its cost and severe side effects it is reserved for severe cases not favourably responding to simpler forms of treatment.
In the past few years there has been renewed interest in the use of gold salts. Not long ago an oral form, which offers considerable help to many, became available. It is called aurantofin (“Ridaura”). Gold injections were widely used 30-40 years ago, and then fell into disfavour. This was largely due to their very unpleasant side effects and some deaths. However, a reappraisal shows that a careful approach to their use can indeed produce excellent res. Some major clinics now use them routinely, provided that adequate blood t ,”monitor” their effects, and skilled supervision is used, it is given by injection every one to two weeks and the do: tailored to the patient’s needs and response. Rashes, skin eruptions. blood abnormalities and other side effects may occur.
The corticosteroid family of medication have been around now for four decades, and they predictably reduce inflammation and pain, often dramatic manner. It is often given in the form prednisone or prednisolone; tailored to the patient’s needs by the doctor. It is used when the disease advances remorselessly, or when breadwinner is placed in a position where he is simply not getting better. economically he is in a serious plight.
Surgery has found a very definite important place in the treatment of rheumatoid arthritis. In fact, large number: patients once confined to bed and the of a cripple can now walk without pain due to surgical replacement of the hip joint. A variety of compounds have been used for the artificial prosthesis. Excellent results are usual. The same kind of surgery has been applied to knee replacements and which carried out frequently. The results are not quite dramatic, for the mechanics of the knee joint are different and extremely difficult to cope with. But many good results are on record and the numbers are increasing each day. Even more recently, orthopaedic surgeons (now in conjunct with biological engineers) are devising ways of replacing many other joints, such as the wrist, shoulder and others.
Besides all this, general therapy is often used in conjunction with drug therapy. Iron and folic acid may be needed correct anaemia. Drugs aimed at reducing tension and depression, removing excess fluid (diuretics) or helping sleep ma: on others. The rest will remain with the disease in varying degrees, more or less dependent on therapy and the assistance of others, probably for the rest of their lives. Fortunately, most cases of arthritis are mild, and do not become excessively crippling.
ESR a Good Index
It is always hard for the doctor to give an accurate assessment of what will happen in any given case. However, the “ESR” is often a reliable index. If it is high only in the first 12 months, it is of little prognostic significance. But if it remains continuously high late in the disease, then the outlook is more unfavourable. Many patients with modified forms of the disease tend to treat themselves, seeing the doctor at intervals for a general check on progress and to obtain prescriptions for renewed supplies of medication. It is good to keep in touch with the doctor when under medication and to report any abnormal symptoms, for this may be the start of serious toxic effects. Continual unsupervised medication is not wise.