Revisiting Remedies for Rheumatoid Arthritis

More than 70 million Americans live with arthritis and chronic joint pain.(SEPTIC ARTHRITIS) and crystal arthropathy (GOUT).
Among these, Rheumatoid arthritis claims an understanding of its nature. This is not only because of its widely prevalent status but also because of its chronic course that poses grave mobility restrictions and debility, often limiting the function of our most adroit organ- our hands!

What Is Rheumatoid Arthritis – Epidemiology

It is typically a persistent, symmetrical (involving both sides), deforming, peripheral (hands/feet/ fingers/toes) arthropathy (inflammation of the lining of the joint space – synovium) of presumed auto immune origin that has its peak onset in the fifth decade and afflicts women thrice as common as men.
With a prevalence of 1% world wide, it has a multi systemic nature that can produce diffuse inflammation of the pericardium (outer lining of heart wall), pleura (outer lining of the lungs), sclera (white of the eyeball) and subcutaneous nodules.

Causes Of Rheumatoid Arthrits

The chief biological event is inflammation of the joint capsule or lining – the ‘synovium’. It is triggered by auto antibodies which treat the host’s synovium and various other body tissues (particularly mesothelial linings) as foreign or non self. Numerous factors acting singly or in coherence predispose to such autoimmune damage. The possibility of any of these factors acting as the inciting agent of auto inflammation has not been conclusively proven, however linkages with them appear incessantly in medical literature. Let us take a look at what these factors are.
GENETIC FACTOR – HLA DR4; Some individuals have defective genes which produce ‘this’ defective gene product or ‘protein’ that is expressed on the surface of white blood cells causing them to attack normal human tissues like the synovium or the pancreas.
INFECTIOUS AGENTS- Mycoplasma, Parvovirus B19, Rubella virus and Herpes virus have been implicated in ‘molecular mimicry’ that incites synovial damage.
DIETARY FACTORS- Cow’s milk, cheese, dairy products and glutens from cereals such as wheat and corn have been implicated as strong sources of food antigens that trigger joint damage especially in susceptible (HLA- DR4) individuals. On the other hand, vegetarian diets and salads have been postulated to reduce joint inflammation.

Signs And Symptoms Of Rheumatoid Arthritis

Rheumatoid Arthritis typically starts with swollen, painful and stiff joints of the hands and feet especially in the morning. Gradually as the disease worsens larger joints like the knee and shoulder become involved.
Signs include ‘sausage shaped’ swollen fingers and knuckles initially, followed by ‘Boutonniere’ and ‘swan – neck’ deformities. The thumbs often resemble ‘Z’. Wrist swelling and deformity of the radial head –‘piano key’ appearance occurs as well. Involvement of the cervical spine leads to ‘atlanto-axial’ joint subluxation threatening the spinal cord.

Extra Articular Manifestations

  • SKIN- Rheumatoid Nodule is a typical centimeter sized subcutaneous swelling over bony prominences like knuckles.
  • LUNGS – Pleural effusion and lung fibrosis.
  • HEART-Pericardial effusion and increased risk of heart attacks (MI)
  • EYES- Red inflamed eyes (EPISCLERITIS) and Dry eyes (KERATOCONJUCTIVITIS SICCA)
  • BLOOD (Hematological) - Anemia, Leucopenia,
  • FELTY SYNDROME – Neutropenia with an enlarged liver and spleen (HEPATOSPLEENOMEGALY)
  • BONES- Osteoporosis occurs around inflamed joints
  • CONSTITUTIONAL- Fatigue, loss of appetite, loss of weight, low grade fever, weight loss.
  • NEUROLOGICAL- In addition to cervical spine abnormalities mentioned above, Peripheral Neuropathy (numbness and tingling of skin- glove and stocking type) is known.

Diagnosing Rheumatoid Arthritis

X – RAYS – Typically exhibit increased soft tissue swelling, juxta – articular osteoporosis, decreased joint spaces and later on joint subluxation with erosions.
BLOOD TESTS- RF- or Rheumatoid factor is positive in 80% of the cases. Reduced Hemoglobin (anemia), raised Platelet count (Thrombocytosis), reduced WBC counts (Neutropenia/ leukopenia) and Elevated ESR (Erythrocyte Sedimentation Rate)

Treatment Of Rheumatoid Arthrits

Non Steroidal Anti-Inflammatory Drugs ( NSAIDS ) are paramount in reducing arthralgia and its associated swelling. This group of drugs makes life bearable with Rheumatoid Arthritis. Ibuprofen(ADVIIL,MOTRIN, BRUFEN, IBUGESIC), Flurbiprofen(ANSAID), Diclofenac(CAMBIA), Piroxicam(FELDENE), Mefnemate are members of the NSAID family.
IBUPROFEN is the prototype drug available as MOTRIN, BRUFEN and ADVIL. MOTRIN works by inhibiting the enzyme cyclooxygenase thereby preventing the formation of PROSTAGLANDINS and LEUKOTRIENES which are the harbingers of inflammation and its effects. ADVIL is usually administered on a full stomach in either 200 or 400 mg thrice daily.

Motrin Side Effects

Side effects of Motrin include gastrointestinal adverse reactions such as nausea, vomiting, acidity/gastritis, ulceration, ‘Gastroesophageal’ reflux and diarrhea. Besides, bronchospasm and NSAID induced nephropathy (renal damage) can occur. Drug reactions and hypersensitivity are known.
Notable is the fact that MOTRIN is least likely to cause GastroIntestinal bleeds among all the NSAIDS.

Steroids

These do reduce the rate of progression of bony erosions. However they are usually needed in high doses (Methyl Prednisolone –MEDROL 7.5mg/day) for long periods, which substantially increase the rate of side effects including fluid retention, GI toxicity (worsened with concurrent NSAID therapy) Osteoporosis and Cataract.

DMARD’s (Disease Modifying Anti Rheumatic Drugs)

These agents reduce the rate of damage to bone and cartilage. They can induce remissions but relapses are unpredictable. They are however more toxic in that they can cause liver, kidney, cardiovascular, hematologic damage and even reduced sperm counts.
Examples include Sulfasalzine (AZULDINE), Azathioprine (AZASAN), Ciclosporin, Penicillamine, Hydroxychloroquine (PLAQUENIL) and Methotrexate(RHEUMATREX).

Other Anti Rheumatic Therapies

Other Therapies include exercise, Occupational therapy, Physiotherapy, Splints for the wrist/hand and intra-lesional Steroids.

Therapies In The Pipeline – The Future Of Rheumatoid Arthritis

Tumor Necrosis Factor (TNF), Etanercept and Infliximab are anti cytokines that promise to revolutionize therapy for Rheumatoid Arthritis.

Conclusion - Rheumatoid Arthritis Treatment

Rheumatoid arthritis is a slow poison and many patients would rather succumb to it quickly than live at its mercy in the daily misery of joint pain. The best advice is to learn not to live ‘for’ Rheumatoid Arthritis, but to live ‘with’ it.