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Arthritis
Rheumatoid Arthritis
By Dr. Shafiq Qaadri, MD

Diagnosis

As musculoskeletal problems are so common in family practice, doctors must be aware of the common forms of arthritis, particularly rheumatoid arthritis. An autoimmune disease, rheumatoid arthritis affects women 2:1 preferentially, usually beginning in middle age and beyond.

As with all areas of medicine, early diagnosis will lead to early institution of optimal treatments.
Autoimmune means self-attack--friendly fire--and rheumatoid arthritis leads to erosive destruction of the joint lining, the synovium, leading to inflammation, pain, swelling, stiffness, and later complications of joint damage, malalignment deformities, and disability.

It is important to remember that rheumatoid arthritis is a systemic disease, affecting not only multiple joints of the body, but also potentially leading to a number of diffuse symptoms: fatigue, fever, anemia, and loss of appetite.

To make the diagnosis, a full history, physical examination, and serology are recommended. Once a patient is deemed to have fit the rheumatoid pattern, a diagnosis can be made.

Typically, the initial joints symmetrically affected in RA are the hands, particularly the proximal interphalangeal joints (PIPs), but many joints can eventually be affected—the elbows, shoulders, knees, and so on. Other findings may include rheumatoid nodules, lumps that develop in pressure spots, such as the back of the elbows.

The serological markers of arthritic conditions are complex, and include rheumatoid factor, antinuclear antigen (ANA), C-reactive protein and sed rate (ESR).

Radiographic monitoring of joints is also warranted, to measure the number of joints affected, as well as disease progression.

Breaking the diagnosis of rheumatoid arthritis to a patient can be a challenge, as patients are often fearful of what they perceive to be an inevitably crippling condition.

New to most family doctors, a functional assessment of the patient’s experience with the disease should also be made; and there are a number of questionnaires that itemize this. For example, the patient should be encouraged to rate their pain experience on a 1-10 scale, and this can be used as a guide to the patient’s treatment.

Treatment

Educating patients about the disease process, alerting them to lifestyle modifications and community resources, and offering the full-array of pharmacotherapy options suited to the individual’s needs--all these are important components of optimal treatment.

Part of the incentive of making an early diagnosis of RA is the possibility of beginning the new generation disease-modifying agents early (DMARDs). This can help induce an initially response early, and can also help to delay joint and cartilage destruction. Early treatment may have a potentially stabilizing effect on joint integrity.

Part of good treatment is knowing when to refer an RA patient to a rheumatologist, who can be the team leader in a shared-care plan.

Each patient’s individual pain experience must also be addressed. It is well-known that the amount of joint pathology does not often match the level of pain that the patient experiences. So appropriate titration must be made, and physicians should neither over-prescribe nor under-prescribe stronger analgesics such as narcotics and codeine based preparations.

The non-steroidal anti-inflammatory drugs are the well-known mainstay of RA management at the family practice level. There are many options, including the new generation COX-2 inhibitors such as celecoxib (Celebrex), rofecoxib (Vioxx), and meloxicam (Mobicox). This class of agents is widely used, but there should be continuous monitoring for potential side effects, including gastrointestinal upset, ulceration and bleeding, as well as aggravation of hypertension.

Systemic steroids, which can be quite effective in controlling inflammation, nevertheless can have significant side effects, especially with chronic administration. Intra-articular steroids are also an important treatment option, although the benefits tend to be transient.

Part of the biotech wave and research into the human genome has been the development of “the biologics,” infusable proteins that have become a significant addition to RA management. For example, infliximab (Remicade) is a monoclonal antibody protein which neutralizes the effects of TNF alpha, tumor necrosis factor alpha, which is an inflammatory cytokine, responsible for joint and cartilage damage. By neutralizing the effect of the cytokine, the antibody can potentially ameliorate the RA status, significantly affecting the joint integrity and overall quality of life.

These powerful medications do have considerable side effects and potential toxicities, and are generally used in a shared-care plan with a rheumatologist.

Prognosis

As knowledge of the RA disease process filters to both patients and physicians alike, there has been considerable progress in the management of this condition. Early diagnosis leads to early treatment, preferably before irreversible joint damage has occurred.
Prognosis can depend on many variables: the time to diagnosis, age of onset, family history, the number of joints affected, the rapidity of spread to multiple joints, the degree of joint destruction and malalignment, response to various levels of pharmacotherapy, and systemic and organ effects.
Family physicians in particular should be aware of the array of treatment options—including referral, medications, exercise and community programs--in order to optimize a patient’s prognosis.
Through the development of new generation biotechnology drugs, “the biologics,” targeted therapies are now available, which significantly impact quality of life, flexibility and mobility, and overall prognosis.

Case History One: Evidence-based experience

A 55-year-old lady presents with symmetric swelling in both hands and feet. She notes morning stiffness, pain and swelling developing in her hands, difficulty with dressing, manipulating a pen, and states that things have been getting worse for the past two months. She enjoys knitting and gardening, and believes this has provoked her joint discomfort. She has tried a number of over-the-counter analgesics, with little effect, if any. She has also tried a number of herbal remedies, but has not noted any benefit at all.

HISTORY
The patient’s past medical history is negative. She describes herself as active and vigorous, but has noted that she feels considerably more tired of late. Stairs have become somewhat of a challenge, and she is terrified of “getting old.” She has a reasonable calcium intake, but takes no supplements, but believes she gets enough to keep “my bones strong.” She became alarmed when multiple joints in her right hand became quite inflamed recently, which provoked her to see her doctor. She rates her pain a 7 out of 10.

EXAMINATION
On physical examination, she clearly has multiple active inflamed small joints, both in the hands and feet. She has a weakened grip strength, and the joints are red, hot, and tender on palpation, the right hand worse than the left.

BLOOD WORK & TESTS
Her bloodwork reveals that she has a positive Rheumatoid factor, elevated sed rate (ESR), mild anemia, negative C-reactive protein. X-rays of her hands reveal “possible early joint erosion, especially in the PIP joints, consistent with inflammatory arthritis.”

DIAGNOSIS
A diagnosis of rheumatoid arthritis is made, and the patient is instructed regarding exercise for her joints, hydrotherapy, and it is suggested that she diminish some her activities such as gardening for the time being.

TREATMENT
Various NSAIDs are prescribed over time, and the patient is encouraged to keep on an exercise regimen. She prefers meloxicam (Mobicox) 7.5 mg po bid. Some days are better than others, but she notes that her pain now fluctuates from a 2/10 to 4/10. She is especially grateful that she can return to her cherished activities, such as gardening and knitting. She now subscribes to newsletters of the Arthritis Foundation, and finds it a useful resource for information, programs and group contact.

PROGNOSIS
Her physical examination shows that much of the joint inflammation has diminished and is mostly controlled, and she notes that she tolerates her NSAID well, with no gastrointestinal upset. She has a guarded but good prognosis, and has been alerted to notify her physician of any deterioration, any flare-up, of her condition. She is now attending a monthly meeting of fellow RA patients, and finds it reassuring to realize she is not alone, and that she doesn’t need to suffer in silence.

Case History Two: Treatment Compliance

A 45-year-old lady was diagnosed with rheumatoid arthritis five years ago. She was devastated by the diagnosis, as she always considered herself healthy, and always paid attention to her diet and exercise. In fact, she was quite resistant to the diagnosis, and is somewhat of a do-it-yourselfer.

HISTORY
This lady has had worsening polyarticular pain due to RA, especially in her hands, wrists, elbows and shoulders. She wanted to stay with “natural medicines,” and tried to manage with various over-the-counter preparations. She was finally persuaded to start Tylenol Arthritis pain tablets, I-II po q4h. These had a reasonable analgesic effect for the first year, but her condition worsened, and she began to notice early malalignment of her fingers.

TREATMENT
This lady particularly needed to accept her diagnosis and learn about the chronicity of RA.
Asked to attend an Arthritis Society lecture program, she found it quite useful, especially the discussion with other RA patients.
Based on her discussions with fellow RA sufferers, she requested Vioxx 25 mg once daily. Partly as she was non-compliant, partly due to the GI side effects of the drug, she discontinued the medication after a six months.

REFERRAL
At this point, referral was made to a rheumatolgist, who began the patient on Prednisone 7.5 mg once daily. Again, she had an excellent initial response, but had to discontinue the steroid after three months due to multiple side effects: hypertension, weight gain, and Cushingoid appearance.
X-rays ordered by the rheumatologist revealed revealed mild to moderate erosive joint damage and narrowing of the joint spaces, particularly in the hands.
She was getting quite despondent with “doctors and their pills,” when the rheumatologist began a regimen initially with methotrexate, then with additional infliximab (Remicade).
The patient noted significant improvement in her joint pain, swelling, stiffness—the many markers of inflammation—as well as her general flexibility and mobility.
She is being managed in a team approach between her rheumatologist and her family doctor. Subsequent x-rays show that the methotrexate + infliximab combination has stabilized the joint integrity, preventing further erosion and joint space narrowing.

Dr. Shafiq Qaadri is a Toronto family physician and Continuing Medical Education lecturer. www.doctorQ.ca


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