Managing arthritis with scientific outlook is a great challenge these days-Prof. Prakash Pispati

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 Postgraduate Course in Rheumatology during PSR Conference

Managing arthritis with scientific outlook is a great
challenge these days - Prof. Prakash Pispati

For managing Rheumatoid Arthritis, treatment with DMARDs
should be stated as soon as possible- Dr. Babur Salim

From our correspondent

LAHORE: Prof. Jamshed Nasir Principal Fatima Memorial College of Medicine and Dentistry formally inaugurated the pre-conference postgraduate course in rheumatology during the 22nd Annual Conference of Pakistan Society for Rheumatology held here from April 6-8th 2018.  In his introductory remarks he pointed out that we need greater collaboration between different specialties to share our knowledge and experience. In case of Uveitis most cases are diagnosed by rheumatologists. Once diagnosis is made, treatment is easy and secondary. We need to learn how to make diagnosis.

Prof. PrakashPispati from India was the first speaker who talked about Clinical approach to Arthritis: Differential Diagnosis without a single lab test.  He discussed in detail how to diagnose, what the treatment is, what will be done and how to avoid making any mistakes in future while treating these patients. Patients, he pointed out have different expectations from us. Speaking about how to differentiate between arthritis and rheumatism, he said that if the patient complains of pain, tenderness, pain on active range of motion, clinical cynovitis/effusion, instability, deformity, it is arthritis. If there is monoarticular pain in one knee, find out is it inflammatory or non-inflammatory, look beyond the affected joint, look for extra articular features in monoarticular ,look at feet of the patient  carefully. Detailed history and clinical examination will be extremely useful. To find out is it Gout, put in needle in the joint and aspirate the fluid. It will help in the diagnosis of Gout.


Prof. Nighat Mir, Dr. Ahmed Saeed (Convener) and Prof. Sumaria Farman Raja (President PSR)
photo-graph during the Int. Rheumatology Conference organized by Pakistan Society
of Rheumatology held at
Lahore from April 6-8, 2018.

Continuing Dr. PrakashPispati said that in case of septic arthritis, be mindful of TB Joint. If there are multiple joint involved, rash, ulcer, think of ankylosing spondylitis, pyoderma. Deformity of hands could be due to Gout. He also talked about Crest Syndrome, LUPUS and TB, Scleroderma, APS clinical impact, soft tissue rheumatism and arthritis. Find out is it monoarticular or poly articular, deformity, diabetes mellitus, thyroid, focus on sore throat and miscarriages. Is the patients’ work destabilized by pain?  He concluded his presentation by stating that managing arthritis with scientific outlook is a great challenge these days. Moreover, we have to do this while competing with Hakeem’s and Homeopaths, he remarked.

Dr. Tan TeckChoon from Singapore discussed new approaches to serologic assessment of systemic autoimmune rheumatic disease. He was of the view that we need to understand why tests are done. Good history and clinical examination remains extremely important. He then referred to Anti-nuclear antibody test, in systemic lupus ANA II F are challenges. He also talked about progress on ANA II F test, ANA alternative Assays, recent ANA testing controversies, false positive ANA test, Anti DFS70 test, and ANA testing classical approach in detail. He then referred to ANCA vasculitis subtypes and ANCA testing revisions.


Dr. Babar Salim’s excellent presentation was on challenges in rheumatoid arthritis. These challenges, he stated, may be different in various countries. We have few qualified rheumatologists as compared to the disease burden. It is estimated that about 1% of the world population suffer from rheumatic disorders. We face more than thirty five challenges in this field. A study involving 2100 patients showed that 15% of patients had some rheumatic disorder. The prevalence in Pakistan is reported to be 0.55%. Hence we have about one million patients suffering from various rheumatic disorders. We have just fifty qualified trained rheumatologists, Bangladesh has forty, India has five hundred rheumatologists.  He suggested mandatory rotation of postgraduates in rheumatology and more awareness at the undergraduate level. It is hoped that by 2020 we will have about eighty trained qualified rheumatologists in Pakistan.

Speaking about the cost of treatment, he said that the patient has to pay a minimum of about five thousand rupees per month. We must find out how we can reduce this cost. We also need to follow guidelines. Earlier referral to rheumatologists is necessary. Treatment with DMARDs should be stated as soon as possible. History and physical examination is important but some time serology is also needed. MSK ultrasound can determine early disease and early targeted treatment will reduce the overall treatment cost. It will also prevent irreversible degeneration. Delayed referral to the rheumatologist was yet another important challenge we are facing. It has been observed that early targeted treatment will reduce the cost. In India reports suggest a delay of 18-23 months before referral to rheumatologist. Moreover almost 70% of patients come to rheumatologist after twelve weeks. Early aggressive treatment will be helpful. Methotrexate as the first line of drug was another challenge. We must use effective dose. One must measure the disease and monitor the patient regularly.


On left Prof. Sumera Farman Raja President PSR presenting memento to Dr. Asim Khan from USA
while on right Prof. Kamran is presenting the memento to one of the foreign delegates during the
Rheumatology
conference held at Lahore recently.

Use of steroids mask RA. Irregular follow up and non-adherence to medications are other challenges for which we need more counselling by trained nurses and by the rheumatologists themselves. We also need to educate those family members who are going to give medications to the patients. While treating patient with co-morbidities, like RA with HCV, there will be no difference in antiviral treatment. As regards rheumatoid arthritis during pregnancy, 75% of patients will feel decrease in their pain but after third trimester it goes up after delivery. As regards safety of DMARDs in pregnancy, one must stop them prior to conception preferably three to six months before conception. There are serious risks with all options hence one has to be careful. Lack of biologics, biosimilars, trained nurses, patient education leaflets are some other challenges, he remarked.

Dr. Samina Ghaznavi from Liaquat National Hospital Karachi was the next speaker who talked about erosive arthritis. This, she said, was an old disease of aging. It is also known as degenerative joint disease. In this condition there is a progressive loss of cartilage, followed by osteophytes formation. Osteoarthritis is the most common form of arthritis in the world.  Speaking about the risk factors she mentioned female gender, obesity, advanced age, genetic predisposition, certain occupations, trauma and inflammation. She also discussed its pathogenesis in detail. There is fragments of cartilage, complete loss of cartilage, bone gets exposed.  For diagnosis, history, physical examination and some investigations are helpful. Pain after use, relief after rest is noted.  Knee and hip joints are commonly involved. On physical examination there will be mild to moderate swelling around joints, tenderness at joints, there will be restricted range of movements. He also talked about functional classical systems, radiographic appearance of joints, and loss of joint space. At times synovial fluid analysis may be helpful in making the diagnosis.


Managing these patients, she opined, will need multifactorial approach. First of all one must identify the risk factors, evaluate the co-morbidity, provide pain relief, ensure proper joint functions. Weight reduction in these patients is very important. Use of braces is also helpful. In some cases change of occupations may be advised. Ask these patients to avoid use of stairs, use of narcotic agents, NSAIDs are helpful and at times two NSAIDS are recommended. These drugs will take about four weeks to show their effects. COX2 inhibitors are also quite useful. Calcium, Vitamin D supplements help in pain relief. Steroids injections are anti-inflammatory and they can be used in acute conditions in severe disease. Stem cells, platelets with plasma are some of the new therapies. They reduce inflammation. They have been used for various joints.  In some patients some surgical measures may also be taken.  Her conclusions were that history, physical examination, individualized management approach, non-pharmacological therapy is hall mark of treatment while drug therapy is also helpful.


On left Dr. Ahmed Saeed Convener of Rheumatology Conference alongwith Prof. Sumaira Farman Raja
presenting a memento to Prof. PrakashPispati while on right Prof. Abid Farooqui is presenting
mementoes
to two other speakers at the rheumatology conference.

This was followed by another excellent presentation by Prof. Terence Gibson from Guy’s and St. Thomas Hospital UK who is a regular visitor to Pakistan at these rheumatology conferences. His presentation was on soft tissue rheumatism. He pointed out that we doctors have poor understanding of how human body works. Why rheumatologists stick needles into the patients, he asked. Most of these are self-limiting conditions. Patients have great expectations. They at times insist for steroids injections in in their joints. Sometime over use of joints leads to lot of discomforts. Trauma, unaccustomed use of joints, systemic diseases like diabetes mellitus, arthritis, inappropriate footwear, nature of work and certain sports can all lead to soft tissue rheumatism. He laid emphasis on recognition of the cause, modifying or stopping the activity, use of simple analgesics, NSAIDS, Splints or restricted movements will be helpful. Correct foot wear should be advised. Ask patients to avoid using shoes with high heal, raised shoes. Corticosteroids injections are indicted if the pain persists for more than four weeks. Despite the above measures if pain persists, use steroids for injections. Use local anesthetics and mix up with steroids. He also explained the technique of injecting.

In shoulder, the patient may have frozen shoulder, tendonitis, and bicipital tendonitis. Shoulder pain may be due to long standing diabetes as well. Exercise by physiotherapist or by patient himself can be helpful. In elbow he mentioned tennis elbow, tear, inflammation, golfer’s elbow, trauma, inflammatory arthritis. There are specific injection sites in elbow and shoulder. He pointed out that while short term relief can be obtained by these injections but it has some side effects as well. In Wrist, one can suffer from carpal tunnel syndrome, finger flexor, trigger finger are some of the common conditions. Surgical decompression may be needed later on after injections in some cases. In the lower limbs the conditions he mentioned included  groin strain, ankle tendonitis, supra patellar bursitis, anserine bursitis, pre patellar bursitis and plantar fasciitis.  In the Hip area the conditions he discussed included groin strain, hamstring tear. He also showed some slides indicating the injection sites besides talking about the risk of rupture in ankle and foot.  Dr. Terence Gibson further stated that the patients have pain for months, they need immediate relief.  Corticosteroids Injections do help. Look carefully as the footwear may be the cause, he added.

Summing up the session Prof. Jamshed Nasir said that all the speakers have emphasized the importance of detailed history and physical examination. We must avoid the misuse of steroids which can be a serious problem. The patients should be advised to avoid stress, obesity, reduce weight. Rheumatic diseases are increasing and they must be managed properly. Prof. Ghiasun Nabi Tayyab who was co-chairing the session commended the foresight, devotion and dedication of Prof. Nighat Mir for promoting the discipline of rheumatology.

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