Early aggressive intervention is essential to check joint destruction in Rheumatoid Arthritis - Prof. Tasnim Ahsan

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Early aggressive intervention is essential to check joint
destruction in Rheumatoid Arthritis - Prof. Tasnim Ahsan

Over 60% of patients will have relapse and remission despite
treatment with DMARDs leading to cumulative destruction

KARACHI: Early and aggressive intervention is essential to check joint destruction in Rheumatoid Arthritis. While managing these patients intervene early with Disease Modifying Anti Rheumatic Drugs (DMARDs) which can result in long remission in 10% of patients, another 15-30% will have partial or complete remission but 60% will have relapses and remission leading to cumulative destruction. On can use more than one DMARDs, combination of two or three DMARDs is used in very severe conditions. These patients complain of joint swelling and pain, early morning stiffness. Destruction which occurs is very common in peripheral joints. Involvement of spine can lead to cord compression. Structural damage is cumulative and irreversible and early introduction of DMARDs is crucial in preventing disability.
This was stated by Prof.Tasnim Ahsan, Professor of Medicine and Director JPMC while speaking on management of Rheumatoid Arthritis (RA) at the Rheumatology Workshop organized by the Dept. Of Medicine, Medical Unit-II at JPMC on SaturdaySeptember 22nd 2012. The workshop programme consisted of numerous case presentations by various speakers besides demonstration of physical examination of upper limbs and lower limbs.
Rheumatoid Arthritis, Prof. Tasnim Ahsan said is the most common autoimmune systemic inflammatory disorders which is most common in women but more severe in males. It has genetic susceptibility, smoking, infections, female gender are some of the important risk factors. It is seen more in asbestos, electric and wood workers. The diagnostic tests include RA factor, Anti CCP and ACPA. RA eats up the cartilage and capsule may be ruptured. She also referred to American Rheumatism Association 2010 criteria for RA scores and said that RA leads to joint involvement and one can see acute phase reactions. Talking about clinical presentations, she referred to classic RA, monoarthritis, extra articular involvement, prolonged morning stiffness, low grade fever, weight loss and depression. In Palindromic rheumatism there is sudden onset of RA episode; one or several joints are affected.
Continuing Prof. Tasnim Ahsan said that in monoarthritis large joins like knee, shoulder, wrist and ankles are affected. Extra articular features include anaemia (not related to iron deficiency anaemia) fatigue, neuropathy, vasculitis, scleritis. Renal involvement is not common in RA but it is common in SLE. Pulmonary involvement can be a disease or due to treatment with disease modifying drugs as well. Fely’s syndrome is common in elderly people but usually it is severe. During physical examination one must carefully look at hands, elbow and wrist. There can be bony erosions in RA or it can be due to osteoporosis. Disease progression destroys the joints. Gonimeter is used to check shoulder joint deformity. As regards physical findings, early involvement of footis common; there could be tenderness of MPT joint, lateral drift of toes, tarsal tuner syndrome while hip is involved in very severe disease. Remember hip pain is neither in the back nor on the sides but it is either in the groin or radiates towards the knee. Some RA patients may need surgery for correction of their joint deformity. Despite treatment 5-10% of RA patients she opined will have relentless progression of the disease leading to joint damage and destruction which may need joint replacement. Almost 70% of joint erosions particularly in hands and feet, she said, occur in the first two years which can be seen on the X-Ray. Once joint is destroyed, noting can be done except replacement hence one must start treatment before boney erosion takes place, she remarked.
These patient, she further stated, are at risk of increased infection. She described in detail the natural history and progression of RA, disease severity from Class I-IV besides discussing grades of tenderness wherein in grade one patient complains of pain, in second grade pain is accompanied with wince while grade three consists of wince and withdrawal while in the fourth grade the disease is very severe. Red joint, Prof. Tasnim Ahsan said should send alarm signal. Disease activity is a destructive process which leads to irreversible damage and it must be distinguished. Disease could be mild, moderate, severe and in remission stage.
Speaking about management of RA, she opined that disease activity is an inflammatory process which leads to joint damage of joint failure and both leads to disability. Every patient should be treated with DMARDs as soon as possible. One often sees that these patients are kept on NSAIDS for months and years. It is better to intervene early with one or more than one DMARDs’. Patient education is important. Patients should be advised rest and then exercise, relieve pain before advising exercise. She also mentioned about occupational therapy, nutrition diet therapy and bone protection. In pharmacological treatment she mentioned analgesics, NSAIDs and DMARDs. Do not use more than one NSAID at a time. They give immediate analgesic relief. Some NSAIDS have more cardiovascular complications. Patients not responding to one NSAIDs may respond to other. Give three weeks’ time to drug to show effect before changing it, NSAIDs can be combined with analgesics. DMARDs take two to six months to show full therapeutic effect. Make patients comfortable with steroids, use local steroids injections in case of localized disease. DMARDs are both biological and non-biological. Patientsshould be screened for Hepatitis C before putting them on DMARDs. LFTs, CBC, and latent TB should be looked at. Ophthalmic examination is also important and ensures adequate immunization before starting treatment.
Some of the novel therapies include statins which are being looked at besides Stems cell transplantation. Combination therapy is more useful in active disease and early established RA. Two biological drugs should not be used at the same time. In very severe disease, one might have to use double or triple DMARD therapy. Prof.Tasnim Ahsan suggested limited use of steroids which should be gradually tapered off, always use small but effective dose of steroids. In end stage disease, pain relief and protection of articular structure should be aimed at, she remarked.
Earlier Dr. Umar Farooq practically demonstrated examination of joints. It was pointed out that incase of anterior dislocation shoulder will be hanging while in exterior dislocation shoulder joint will be lifted upward. Ask the patient to flex muscles over shoulder joints, see internal and external rotation of arm, any tear of tendinitis can be easily found out during examination. Examination of elbow joint, hand examination, see for bone changes, soft tissue swelling, deformity, any rash, diabetes, scleroderma, wasting of muscles and ask the patient if he or she has any pain or tenderness. Check for any deformity and assessfunctions’ of hand. General physical examination as well as screening examination was discussed in detail. Some of the instruments used in research and clinical practice were also highlighted. Three cases of SLE were also presented and diagnosis, investigations and management of these cases was discussed. Quick screening, Prof. Tasnim Ahsan said can be done by anybody. Shoulder pain can be due to many things and it is not necessarily a frozen shoulder. To treat it one must know what it is. Once the problem has been localized, local corticosteroids injections can be used which gives excellent results.
The participants were also provided reading material and flow charts about lupus nephritis, lupus cerebritis, and antiphospholipid syndrome. Those who presented cases included Dr. Urooj, Subheen, Rukhshanda, Zeenat Banu while Dr.Nabeela Soomro was to talk about rehabilitation in rheumatoid arthritis and ankylosing spondylitis.

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