WHEN rheumatoid arthritis strikes

Ravi Gupta

Mridula was diagnosed with rheumatoid arthritis (RA) after the birth of her first child when she was only 25. Stiff, swollen, painful joints, particularly of hands, made even routine movements near-impossible. “Even picking up my baby caused extreme pain,” recalls the Chandigarh-based media professional. “From walking to household work, everything became painful. Popping painkillers became a necessity, but even these brought only temporary relief. There were hardly any rheumatologists at that time though orthopaedicians were able to manage the pain and symptoms. Yoga and stretching exercises helped.”

Within a year, joints of her hands and feet became misshapen. “As doctors had prescribed steroids and disease-modifying antirheumatic drugs (DMARDs), their side-effects caused skin discoloration and it darkened considerably. I started avoiding family gatherings. The emotional trauma of this physical change was so much that I even considered plastic surgery,” recalls Mridula.

Multi-pronged treatment

• Drug treatment in the form of nonsteroidal anti-inflammatory drugs (NSAIDs), sometimes corticosteroids, and disease-modifying antirheumatic drugs (DMARDs).
• Healthy lifestyle, including proper healthy diet, daily exercise and stretching to maintain joint function and mobility, proper sleep and stress-free life.
• Assistive devices like splints or braces may be prescribed by the expert if there is tendency/risk of developing deformities.
• Physiotherapy with modalities like wax therapy, hot/cold packs, joint mobilisation exercises, etc.
• Surgery for improving the function in the form of arthroscopic synovectomy (removal of the inflamed synovium) and ultimately, joint replacement surgery.

The mother of two has to undergo regular medical tests for liver and kidney functions as well as eyes, as side-effects of the RA drugs can affect their functioning.

Time may not have healed everything, but has certainly brought acceptance. “I gained strength to deal with it when I saw others fighting fatal diseases with a positive attitude.” RA may not be life-threatening but it certainly is not easy to live with it life-long, she adds.

Affecting more women than men, rheumatoid arthritis (RA) is a multisystem disorder that can affect joints, heart, blood vessels, lungs, kidneys, eyes, etc. Currently, there is no cure, but symptoms can be manged through a multi-disciplinary approach.

Around 1.3 crore Indians are affected by RA, one of the two common forms of arthritis affecting over 21 crore Indians, a number higher than even diabetes and cancer. The other major type is osteoarthritis (OA), affecting nearly 7 crore Indians.

Because it commonly affects joints too, RA has been named as a type of arthritis. It is an autoimmune disease in which the body’s immune system mistakes its own healthy tissues as foreign and starts attacking them. This autoimmune destruction causes secretion of the inflammatory materials in the joints, causing pain, swelling and destruction of the joints, leading to deformities.

RA can affect any age group and gender but is most common in middle-aged women. Typically, it starts from small joints of hands and gradually progresses to other joints, including spine. If the disease starts during childhood, often it is more severe and is called juvenile RA. Symptoms like fever, weakness, fatigue, etc, are more common in kids as compared to the adult form of RA. Sometimes, it presents only in one large joint like knee when it is known as monoarticular RA. The exact cause of rheumatoid arthritis is still unknown, though it is believed to be caused by both genetic and environmental factors, including family history, age, genetic predisposition and gender.

Since the prevalence of RA is more in the western countries, western diet with a high intake of red meat, saturated and trans fats, a low ratio of omega-3 & omega-6 fatty acids and high consumption of refined carbohydrates, has been associated with an increased RA risk. Smoking also has the potential to worsen the disease.

RA can present itself as a devastating disease in certain cases, while it may be mild in others. The symptoms include joint pain, stiffness, swelling and warmth. These are often more severe after a period of rest and in the morning, characteristically known as morning stiffness. Due to waxing and waning of the symptoms with time, patients can experience periods of remission and relapses, or good days and bad days. If untreated, RA has the potential to destroy the joints, causing deformed joints and disability and thus obstructing the routine daily activities.

The main differential diagnosis of RA from OA is that OA is primarily caused by mechanical wear and tear of the joint surfaces due to ageing, malalignment, overweight, etc. OA is the most common type of arthritis in India and globally due to the increase in the number of the aged population.

Also, RA is amenable to medical treatment before the destruction of the joints as compared to OA, where there is hardly any beneficiary effect of the drugs. Hence, it is important to differentiate between both forms to start the appropriate treatment. Other types of arthritis like gouty and non-gouty arthritis, ankylosing arthritis, psoriatic arthritis, Reiter’s disease, infective arthritis and rheumatic arthritis can also cause similar symptoms. So, if you experience painful joints, it’s best to consult a rheumatologist as early as possible.

The diagnosis of RA is made by proper clinical examination, including a detailed medical history, physical examination, blood tests and imaging studies. Lab tests like rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) antibodies are usually positive, but RA can present itself as a seronegative arthritis also where the RF is negative. Even a positive RF does not always mean RA because RF may be positive sometimes in normal population also. Any lab test should always be interpreted in combination with a clinical examination. X-rays, ultrasound and MRI may be used by the clinicians to know the extent of joint damage and inflammation.

The treatment of RA involves orthopaedic surgeons, rheumatologists and physiotherapists. The goals of treatment are to relieve symptoms, prevent joint damage, and improve the patient’s quality of life. Although RA is not curable, a multi-disciplinary approach has improved the outcomes in recent times and the symptoms can be effectively controlled so that patients can lead a comfortable and quality life.

— The writer is chairman, orthopaedics, Paras Hospital, Panchkula