Autoimmune Disease | BJC Health Connected Care

Rheumatoid Arthritis & DMARDs 0

By Dr Irwin Lim, Rheumatologist

When the diagnosis of rheumatoid arthritis is confirmed, it is now standard practice for rheumatologists to commence a disease-modifying anti-rheumatic drug (DMARD) as soon as possible. If there are no contra-indications, the most commonly used medication is Methotrexate.

Unfortunately, patients with rheumatoid arthritis who do not see a rheumatologist are typically not commenced on DMARDs.

One reason may be that general practitioners are not comfortable or experienced in using these medications. Another reason is that there is a lot of misconceptions about these medications. Like all drugs, there are of course, possible side effects and these often scare patients. However, rheumatologists only use these medications when the benefits of the drug clearly outweigh the risks. Education about appropriate use and regular monitoring also reduce any risks dramatically.

In essence, DMARDs are used when the outcome of the disease is bad & the aim of using DMARDs is to prevent this bad outcome.

Rheumatoid Arthritis is a classic example of a disease where effective medication is clearly needed.

Don’t delay. If you have rheumatoid arthritis & haven’t seen a rheumatologist lately, it’s time.

Dr Irwin Lim is a rheumatologist and a director of BJC Health.

BJC Health provides a connected care multidisciplinary team philosophy to deliver positive lifestyle outcomes through a holistic approach to those with degenerative & inflammatory arthritis, tendon injury and lifestyle diseases. Our clinics are located in Parramatta, Chatswood and Brookvale. Contact us.

Posted on: 10-2-2011
Posted in: Arthritis: inflammatory, Autoimmune disease, Medications, Rheumatoid Arthritis

Ankylosing Spondylitis: What is it? 0

By Dr Roberto Russo, Rheumatologist

Inflammatory Back Pain

Ankylosing Spondylitis (AS) is an inflammatory rheumatic condition that is one of a number of diseases that are characterised by inflammation of the spine termed Spondyloarthritis.

The inflammation that occurs particularly affects the sites at which tendons or ligaments join onto bone. The most commonly affected region is the sacroiliac joints, which is where the spine joins onto the pelvis. However, any joint can be affected and, in addition, sites where tendons join onto bone elsewhere are also commonly involved, such as at the insertion of the Achille’s tendon into the calcaneus (heel bone). Furthermore, inflammation can occur at other organs in addition to the musculoskeletal system, such as at the eye, intestines, and lungs.

AS afflicts a small proportion of the population, estimated at about 0.5%, but is commonly under recognized in those suffering with back pain.

Consequently, the average time to diagnosis can be quite long, which some have estimated to be as long as 7 years or more. The ability to diagnose this condition early continues to be a significant challenge despite the fact that the disease has been present in humans for thousands of years, as shown in the remains of three Egyptian pharaohs, and the first specific description of the disease being published in 1693.

Therefore, a current focus in Ankylosing Spondylitis is how to identify those suffering with the condition at an earlier point in their disease course, at which time the condition is termed Axial Spondyloarthitis.

Spondyloarthritis encompasses a group of conditions that share the common clinical manifestation of inflammatory back pain.

These conditions include Ankylosing Spondylitis, Reactive Arthritis, Psoriatic Arthritis, and Enteropathic-associated arthritis.

There are differences between these conditions that may not be evident early in the disease and only become apparent over time. However, the emphasis in this early phase of the condition is to determine the presence of an inflammatory spinal disease, rather than differentiating between these specific conditions.

Ankylosing Spondylitis is the most common of the Spondyloarthritides. The condition is symptomatically more common in men, with the usual age of onset being in the 3^rd and 4^th decades of life (average age at onset is 26 years). It is unusual for the disease to commence after the age of 50.

Overall, AS is more common in the Caucasian population. There is a familial predisposition to the disease, whereby the risk of developing AS is increased if a first degree relative is affected, especially if HLA B27 (a genetically determined cellular marker) is present.

The consequence of the inflammation present within the spine and other musculoskeletal structures is subsequent uncontrolled increase in bone formation that results in stiffening and ultimately fusion of the joints.

It is this process that gives the condition its name of Ankylos – Greek (Gr) for stiffening; Spondylos – vertebra (Gr); itis – inflammation (Gr).

The fusion that occurs in the spine commonly causes the affected to have a stooped (flexed hip) posture, that ultimately has a significant impact upon their ability to look forward and walk.

Dr Roberto Russo is both a rheumatologist and a nuclear medicine physician, as well as a director of BJC Health. BJC Health provides coordinated, comprehensive, and colocated multidisciplinary care to achieve effective solutions for patients. We call this model of care, Connected Care. Our clinics are located in Parramatta, Chatswood and Brookvale. Contact us.

This blog focuses on musculoskeletal disease, healthcare in general, and our Connected Care philosophy. Read More.

Posted on: 09-29-2011
Posted in: Ankylosing Spondylitis, Arthritis: inflammatory, Autoimmune disease

Enthesopathy: If it’s not overuse, then what could it be? 0

Google images: Oxford Medicine Online

By Dr Roberto Russo, Rheumatologist

In my last post I introduced the enthesis, explaining that it is the site where the tendon (or other soft tissues) joins onto bone (hard tissue) to transmit force, which is either wanted or unwanted. In addition, I highlighted the close relationship between the enthesis and surrounding structures, such as the bursa and fat, forming what is known as the enthesis organ.

I wish now to bring that discussion forward and draw your attention to when things go wrong.

It is a simple concept to consider that when the forces put through an enthesis are larger than what that structure can withstand, then injury must follow. This is in fact true, and this form of enthesopathy is termed mechanical.

This is often encountered in the sporting population or in those who perform a repetitive task under load. However, I should point out that in this situation the enthesis is less likely to fail than the adjacent tendon or ligament, such that this population is more common to experience a tendon injury, termed a tendinopathy, or a ligament strain or rupture.

So if it is not mechanical, then what could it be?

As a Rheumatologist I wish this question were more frequently considered. That is because there are a number of medical conditions that can affect the enthesis, including most commonly a number of rheumatic diseases and a range of metabolic illnesses such as diabetes, high cholesterol, and other endocrine disorders.

Of the rheumatic diseases, a group of related conditions termed sero-negative arthropathies are characterized by inflammation/injury of the enthesis, termed enthesitis. They are termed sero-negative because those affected do not have an antibody in their blood called Rheumatoid Factor, which is seen in about 70% of those afflicted by Rheumatoid arthritis (which is also a condition associated with enthesitis). Other rheumatic diseases where enthesitis occurs include the arthritis caused by crystals, such as gout, and even osteoarthritis.

The sero-negative arthropathies are comprised of Ankylosing Spondylitis, Psoriatic arthritis, Reactive arthritis, and Enteropathic arthritis. Although as mentioned, they are related by the fact that Rheumatoid Factor is absent they also often share a genetic marker termed HLA-B27. This genetic marker is present in about 90% of those with Ankylosing Spondylitis and about 50% of those with Psoriatic arthritis. However, HLA-B27 is present in up to 10% of the ‘normal’ population and so there are other factors at play that will determine who will develop one of these diseases and who does not. What these factors are exactly is not as yet known, although an environmental agent is probably involved, which is most likely to be an infection (despite the fact that a specific causative infection has not been found). Therefore, the current idea is that these conditions develop in a genetically predisposed host who encounters a particular environmental factor at a time that is just right to trigger the disease.

So why does this sequence of events lead to an immune attack against the enthesis?

Well there are a number of theories but none that are certain. The most popular is that there is a similarity between the factor that triggered the disease and the structure of the enthesis attracting the attention of the immune system.

Whatever it is, what is certain is that the inflammation and injury that occurs at the enthesis results in pain and swelling, such that when the question is asked ‘if it is not mechanical, then what could it be?’; the answer ‘a rheumatic disease, such as a sero-negative athropathy’ should soon follow.

This blog focuses on musculoskeletal disease, healthcare in general, and our Connected Care philosophy. Read More.

Posted on: 07-22-2011
Posted in: Ankylosing Spondylitis, Arthritis: inflammatory, Autoimmune disease, Psoriatic Arthritis, Tendon & Ligament

Rheumatoid Arthritis: What is it? 0

By Irwin Lim, Rheumatologist

One of the major diseases we have expertise in treating in BJC Health is Rheumatoid Arthritis (RA). I thought it was time to explain to you what RA is.

RA is an autoimmune disease.

Normally, your body’s immune system helps fight off infections, keeping you healthy. With an autoimmune disease, this very complex immune system becomes a little disordered, resulting in some healthy tissues in the body being attacked.

In rheumatoid arthritis, the immune system attacks the lining of the joints, a tissue called synovium. This leads to inflammation and joint damage.

While research into causes of rheumatoid arthritis are advanced, we still do not know the exact reason why the immune system does this.

RA is common.

About 1% of the population is affected with this disease. Rheumatoid arthritis tends to run in families. It is more common in women (see Women’s Insights into Rheumatoid Arthritis), occurring twice as frequently as it does in men. Smoking clearly increases the risk of developing rheumatoid arthritis, and leads to more severe disease.

RA causes pain, stiffness & swelling of the joints.

Typically, the smaller joints, such as those in the hands and feet are affected earlier. However, larger joints such as the hips and knees are also often involved.

RA causes suffering & loss of function.

In many patients, rheumatoid arthritis is a progressive illness that may cause joint destruction with reduction in a person’s functional ability. This may mean difficulty with simple daily tasks such as gripping or dressing, or it may mean pain with walking. Simple activities we usually take for granted.

RA requires early referral & treatment.

This is a disease that really benefits from early intervention. Early diagnosis followed by early, effective treatment prevents much of the joint destruction and deformity. As a result, early referral to a rheumatologist is crucial to avoid missing this period, known as the window of opportunity.

Rheumatoid Arthritis is a serious disease.

It’s not “just arthritis”. There’s a good chance you’ll know someone with this problem & hopefully, this post will help you understand a little more about what they’re going through.

Dr Irwin Lim is a rheumatologist and a director of BJC Health.

This blog focuses on arthritis-related diseases, healthcare in general, and our Connected Care philosophy.

Posted on: 05-24-2011
Posted in: Arthritis: inflammatory, Autoimmune disease, Rheumatoid Arthritis

Ankylosing Spondylitis: “Wonder Drugs” do exist! 2

By Irwin Lim, Rheumatologist

It’s (almost) true. Yes, doctors do tend to prescribe medications, and all medications have potential side effects. However, this is one example of medication which is truly life changing. In this case, the benefits can far outweigh the risks.

Ankylosing Spondylitis (AS) is a chronic disease characterised by inflammatory low back pain and stiffness. Over time, this spinal inflammation leads to progressive spinal restriction, with pain, deformity and loss of the ability to perform the daily activities that we take for granted.

The whole spine can be involved. The disease can also target other areas, including arthritis at the joints of the upper and lower limb (commonly at the hips or knees). It can cause inflammation of the eye (uveitis), and inflammation at the region where tendons insert into bone (enthesitis). The lungs, heart and gastrointestinal tract can also be affected.

For many years, treatment was limited to exercise and anti-inflammatory medication (NSAIDs & Cox-2 inhibitors). These remain very useful. However, a significant number of patients have persistent, debilitating symptoms.

Tumour necrosis factor-alpha (TNF) is a potent chemical (cytokine) produced by the immune system. TNF seems to be a key player in causing the manifestations of Ankylosing Spondylitis. Drugs which block the action of TNF have essentially revolutionized the management of AS.

And yet, many patients and doctors remain unaware of these new biologic agents as highly effective treatments for rheumatic disease. This is a shame as in AS in particular, they are life-changing.

In Australia, the TNF inhibitors available for use in Ankylosing Spondylitis include Infliximab, Etanercept, Adalimumab and Golimumab. Infliximab is given by intravenous infusion while the other 3 are self-administered injections.

These are powerful drugs, with their own set of problems. The cost is prohibitive, currently more than A$20,000 a year. They have a range of potential side effects, some nasty, such as severe infections.

And yet, in most cases, the benefit greatly outweighs the risk.

Patients respond quickly, sometimes within a week. The improvement is usually marked, and most importantly, patients report a vast improvement in quality of life.

Often, to a degree they didn’t think possible after years of suffering. Ask an AS sufferer who responds to these drugs, and the person will very likely agree that “wonder drugs” do exist.

If you suffer from Ankylosing Spondylitis, please go and find out more. Use the internet. See a rheumatologist. Things have changed a lot.

Dr Irwin Lim is a rheumatologist and a director of BJC Health. BJC Health provides coordinated, comprehensive, and colocated multidisciplinary care to achieve effective solutions for patients. We call this model of care, Connected Care. Our clinics are located in Parramatta, Chatswood and Brookvale. Contact us.

This blog focuses on musculoskeletal disease, healthcare in general, and our Connected Care philosophy. Read More.

Stop Press: For Physiotherapists only. Attend the BJC Health Professional Development Seminar on February 20, 2011. Register to attend and link or join the professional page on Facebook. Our Hootcourse will also be online soon. Details on Facebook.