December, 2010 — BJC Health Connected Care
Rheumatoid Arthritis: Don’t miss the Window of Opportunity
I can’t allow 2010 to end without mentioning the importance of the window of opportunity in the treatment of Rheumatoid Arthritis.
TIME (wasted) = JOINT (damage)
Rheumatoid Arthritis is a chronic inflammatory disease of the immune system, attacking joints primarily.
This disease causes progressive joint pain, stiffness, swelling, difficulty in use and then ultimately, destruction and deformity of the joints.
This path occurs with untreated disease.
It has become clear, through many scientific trials, that early diagnosis, followed by aggressive treatment, can alter this natural history of rheumatoid arthritis.
This window of opportunity is thought to exist in the first few months of the disease.
It is therefore crucial that patients are referred to and assessed by a rheumatologist as early as possible.
If the diagnosis of rheumatoid arthritis is made, treatment will typically be commenced early with the aim of achieving remission as soon as possible.
Rheumatologists now have access to highly effective medications, and we also understand the importance of regular monitoring, measuring disease activity and treating a patient with rheumatoid arthritis holistically.
The aim is to avoid unnecessary pain and suffering. The end result we want to avoid is crippling joint disease.
Don’t accept that “it’s just arthritis”. Please seek attention early.
The Disease of Kings, and the King of Diseases: Gout
For Christmas Eve dinner, our family congregated at Café Opera, in the Intercontinental Hotel for a scrumptious seafood buffet. Going to a buffet is a little bit evil, as you know that you’re about to commit the sin of gluttony.
I usually tell my patients who suffer with gout to avoid buffets. That 3rd mountain of prawns may precipitate an acute episode of gout. Christmas party season is a dangerous time.
Overindulgence in rich food and wine has long been thought to be the primary cause of gout, a little inaccurately. Gout had been referred to as “the disease of kings, and the king of diseases” on the misperception that it was the joint disease of wealthy men.
Gout is a very common cause for episodic joint pain and swelling. The pain can be severe, with the joint becoming red and hot. Most commonly, the big toe is involved but most other joints can be affected.
In patients who develop recurrent episodes over a long time, chronic joint destruction can occur with a more constant pain pattern.
Gout is classified as crystal arthritis. The crystal, monosodium urate monohydrate, is very irritating to the lining of the joint. The larger a person, the more urate the body produces.
Up to one third of the urate comes from what you eat and drink, and many sufferers try to avoid various foods, often without success unless they really love their seafood and offal.
In many cases, addressing the elephant in the room would also be useful: alcohol, alcohol, and alcohol. Apart from weight loss, this is the most important modifiable factor. It’s often proves very hard to convince your typical middle-aged male drinker to reduce their alcohol intake in a significant way. In the USA, the excessive soft drink intake needs to also be addressed as the high levels of fructose (corn syrup sweetener) increase risk of gout. This isn’t a big issue in Australia as soft drinks typically use sucrose (cane sugar, and this doesn’t have a similar effect) instead.
Dietary modification has a clear place however, in complementing weight loss measures, and in helping the many patients with gout that have coexisting high blood pressure and high levels of cholesterol/triglyceride.
Younger patients, predominantly male, with gout, typically have a different reason. They are typically under-excretors of urate and may to a much lesser extent, be over-producers of urate. This means that they don’t get rid of enough of it through the kidneys and/or make too much of the urate. Such patients typically get severe disease and typically end up with joint deformity and chronic pain. Amongst the hardest patients to treat due to this genetic predisposition are Maori and Polynesians.
I want to draw attention to this disease because it is essentially a “curable” arthritis. If the amount of urate in the body can be lowered sufficiently, the episodes of acute joint pain and swelling will stop, and the risk of chronic joint damage will be substantially reduced.
Combinations of alcohol reduction, some dietary modification, weight loss, and for most, urate-lowering medications can make a huge difference to a gout sufferer’s quality of life.
Yet, most sufferers just treat their pain and swelling (often severe and crippling) at the time of the episode with anti-inflammatory medication or rest. In between episodes, little attention is paid to preventing the next episode.
Treatment compliance is also usually poor in the patient groups who develop this disease.
This is compounded by the fact that the urate-lowering medication, most commonly Allopurinol, is a tricky medication to use. Getting the dose wrong and reducing the level of urate too quickly, can paradoxically trigger a severe episode of gout.
It’s regrettable that gout, a disease that we can effectively stop, is often trivialised by both the sufferer and the doctor. “It’s just gout, it’ll be better in a couple of days”. I would argue that in patients with frequent, recurrent disease, that this isn’t good enough.
Sciatica: But it’s not a pinched nerve!
Thank you to all who have sent their well wishes to my wife.
It’s day 3. She’s very much better. M can now walk without crutches and can even sit more comfortably. The numbness at the right foot has disappeared and she has strength at the ankle.
The discomfort has “centralised”. She now has a deep ache at the right buttock, without the right leg symptoms. This is a good sign.
This morning, she had an MRI scan of the lumbar spine. The musculoskeletal radiologist brought us into his room to discuss the findings. Normal. No disc bulge. No pinching of the nerve root. Really good news.
What caused it then?
She was in so much pain, with classic symptoms. Sciatica describes pain travelling from the lower leg to the buttock, and then down the leg. The pain can be described as shooting or sharp. It can be accompanied by tingling, pins and needles, and numbness. While pressure on a nerve root (“pinched nerve”, typically due to a bulge of an intervertebral disc) is a common reason, there are a number of other causes. She could have had piriformis syndrome but the cause remains uncertain.
M’s situation was also quite unusual. Within a couple of hours of the pain moving down her leg, she was assessed by a rheumatologist and a physiotherapist, and she was very promptly commenced on high dose anti-inflammatory medication.
The reason for her pain was also explained to her. I feel that this education and reassurance is very important for a person’s recovery as it alleviated anxiety and helps reduce aggravating activity. The importance of this is often underestimated.
A word of caution. Anti-inflammatory medications need to be used very carefully, as these medications have many possible side effects. While they can be used relatively safely with your doctor’s guidance, this does depend on the other medical conditions you may have.
In M’s case, the doses of her medications are being rapidly reduced. She commenced physiotherapy with Pearce today, our spinal guru at BJC Health Chatswood, and I’m ensuring she does the exercises prescribed at home.
The Xmas party will now be at our home. She still won’t be able to tolerate a 2-hour car trip to the Central Coast. She should however, be able to help, so that I don’t have to do all the cleaning, cooking and setting up!
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.