CLINICAL OVERVIEW AND TIPS FOR MANAGEMENT

RHEUMATOID ARTHRITIS

Rheumatoid arthritis is a chronic ,inflammatory, autoimmune disorder that mainly affects the small joints of the body

Definition

…resulting in pain, stiffness ,deformity and loss of function of the joints involved.

Chronic- symptoms last for several years, with a relapsing- remitting course

Inflammatory- disease process affects the synovial membrane of joints causing bone erosion

Autoimmune-immune system which normally protects the body, attacks its own tissues

Systemic- inflammation may affect other organs such as heart,lungs,blood and blood vessels,nerves etc

Disease Characteristics

Risk Factors

Genetic Factors

• RA has a genetic link, it can run in families

• HLA-DR4 gene may play a role in increasing the risk

• Although, not everyone with this marker has RA, nor everyone with

Gender

• Females are 2-3 times more likely to develop RA than males

• Almost 70% of patients of RA are females

Age

• RA may develop at any age

• More likely to begin in the age group of 40-60 years

Other Factors

Viral and bacterial infections may trigger the faulty auto-immune response

Stress may also precipitate disease activity Hormonal factors females who have given birth or have breast

fed have slightly lower risk . Pregnancy and lactation improve symptoms temporarily

Trauma Smoking increases the risk of developing disease in genetically

predisposed persons Low testosterone level in males may be a predictor of developing

RA in the future

Joint pathology

Small joints like those of wrist and hand are most commonly affected

Chronic Inflammatory process mainly affects the Synovium i.e. the lining of the joints causing joint swelling, bone erosion, and eventually deformity

Signs & symptoms of RA

Bilaterally symmetrical pattern of joint involvement

Small joints of hand and wrist are affected first

As the disease progresses others joints like knee, hip, shoulder, ankle get affected

Pain in joints is the main presenting complaint

Stiffness of joints in the morning or after a period of rest which may last for several hours

Fever Fatigue Weight loss Nodules under the skin of arms,

elbows Symptoms may come and go, and

vary in severity Periods of increased activity or “Flare

ups” are interspersed with episodes of relative remission.

Loss of function of joints and disability

Systemic complications of RA

Anemia Eye: Redness, gritty sensation, corneal damage Skin: fine nodules under the skin, rashes, ulcers Lungs: interstitial lung disease Bones: Osteoporosis Inflammation of small blood vessels called vasculitis Heart and circulatory system: increased risk of Coronary artery Disease,

atrial fibrillation, pulmonary embolism Psychological effects: depression ,anxiety

Diagnostic testsBlood

• Rheumatoid Factor (RF): This antibody is present in almost 80% of patients of RA. some patients of RA may be seronegative for rheumatoid factor

• Anti cyclic citrullinated peptide (anti-CCP antibody) : present in about 50-75% cases. It is useful in diagnosing early cases and more aggressive forms of RA

• Anti nuclear antibody (ANA) : frequently found in RA patients

• ESR and C-reactive proteins: Indicate chronic inflammation and disease activity

Imaging

• X-ray: may be useful in tracking the extent of bone damage over a period of time

• MRI may also reveal evidence of bone and joint pathology

• Bone densitometry: may be used to detect signs of osteoporosis

Objectives of treatment

Reduce inflammation Prevent bone and joint damage Preserve joint mobility Aggressive treatment at an early stage to prevent disease

from becoming severe and chronic Prevent and treat systemic complications Palliative care and rehabilitation in progressive cases

Conventional treatment and adverse effects

Drugs Adverse effects

NSAID’s and other anti-inflammatory drugs Gastritis, G.I bleed

Anti rheumatic drugs (DMARD’s) like Methotrexate

Vomiting, diarrhea, hair loss, abnormal liver function

Anti-TNF drugs Immunosuppression, lymphoma, skin cancer

Immunosuppressants Risk of infection, infertility

Scope of Homoeopathy

• Homoeopathic medicines work by regulating immune system, thereby making them effective in treating auto-immune disorders like RA

• Carefully selected Homoeopathic medicines act as tailor made remedies for an individual patient in contrast to a “one size fits all” approach of conventional treatment

• Symptomatic relief can be achieved with Homoeopathic medicines without any side effects

• The underlying genetic/miasmatic cause is addressed by prescribing an anti-miasmatic remedy

Clinical tips – Homoeopathic management

Actea Spicata- Rheumatism of small joints especially wrist, ankle and toes. Swelling of joints from slight fatigue

Berberis Vulgaris- Rheumatic  symptoms with urinary complaints, rapid change of symptoms  specially in regard to place and character pain in heels. Rheumatic pain in shoulders, arms, hands and fingers, legs and feet. Pain between metatarsal bones ,Pain in balls of feet on stepping. Intense weariness and lameness of legs after walking a short distance.

Clinical tips contd.

Bryonia alba- joints are hot, red and swollen. Tearing pain aggravated by least movement, better by rest. Stiffness of nape of neck

Caulophyllum- pain and stiffness of small joints of fingers ,toes, wrist. Pains are erratic, changing place every few minutes

Causticum- Burning, rawness and soreness of joints with contracted tendons. Ailments from long-lasting grief. Aggravation in clear, fine weather while better by warmth and damp weather.

Cimicifuga- rheumatic pains with stiffness of neck and back

Clinical tips contd

Colchicum- Joints are stiff and hot. Shifting joint pains, aggravated at night. Patient screams with pain on touching the joint or stubbing a toe

Dulcamara- Joint pains induced by exposure to damp cold, aggravated by every cold change and somewhat relieved by moving about and by external warmth

Formica rufa – Pains worse from motion cold & before thunderstorm, better by pressure

Gaultheria- Inflammatory rheumatism Guaiacum- Indicated in acute condition with pain and swelling , also

effective for stiffness, contraction and immobility of limbs. Intolerance to heat and pressure

Clinical tips contd

Kali hydroiodicum- Rheumatism of knee with effusion. Pains at night ,and in damp weather. Better by motion , open air

Kalmia latifolia- Intense pain in joints, changing place suddenly, joints are red and hot

Lac Caninum - Affection of joints with alteration of sides; erratic pains. forgetfulness.

Ledum palustre- affected parts are cold to touch but it is not felt subjectively to the patient. Joints are affected from below upwards and or upper left, lower right. Joint pains worse from warmth, at night; better from cold or icy-cold application.

Clinical tips contd

Medorrhinum- Pains are worse from sunrise to sunset, during thunderstorm and from covering, relief in open air

Phytolacca decandra- Joint pains and stiffness are worse in the morning, shift rapidly ,and worse from motion and at night

Pulsatilla- Pains in limbs shifts rapidly, erratic pains aggravation on beginning to move, better in open air, by cold application, chilliness

Rhus tox- Pain and stiffness of limbs, better by motion, aggravated in cold weather

Clinical tips contd

Stellaria media- Synovitis, pain in shoulder, arms, legs, different parts, shifting pains with stiffness of joints morning aggravation, sharp shifting  rheumatic pains all over with stiffness better evenings , cold air, by motion

Stillingia- Chronic periosteal rheumatism, Worse, in afternoons, damp air, motion. Better in morning, dry air.

General Measures

Regular exercise within the limit of pain to improve muscle strength

Avoid exercise when joints are acutely inflamed

Hot or cold application as required to ease pain and muscle stiffness

Contributors Dr. Anjali Miglani, S.M.O Dr. Anubha Sikka, M.O Dr. Jithesh T.K, C.M.O Dr. Pradip Kumar Roy, S.M.O

Compiled by : Dr. Deepti Chawla, C.M.O, Dte. Of AYUSH, GNCT of Delhi