The pattern of joint involvement, the patient’s age and gender and the medical and family history all provide clues to the type of arthritis an individual patient may have. The spectrum of severity is enormous and the treatments vary accordingly. Some patients may have a mild form of arthritis and rarely require medications. Others may have a more severe condition that requires drugs to help slow down progression and ease the classical symptoms; pain, swelling and stiffness.
An important general principle is to make a diagnosis early so that treatment can be initiated promptly, if necessary.
Here are some of the more common types of arthritis:
Rheumatoid Arthritis (RA)
Many different joints may become involved, most typically the finger joints, the wrists, the knees and the toe joints. With an inflammatory arthritis such as RA, symptoms are usually worse at rest rather than with activity. Joint pain may disturb a patient’s sleep and there is often a lot of pain and stiffness in the mornings and after periods of inactivity.
RA is a chronic condition, meaning it is long-term and we don’t have a cure. But, it is very treatable and the modern management of inflammatory joint diseases like RA has been one of the great medical success stories over the last 20 years.
Typical drugs that may be prescribed include non-steroidal anti-inflammatory drugs to ease symptoms (such as Ibuprofen, Naproxen, Diclofenac, Etoricoxib) and the disease modifying anti-rheumatic drugs (DMARDs, such as Methotrexate, Sulphasalazine and Leflunomide), which are used to suppress the inflammatory process and prevent joint damage. The introduction of ‘magic bullet’ drugs, which target individual messengers of inflammation, such as TNF, has been a huge advance. These drugs can be used very successfully, though they are expensive and tend to be used in patients with more severe forms of RA.
We generally try to avoid the long-term use of steroids, but they can have a very important role in getting on top of inflammatory arthritis in its early stages. A rheumatologist may offer an intramuscular steroid injection, which will suppress inflammation within 24 hours and ease symptoms quickly. Weight gain and other side effects with this type of steroid administration are unusual.
One of the most significant observations we have learned over the last few years is the importance of early diagnosis and treatment. If we treat RA aggressively in it’s early stages, then patients tend to have a much better prognosis with less chance of future joint damage. Thanks to rapid treatment and using better drugs, the outlook for patients with RA has changed dramatically over the last two decades. Thankfully, the days of joint deformities and joint operations are almost over.
Recommended website www.nras.org.uk
Some patients may have swelling of a whole toe or finger, termed “sausage digit”, other patients may develop inflammatory pain and stiffness of the spine. Treatments depend on the type of joint involvement but are quite similar to those used in RA. Methotrexate, Leflunomide and the anti-TNF drugs can all be very effective. Tendon inflammation may be less responsive to oral drugs and may require injections. Topical treatment of the skin rash has no effect on the behaviour of the arthritis.
Recommended website www.papaa.org
The mainstays of treatment are exercise programmes focusing on maintaining spinal mobility. For patients with a more severe form, anti-TNF drugs – which target the pro-inflammatory messenger called tumour necrosis factor – can be very effective. These drugs are expensive, though they are available in an NHS setting for any patient with severe and unresponsive AS.
Recommended website www.nass.co.uk
A very small number of patients will suffer long term joint pain. Reactive arthritis is usually well controlled with anti-inflammatory drugs or steroids.
Crystal Arthritis, Including Gout
Whereas the aforementioned conditions are mediated through the immune system, gout is caused by the deposition of uric acid crystals in and around joints. Uric acid is a breakdown product of normal purine metabolism and is excreted via the kidneys. Some individuals have an impairment of the kidney’s transport mechanism that handles uric acid, resulting in retention of uric acid in the body.
If the blood uric acid level is high enough, uric acid crystals become deposited in joints and soft tissues. From time to time, the crystals can cause an intense inflammatory reaction within a joint, usually the great toe joint, knee or ankle. These gouty attacks are miserable, patients can barely weight bear and sleep is disturbed. An attack often starts at night and tends to last 2 days to 2 weeks.
For most patients, an under-excretion of uric acid through the kidney is the cause. Genetic factors are important and many patients have a family history. There is also an association with high blood pressure, high cholesterol and heart disease – all these conditions should also be addressed. Higher uric acid levels are seen in patients who are overweight and those who drink too much alcohol. Any form of alcohol can act directly on the kidney to cause increased retention of uric acid. Beer is especially bad as it is also contains purines which are broken down to uric acid.
Alcohol is a much more important culprit than food groups in gout, though offal meats and shellfish also play a role.
Unfortunately, dietary modification (reducing alcohol, offal meat, seafood and other purine rich food groups and increasing dairy produce and taking cherry juice) can only reduce uric acid levels by 10-20% which is not usually sufficient to control gout attacks. There are well tolerated drugs (Allopurinol, Febuxostat) which are very effective at lowering uric acid levels and preventing future gout attacks. Most patients eventually take a long term treatment, but it depends on the individual patient and how often they have an attack. An acute attack is best treated with an anti-inflammatory drug, a short course of steroids or a cortisone injection.
We commonly encounter some important mistakes in the management of gout –
- Don’t rely on a blood test for uric acid during a gout attack, the level can drop into the normal range and is falsely reassuring. Have the blood test after the attack is over.
- Allopurinol is an excellent drug but can paradoxically cause an attack when it’s started. Patients must concurrently take another tablet (preferably Colchicine 500mcg twice daily) which prevents this flare.
- Patients may still have gout attacks during the first few months of treatment because the joint crystals take a while to dissipate – some patients give up on treatment prematurely.
- There is a target blood uric acid level of 350ummol/l, below which the joint crystals dissolve. Patients must have blood tests after treatment has been started and the dose of Allopurinol may need to be increased until the target level has been reached.
Recommended website www.ukgoutsociety.org
There are some associations that include thyroid disease, diabetes and hyperparathyroidism but there is no specific treatment for pseudogout. Attacks are best treated with a short course of an anti-inflammatory drug or a cortisone injection.
The commonest affected joints are the small joints of the fingers, the thumb bases, the hips, knees and great toe joints. Occasionally there are metabolic causes that should be excluded, such as iron storage disease (haemochromatosis).
Unlike the successful advances made in the treatment of the immune-mediated arthropathies previously listed, the treatments for osteoarthritis are limited and mostly depend on symptom relief. Weight loss is crucial for patients with knee OA who are overweight and the use of exercise programmes and foot orthoses to correct biomechanical issues are very helpful. Intra articular injections of steroids or hyaluranate derivatives can be effective and are much safer than generally considered. “3 steroid injections in a lifetime” is a bit of a myth. Hand exercises can be very helpful for patients with difficult hand OA, as can thumb and finger joint surgery. Joint replacement surgery has been a huge advance for knee and hip OA.
Do supplements work? There may be a case for glucosamine sulphate with chondroitin, at the right dose, and fish oils but the scientific evidence is not strong.
Recommended website www.arthritisresearchuk.org