Arthritis includes a broad spectrum of diseases characterised by inflammation of the joints. The most common forms of arthritis are: osteoarthritis (OA), rheumatoid arthritis (RA), ankylosing spondylitis (AS), gout, psoriatic arthritis (PsA) and arthritis in children, which is juvenile idiopathic arthritis (JIA). Each of these diseases have their own characteristics that include age of onset, sex predilection, joints involved, complications, diagnostic modalities and treatment options.
Diagnosing arthritis
Many a time, symptoms of arthritis are mild and non-specific. Early diagnosis is key to preventing complications, and a high index of suspicion is necessary. A detailed history and physical examination are essential (pattern of joints involved, symmetry, duration of symptoms and other cues) to establish a diagnosis.
Common symptoms of arthritis include joint pain, stiffness of the joints, swelling, limitation of movement, redness over the joints, systemic symptoms such as fever, fatigue, weight loss, loss of appetite and a family history of joint problems.
Once a provisional diagnosis is established based on symptoms and physical findings, appropriate laboratory investigations are necessary to confirm the diagnosis. Common lab tests include: Rheumatoid factor (RF) for rheumatoid arthritis; Anti Citrullinated protein antibodies (CCP) for rheumatoid arthritis; Erythrocyte sedimentation rate (ESR), a marker of inflammation; C reactive protein (CRP), a marker of inflammation; HLA B27 for ankylosing spondylitis; Serum uric acid for gout and joint fluid analysis to look for infections and crystals. Imaging studies include x-rays, musculoskeletal ultrasounds and MRIs of the involved joints.
A combination of symptoms, physical findings and appropriate investigations is essential to arrive at a diagnosis, and mere laboratory reports do not confirm or refute the diagnosis of arthritis. For example: both RF and CCP can be negative in up to 20% to 30 % of patients with rheumatoid arthritis; similarly, RF can be positive in non-rheumatic diseases including in a minority of healthy individuals.
Prevention strategies
A combination of genetic, environmental and other unidentified factors play a role in many arthritis cases. Therefore, not all arthritis can be prevented. However, lifestyle modifications play a significant role in reducing the risk, as well as in delaying the onset and progression of arthritis.
Maintain a healthy body weight: This reduces the risk of developing and progression of osteoarthritis. There is evidence to suggest that reduction of body weight prevents the progression of other forms of inflammatory arthritis as well.
Practice regular, low impact exercises: Exercises that improve muscle strength, flexibility of joints (eg. walking, cycling, swimming, yoga) must be practiced. Avoiding high impact activities, especially in patients with OA, is also recommended.
Avoid smoking and alcohol: Smoking increases the risk of developing RA and worsens its course. Alcohol increases the risk of gout and interferes with treatment of other arthritis.
Use appropriate joint protection techniques: This can be at fitness centres and whenever required. Also use proper ergonomics at the workplace.
Do not ignore joint injuries: Improperly treated ligament and meniscal injuries increase the risk of developing OA.
Dietary recommendations: Avoid red meat, sea foods and fructose-rich foods – in patients with gout. Increase omega 3 fatty acids (flax seed, walnuts, fatty fish) for inflammatory arthritis (anti-inflammatory diet). Consume fruits and vegetables rich in antioxidants (such as berries, spinach, broccoli). Reduce processed foods, excess sugar, trans fats (inflammatory diet). Ensure you get adequate vitamin D and calcium for bone health.
Treatment of arthritis
Early initiation of treatment is essential to prevent the progression of arthritis and joint damage. The aim of treatment is relief from pain and symptoms, prevention of joint damage, restoration of joint function and improvement of the quality of life of the patient.
Treatment options include non-pharmacologic and pharmacologic methods.
Non pharmacologic measures: These include exercise therapy to strengthen muscles around the joint and improve stability; heat and cold therapy to relax muscles and reduce inflammation; assistive devices such as splints, braces and walkers to reduce strain on the joints
Medications: There are a number of medications that are used to help treat arthritis.
Rheumatoid arthritis/JIA: DMARDs (disease modifying anti rheumatic drugs) such as Methotrexate, Sulfasalazine, Leflunomide, Hydroxychloroquine; biological therapy including Etanercept, Adalimumab, Golimumab, Tocilizumab, Rituximab, Infliximab and targeted synthetic molecules include Tofacitinib, Upadacitinib.
Psoriatic arthritis: DMARDs including Methotrexate, Sulfasalazine, Leflunomide; Apremilast; biological therapy such as Etanercept, Adalimumab, Golimumab, Infliximab, Secukinumab, Ustekinumab and targeted synthetic molecules including Tofacitinib, Upadacitinib.
Ankylosing spondylitis: DMARDs including Methotrexate, Sulfasalazine, Leflunomide; biological therapy such as Etanercept, Adalimumab, Golimumab, Infliximab, Secukinumab and targeted synthetic molecules including Tofacitinib, Upadacitinib.
Gout: Pain relief – Non-steroidal anti-inflammatory drugs, steroids, colchicine; uric acid reducing drugs such as Allopurinol, Febuxostat.
Osteoarthritis: Topical NSAIDs such as paracetamol for mild pain; non-steroidal anti- inflammatory drugs.
Interventional therapy consists of joint injections (corticosteroids or hyaluronic acid) and nerve blocks for pain relief. Surgical options include joint replacement for advanced refractory arthritis.
Take home messages
Do not ignore persistent joint pain, irrespective of age. Consult a rheumatologist at the earliest if there is joint pain. Early diagnosis is important to prevent disabilities. Treatment is individualised, and includes a combination of lifestyle changes, medications and physiotherapy.
Arthritis is treatable and most people can lead an active life if diagnosed early.
This article was first published in The Hindu’s e-book Care and Cure.
(Dr. N. Raja is a senior consultant rheumatologist at Naruvi Hospitals, Vellore. raja.n@naruvihospitals.com)
