Thursday, February 14, 2013

Rheumatoid Arthritis as a Disease of the Whole Body

We aren't happy with calling the disease rheumatoid arthritis or chronic Polyarthritis. I've made some suggestions, how to get more information out of the diagnosis, which only covers one aspect of a multifaceted disease; Link:  @Rawarrior has suggested to call it rheumatoid arthritis disease, which surely would be a step in the right direction; Link:

The Deutsche Gesellschaft für Rheumatologie (German aquivalent of the ACR - American Colloege of Rheumatology) issues the Zeitschrift für Rheumatologie (Journal of Rheumatology). The December 2012 issue is fully devoted to the topic of rheumatoid arthritis as a system's disease.

The editorial stresses, that systemic inflammation is the key factor of quality of life and prognosis in rheumatoid arthritis patients.

C. Baewald and colleagues looked at extraarticulary manifestations of rheumatoid arthritis. They divided into serious and less serious manifestations. Less serious would be sicca syndrome or Ranaud's. Under erious manifestations they count: interstitial lung disease, amyloidosis, glomerulinephritis, peripheral neuropathy, vasculitis, serositis and more. They proposed a two step diagnostic procedure: step one screening and step two specific diagnostic. They went into detail for vasculitis, kidneys, neurologic involvement, skin, eyes, lung, and heart.

S. Kleinert and colleagues presented an overview to the atherosclerotic risk of inflammation in rheumatoid arthritis. The good news is that with controlled disease activity hazard ratio decreases to nearly normal. The bad news is that the risk increases to a hazard ratio of 3.3 in uncontrolled disease activity. They stressed the importance of looking at risk factors in rheumatoid arthritis patients to reduce the risk; that could include prescribing statins and life style changes.

M. Kleinert and colleagues looked at depression as system effect of rheumatoid arthritis. They found prevalence in different cohorts of rheumatois arthritis patients in between 10 and 45%. Early diagnosis and treatment can improve both depression and disease activity! A central factor seems to be learned helplessness and hopelessness. Screening is essential. (I don't screen every patient, but I use the Patient Health Questionnaire, if I suspect depressive mood changes. I shuold do so more often.) Protective factors against depression include social support like friend, relatives, and patient’s organisations. (So Twitter might be more than just exchanging information.)

M. Wahle looked at different forms of anemia in rheumatoid arthritis. In rheumatoid arthritis patients anaemia might be due to inflammation and/or iron deficiency, for instance due to gastro-intestinal loss of blood as an adverse effect of NSAIDs. Good overview for the interpretation of results of less used lab parameters.

M. Rauner and colleagues presented an overview to local and systemic effects on bone. Patients with rheumatoid arthritis have a higher risk of developing osteoporosis. Sufficient calcium intake and substitution of vitamin D deficiency is necessary. (Vitamin D defiency is very common already for the general public in Germany, as Germany is higher north on the map and we don't have fortification of milk or milk like products as soy milk.) Local effects are next to inflamed joints, systemic effects of cytokines lead to systemic osteoporosis. Therapy with bisphosphonates should be started earlier if glucocorticoids are prescribed. In a female patient aged 50-60 with rheumatoid arthritis cut off would be a DEXA densitometry t-score of -3.5, with prednisolone up 7.5 mg daily -2.5 and for prednisolone exceeding 7.5 mg daily one would induce therapy with bisphosphonates already at a t-score of -1.5. (Recommendations might be different in other countries!)

All in all this issue of Zeitschrift für Rheumatologie (Journal of Rheumatology) represents a step further to recognize and promote rheumatoid arthritis as a systemic disease.

No comments:

Post a Comment