Diagnosing Rheumatoid arthritis

Last week I saw a 50 year old lady from the UK and she had a 6 week history of pain and swelling in her right index finger and also toes.  When I examined her I found swelling and tenderness of 1 joint in the right 2nd finger (PIP) and 2 joints of the toes (MTP).  The signs were so minimal and even though she had a high titer positive Rheumatoid factor I did not believe she had full blown rheumatoid arthritis.  I repeated the rheumatoid factor which came back very high and she also had a positive test for anti- CCP.  Although she had minimal symtoms she was classified as early rheumatoid arthritis and we started her on methotrexate .  In this case the positive tests helped the diagnosis. 

Another patients I saw today had a 6 month history of swelling and tenderness of fingers and toes.  Many joints were involved but she had normal ESR CRP Rheumatoid factor and anti-CCP.  She was told she did not have rheumatoid arthritis.  I told her she has definite rheumatoid arthritis and she was started on treatment.  In this case the clinical signs are more important than the blood tests.

Classification criteria for RA (score-based algorithm: add score of categories A–D; a score of ≥6/10 is needed for classification of a patient as having definite RA)‡
A. Joint involvement §
1 large joint¶	0
2-10 large joints	1
1-3 small joints (with or without involvement of large joints)#	2
4-10 small joints (with or without involvement of large joints)	3
>10 joints (at least 1 small joint)**	5
B. Serology (at least 1 test result is needed for classification)††
Negative RF and negative ACPA	0
Low-positive RF or low-positive ACPA	2
High-positive RF or high-positive ACPA	3
C. Acute-phase reactants (at least 1 test result is needed for classification)‡‡
Normal CRP and normal ESR	0
Abnormal CRP or abnormal ESR	1
D. Duration of symptoms§§
<6 weeks	0
≥6 weeks	1

Milk powder can prevent gout flares. Posted by Rheumatologist in Dubai.

"Daily consumption of enriched skim milk powder could help prevent gout flares," according to a proof-of-conceptstudy published in the Annals of the Rheumatic Diseases. "Compared with patients randomized to receive control treatment with simple powdered lactose, those given enriched skim milk powder had greater reductions in flares of gout during a three-month period (P=0.044), according to Nicola Dalbeth, MD, of the University of Auckland in New Zealand, and colleagues." But "there was no difference in flare frequency for patients given plain skim milk powder rather than the enriched formulation, compared with those given lactose (P=0.81)," the study found.

        "In this study, researchers at the University of Auckland in New Zealand looked at the effects of drinking a skim milk powder enriched with two dairy components, glycomacropeptide (GMP) and G600 milk fat extract (G600), on the frequency of gout attacks in 102 people," WebMD (1/24, Warner) adds. "The people were divided into three groups" and "drank either the enriched milk powder, a plain skim milk powder, or a lactose powder mixed with water as a vanilla-flavored shake each day." The study found that "after three months, the frequency of gout attacks dropped in all three groups" but "those who drank the enriched skim milk had a significantly bigger reduction in gout attacks than those in the other two groups."

Knee replacements on the rise.

A new study published online on 17 January in the journal Arthritis & Rheumatism reports that rates of knee replacement surgery in Finland's 30 to 59-year-olds soared between 1980 and 2006, with women being the more common recipients throughout. Lead author Dr. Jarkko Leskinen, an orthopedic surgeon at Helsinki University Central Hospital, and colleagues also report that the greatest increase was among those aged between 50 and 59.

Knee replacement surgery is the common term for partial and total knee arthroplasty, an operation where part or all of the diseased or damaged surfaces of the knee joint are replaced with metal and plastic parts shaped to allow the patient to move the knee normally.

Arthroplasty is often the only treatment option for people who have severe osteoarthritis (OA) of the knee, as Leskinen explained the press:

"OA risk is shown to increase with age and for severe knee OA arthroplasty is a commonly used treatment option when patients are unresponsive to more conservative therapies."

But although arthroplasty has become increasingly more common, we don't have much information on rates among different parts of the population, and its effects in younger patients.

For their study, Leskinen and collegues looked at records of all unicondylar (partial) and total knee replacements performed between 1980 and 2006 in Finland. These records are kept by the Finnish Arthroplasty Registry.

They looked at how incidence rates of arthroplasty for knee osteoarthritis varied by gender, age, and hospital volume.

Their main findings show that:

• Rates of total knee replacement among those aged 30 to 59 went up 130-fold in the 27-year period.


• The incidence went up from 0.5 procedures per 100,000 of Finland's population to 65 per 100,000.


• The fastest rise happenend between 2001 and 2006 (from 18 to 65 per 100,000).


• There was a similar rapid rise in partial knee replacements: from 0.2 to 10 procedures per 100,000 of the population.


• In the last ten years of the study (1997 to 2006), the rate of total knee replacements was 1.6 to 2.4 times higher in women than in men.


• The rates of total and partial knee replacements were highest among 50 to 59-year-olds.

The researchers conclude that their study demonstrates "the rapid increase in incidences of arthroplasty among patients with primary knee osteoarthritis in Finland, especially in age group of 50 to 59 years of aged."

"There was no single explanatory factor behind this phenomenon though some of the growth might be due to the increase of incidences observed in low and intermediate volume hospitals," they note.

Leskinen said:

"Given that younger patients may be at higher risk of artificial knee joint failure and thus in need of a second replacement surgery, long-term data are needed before widespread use of total knee arthroplasty is recommended for this patient population."

In an accompanying editorial, Dr. Elena Losina, of Brigham and Women's Hospital and Harvard Medical School in Boston, Massachusetts, agrees with Leskinen. She writes that total knee replacement is an effective treatment for OA in older patients, those in their 60s, 70s and 80s.

"However, past performance may not guarantee future success, and with an increasing number of knee replacement recipients under 60 years old, more intensive study of arthroplasty outcomes in younger patients is warranted," she urges.

According to the World Health Organization (WHO), osteoarthritis is the fourth leading cause of years lived with disability worldwide.

Experts estimate that around 10 million people are living with osteoarthritis in the US, where over 600,000 knee replacements were carried out in 2009, according to a report from the Agency for Healthcare Research and Quality. A previous study estimated that by 2030 the number of such procedures could grow by over 670% to nearly 3.5 million a year.

Rheumatoid arthritis treatment in Dubai. Methotrexate, an old drug.

Methotrexate is commonly prescribed and effectively used to treat rheumatoid arthritis andother rheumatic conditions. Methotrexate has the potential for side effects, especially if the drug is not taken exactly as prescribed. Safety warnings about methotrexate should be respected. To enhance patient safety, methotrexate must be taken according to directions. Here are 10 important things you should know about methotrexate.
1 – Methotrexate (brand names Rheumatrex, Trexall) is classified as a DMARD (disease-modifying anti-rheumatic drug).
Methotrexate is classified as a DMARD because it decreases pain and swelling associated with arthritis, and also, methotrexate can lessen joint damage and lower the risk of long-term disability. Improvement from methotrexate may be seen at 6 weeks but it may take 12 weeks or even 6 months of treatment for full benefit to be realized.
2 – Methotrexate was approved by the U.S. Food and Drug Administration in 1988 for the treatment of rheumatoid arthritis.
Methotrexate had been used to treat psoriasis and cancer prior to its approval for rheumatoid arthritis. It is also used to treat other rheumatic conditions including:

• psoriatic arthritis
• lupus
• ankylosing spondylitis (peripheral joint disease)
• vasculitis
• juvenile arthritis (some types)

3 – Methotrexate interferes with certain enzymes which play a role in immune system function.
Methotrexate blocks the enzyme dihydrofolate reductase. By doing so, it affects production of a form of folic acid, which is needed for actively growing cells. It remains unclear exactly how methotrexate decreases arthritis activity.
4 – Methotrexate is taken one day a week for arthritis. It is not taken daily like most pills.
Methotrexate is available in 2.5 mg tablets. The starting dose for most adults with rheumatoid arthritis is 7.5 to 10 mg (i.e. 3 or 4 pills). The 3 or 4 pills are taken together once a week (i.e. the same day each week is optimal). As needed, the dose of methotrexate can be increased to 20 to 25 mg each week. Methotrexate is also available in an injectable form which most patients can self-inject.
5 – It’s important to have liver function blood tests every 8 to 12 weeks to look for any liver-related side effects.
Methotrexate can cause abnormal liver function. It’s important to routinely have blood drawn forliver panels so your doctor can monitor for unwanted side effects.
6 – Alcohol increases the risk of liver damage for people taking methotrexate.
The increased risk of liver damage is significant for people who are drinking alcohol while taking methotrexate. Ideally, you should not drink alcohol if you take methotrexate. At most, with your doctor’s permission, you should have no more than two drinks per month.
7 – Other than abnormalities with liver function, the most common side effects associated with methotrexate are nausea and vomiting.
The side effects already named (nausea, vomiting, liver function) may be dose-dependent. If you have any of these side effects, adjusting the dose may eliminate the problem. Many patients experience no significant side effects while taking methotrexate. Other possible side effects include:

• mouth sores
• rash
• diarrhea
• blood count abnormalities
• cirrhosis of liver (rare)
• persistent cough
• unexplained shortness of breath
• hair loss (gradual)
• sun sensitivity

Methotrexate should not be taken by people with known liver or kidney disease and may need to be temporarily stopped before having surgery.
8 – Folic acid supplementation is required if you take methotrexate.
Since methotrexate is a folic acid antagonist, it must be replenished by taking a 1 mg folic acid supplement daily. Folic acid supplementation should also minimize side effects associated with taking methotrexate.
9 – Methotrexate should not be taken if you are pregnant or plan to become pregnant.
Methotrexate can cause serious birth defects as well as pregnancy complications. You should be using some form of contraception while taking methotrexate and for 3 months after you stop taking methotrexate. It’s important to note that although a woman should not take methotrexate during pregnancy, taking the drug does not decrease the chance for future pregnancies. Aman who plans to get his partner pregnant should stop methotrexate for 3 months prior to conception.
10 – It’s important to remind your doctor of all the medications you take (prescription and over the counter). Some medications and natural remedies may increase methotrexate toxicity.

Drugs known to increase methotrexate toxicity include the antibiotic Trimethoprim (Bactrim).NSAIDs (nonsteroidal anti-inflammatory drugs, though often prescribed together with methotrexate, can affect the level of methotrexate. Your doctor and pharmacist will be aware of unsafe drug interactions.

Rheumatologist in Dubai discusses RA treatment updates

Dr. Humeira Badsha, Rheumatologist, Dubai, discussed treatment of rheumatoid arthritis at a noon conference in City Hospital, Dubai Health Care City on January 11, 2012.  Dr. Badsha discussed ways to assess a patient presenting with joint pain, including joint examination, testing such as anti-CCP and Rheumatoid factor, and the use of ultrasound to assess joints.  In addition, she discussed newer treatments for Rheumatoid arthritis including ant-TNF drugs, and the biologicals, and assessing their efficacy through measurements such as das28 scores.  the talk was accredited for 2 CME hours.

TNF drugs do not increase infection risk in arthritis patients

“Patients with autoimmune diseases who begin treatment with tumor necrosis factor (TNF) inhibitors are no more likely to develop serious infections than those who start treatment with conventional disease-modifying drugs,” according to research presented at the American College of Rheumatology’s annual meeting and published online Nov. 6 in the Journal of the American Medical Association. Specifically, “among patients with rheumatoid arthritis (RA) who initiated treatment with a TNF inhibitor, the rate of serious infection requiring hospitalizations was 8.16 per 100 person-years,” whereas “the rate among patients with RA who started on a regimen using a conventional agent had a rate of 7.78 per 100 person-years, for an adjusted hazard ratio of 1.05 (95% CI 0.91 to 1.21), which was not significantly different.”

Fibromyalgia , managing this in Dubai

I see many patients in Dubai whose fibromyalgia is not recognized or diagnosed for years.

What Is Fibromyalgia?

Fibromyalgia is a common condition associated with muscular pain and fatigue. It occurs more commonly in women than in men especially in women of childbearing age.

Fibromyalgia is not a form of arthritis nor is it associated with inflammation. Instead, fibromyalgia is a form of soft-tissue rheumatism, a broad term
including a group of disorders that cause pain and stiffness around the joints and in muscles and bones.

Symptoms and Signs

Widespread musculoskeletal pain is the most prominent symptom of fibromyalgia. Most individuals complain of aching and stiffness in areas around the neck, shoulders, upper back, lower back and hip areas. It generally occurs throughout the body, although it may start in one region, such as the neck and shoulders, and may spread over a period of time.

Fibromyalgia pain has been described in a variety of ways, such as burning, gnawing, aching, or as stiffness or soreness. It often varies according to time of the day, activity level, the
weather, sleep patterns and stress. Most people with fibromyalgia say that some degree of pain always is present. They feel the pain mainly in their muscles.
For some people the pain may be quite severe.

Although the results of a general physical examination usually are normal and individuals may look healthy, a specific examination of the muscles of people with fibromyalgia reveals tender
areas at locations known as tender points. Tender points are areas of the body that are painful when pressed. The presence and pattern of these characteristic tender points separate fibromyalgia from other conditions. People often are not aware of the exact location or even the presence of many of these tender points until a doctor performs a tender point evaluation.

Fatigue and Sleep Disturbances

Most people with fibromyalgia have fatigue, decreased endurance, or the kind of exhaustion felt with the flu or lack of sleep. Sometimes the fatigue is severe and a much greater problem than
the pain. Most people with fibromyalgia experience sleeping problems. Although they may be able to fall asleep without major difficulty, they sleep lightly and wake up frequently during the night. They often wake up feeling tired, even after sleeping through the night. The tiredness can range from listlessness and decreased endurance to exhaustion, and can vary from one day to the next.

Nervous System Symptoms

Changes in mood are a common symptom of fibromyalgia. Feelings of sadness or being down are common and some people with fibromyalgia have depression. People with fibromyalgia also may feel anxious. Some researchers think there is a link between fibromyalgia and certain forms of depression and chronic anxiety. However, any person with a chronic illness -
not just fibromyalgia – may feel depressed at times while struggling with their pain and fatigue.

People with fibromyalgia may have difficulty concentrating or performing simple mental tasks. These problems tend to come and go and are often most prominent at times of extreme fatigue or
anxiety. Similar problems have been noted in many people with mood changes, sleep disturbances or other chronic illnesses.

Other Problems

Headaches, especially tension headaches and migraine headaches, are common in people with fibromyalgia. Abdominal pain, bloating and alternating constipation and diarrhoea (called irritable bowel syndrome or spastic colon) also are common. Bladder spasms and irritability may cause urinary urgency or frequency. Additional problems may be associated
with fibromyalgia include cramps, dizziness, pain in the temporomandibular joint (TMJ), hands, arms, feet, legs or face.

How Is Fibromyalgia Diagnosed?

Fibromyalgia cannot be diagnosed with laboratory tests. The results of X-rays, blood tests and muscle biopsies look normal. Therefore, the diagnosis is based on a careful history and physical
examination. According to the American College of Rheumatology (ACR) criteria, a person has fibromyalgia if he or she has a history of widespread pain of at least three months’ duration, and pain in at least 11 or more of 18 specific tender point sites.

Common conditions that may mimic fibromyalgia include hypothyroidism, lupus, rheumatoid arthritis and infections. These can usually be excluded by examination and laboratory tests.

Because the complaints of fibromyalgia are so general and often bring to mind other medical disorders, many people undergo complicated and often repeated evaluations before they are diagnosed
with fibromyalgia. It is important to see a physician or rheumatologist who knows how to diagnose and treat the condition.

What Causes Fibromyalgia?

The cause of fibromyalgia is unknown.
There are many different factors, alone or in combination, may cause fibromyalgia. For example, factors such as an infectious illness, physical trauma, emotional trauma or hormonal changes, may contribute to the generalized pain, fatigue and sleep disturbances that characterize the condition.
Studies have suggested that people with fibromyalgia have abnormal levels of several of the different chemicals that help transmit and amplify pain signals to and from the brain. Whether these
abnormalities are a cause or a result of fibromyalgia is unknown.
How Is Fibromyalgia Treated?

There is no known cure for fibromyalgia. Patients may be reassured that the condition, while painful, does not damage tissues and that it can be managed successfully in many cases.

Treatment options for fibromyalgia include:

Medications to diminish pain and improve sleep;

exercise programs that stretch muscles and improve cardiovascular fitness;

relaxation techniques to ease muscle tension and anxiety;

educational
programs to help you understand and manage fibromyalgia.


Your doctor can create a treatment plan specifically for you. Some people with fibromyalgia have mild symptoms and need very little treatment once they understand what fibromyalgia is and how to
avoid what worsens their condition. Other people, however, require a comprehensive care program, involving medication, exercise and pain coping skills training.

Managing Fibromyalgia

Frequently, people with fibromyalgia have undergone many tests and have seen several specialists in their search for answers. They often are told that because they look well and their tests are
normal, there is nothing wrong with them. Their family and friends, as well as physicians, may doubt the reality of their complaints, increasing their
feelings of isolation, guilt and anger. You and your family should understand that fibromyalgia causes chronic pain and fatigue. You must take an active role
in managing your fibromyalgia by exercising regularly, educating yourself about your condition, and learning how to implement relaxation techniques and stress
management strategies.