Rheumatology – Ask A Doctor

Arthritis is a term that refers to over 200 conditions that may affect not only the joints and muscles but may involve internal organs as well.  Specifically the term refers to painful, tender, or swollen joints.  While many physicians may take care of arthritis, rheumatologists are the subspecialists of internal medicine that care for arthritis.  The most common types of arthritis are osteoarthritis, fibromyalgia, gout, rheumatoid arthritis, and osteoporosis. Others types of the 200 types of arthritis include lupus, scleroderma, myositis, sarcoid; even dabetes and thyroid disease may also have arthritis.

Arthritis is typically classified as inflammatory or non-inflammatory.  Non-inflammatory arthritis tends towards more pain and less swelling, redness and stiffness and includes osteoarthritis and fibromyalgia, and is, which in many respects is more difficult to treat than inflammatory arthritis.  Inflammatory arthritis is also associated with pain but has more prominent swelling, redness, and morning stiffness.  Primarily inflammatory arthritis includes rheumatoid arthritis (RA), lupus, poly and dermatomyositis, sarcoid, Wegener’s granulomatosis, and vasculitis.

Osteoarthritis (OA) or degenerative arthritis usually occurs in patients over 50 years of age and is due to loss of cartilage between the bones.  It is characterized by pain, less than an hour of morning stiffness, mild swelling, and worsens in the evening and made worse with weather changes.  It primarily affects the hands, neck, low back, hips and knees.  There are a variety of potential treatments for OA that are variably successful.  Consult with us for accurate diagnosis and appropriate treatment.

Treatments for osteoarthritis include non-drug and drug therapies alone or in combination,  Non-therapies for OA are graded exercise (especially quadriceps strengthening for knee OA), weight loss (every pound lost reduces pressure on the affected joint), and acupuncture.  Alternative therapies include glucosamine/chondroitin sulfate (variable success) and topical treatments (capsaicin, diclofenac lidocaine patch). Drug therapies, include acetaminophen, NSAIDs, and joint injections.  At the appropriate time, definitive treatment is surgery.  Consult with us for accurate diagnosis and appropriate treatment.

Non-steroidal anti-inflammatory drugs (NSAIDs) have been widely used to treat pain and inflammation (swelling, redness, warmth) for a variety of conditions, primarily arthritis.  NSAIDs, when used appropriately, can provide significant pain relief for a variety of conditions.  Because of NSAIDs risk of causing stomach, kidney, and heart problems, they have fallen out of favor as a primary treatment.  However, when used judiciously and in the appropriate setting, they can provide significant and long lasting pain relief,  .  Consult with us for accurate diagnosis and appropriate treatment.

Recent studies have shown that all NSAIDs are associated with increased risk of heart attack (MI)/storke and should be avoided in patients with cardiac risk factors (hypertension, high cholesterol, etc.) .  However the increased risk was relative (2-3 times more likely risk) as opposed to absolute risk (still less than 5-7%, as 3 times risk times 2% = 6% absolute risk).  Used judiciously they are still successful in treating many types of arthritis including osteoarthritis, rheumatoid arthritis, low back pain, tendonitis/bursitis, etc.  Consult with us for accurate diagnosis and appropriate treatment.

Psoriatic arthritis is an inflammatory-type arthritis that may occur in the hands, neck, low back, sacroiliac (SI) joints, hips, knees or toes that may present before, during, or after the diagnosis of psoriasis (skin rash).  The arthritis may be peripheral (hands, knees, feet) or central (neck, low back, SI joints) and the arthritis frequently flares when the psoriatic skin rash flares.  Although treatments are individualized, the best treatments are sulfasalazine, methotrexate, and the anti-tumor necrosis factor drugs (Enbrel, Humira, Remicade, etc.). Corticosteroids (prednisone) should be avoided.   Consult with us for accurate diagnosis and appropriate treatment.

Osteopenia and osteoporosis describe abnormally thin bones and then those that are at high risk of fracture.  Osteopenic bones have below normal density, with a relatively small percentage at risk for fracture.  Those patients with osteoporosis are at high risk of fracture and need treatment.  The only way to distinguish between normal bone and abnormally thin bone is with a DEXA scan.  Every woman >60 and man >70 should get at least one DEXA which usually paid for by Medicare or insurance and is part of many wellness insurance programs.  Consult with us for accurate diagnosis and appropriate treatment.

The treatment for osteopenia (thin bones) is usually weight bearing exercise, calcium supplementation, and vitamin D supplementation (or replacement if low on laboratory testing.  The treatment for osteoporosis is broad and patient specific and includes the bisphosphonate drugs (Fosamax, Actonel, Boniva, and intravenous Reclast) or the injectable drugs Prolia or Forteo in addition to vitamin D and calcium supplementation.  Consult with us for accurate diagnosis and appropriate treatment.

Risk factors for osteoporosis are weight < 114 pounds, smoking, amenorrhea (loss of menstrual cycle) or premature or normal menopause, vitamin D deficiency, smoking, non-weight bearing exercise, heavy use of PPIs or H2 blockers for ulcers/indigestion, gut problems (malabsorption), low calcium intake, hyperthyroidism or hyperparathyroidism, and low testosterone levels in men.  Fracture risk increases with age - not much we can do about that!?  In the meantime, exercise, supplement appropriately, and stop smoking.  Get evaluated with a DEXA scan.  Consult with us for accurate diagnosis and appropriate treatment.

Fibromyalgia is an all-over-the-body pain syndrome of greater than 3 months duration and characterized by specific tender points and subjective swelling as well as poor sleep/exercise habits .  50% of patients have an inciting event (mental, physical, or psychological event).  Fibromyalgia can be associated with other types of arthritis as well as migraine headaches, premenstrual syndrome, irritable bowel syndrome and other pain/functional syndromes.  Consult with us for accurate diagnosis and appropriate treatment.

There is not one great treatment for all fibromyalgia patients.  Many different treatments are frequently employed.  The first step to best treatment is accurate diagnosis and compliance with an individualized treatment plan that may include cardiovascular exercise, sleep hygiene, improvement, and may include vitamin supplementation, hormone therapy, as well as single/multiple drug therapies with Flexeril, Elavil, Neurontin/Lyrica, Cymbalta, Prozac, Desyrel, and occasionally NSAIDs.  In our opinions, patients diagnosed with fibromyalgia should, in general, avoid narcotics, narcotic-like drugs (Ultram), and polypharmacy (multiple drugs).  Consult with us for accurate diagnosis and treatment.

Rheumatoid arthritis (RA) is an inflammatory arthritis (read pain, redness, swelling, warmth) of the bilateral upper extremities associated with prolonged (>1 hour) of morning stiffness.  The diagnosis of RA is generally confirmed by a positive rheumatoid factor (RF) or anti-CCP, and abnormal inflammatory markers such as an elevated ESR or CRP.  Treatment must be individualized into single drug or multi-drug regimens and includes hydroxychloroquine, sulfasalazine, methotrexate, leflunomide, or the biologic response modifier drugs (Humira, Enbrel, Actemra, Cimzia, Orencia, Rituxan).

Sarcoid is an inflammatory condition that can involve any organ of the body including the lungs, liver, and eyes as well as the skin and the joints.  The diagnosis is typically made by biopsy of the involved organ or a combination of symptoms/laboratory findings.  Initial treatment is usually aggressive steroid therapy and steroid sparing drugs such as azathioprine, methotrexate, leflunomide, or an anti-tumour necrosis drugs (Humira, Remicade),  There are few studies to base recommendations on, so therapy must be individualized.  Consult with us for accurate diagnosis and appropriate treatment.

Lupus is a multi=systemic inflammatory autoimmune disease that primarily affects women.  The majority of patients have skin and/or joint involvement/arthritis as the initial symptoms.  Lupus can spread to the kidneys, brain, heart, lungs, and affect the blood.  The diagnosis is confirmed by blood test, specifically the ANA; however, a negative ANA essentially excludes the diagnosis.  Treatment must be individualized to symptoms/organ involvement and includes corticosteroids, Plaquenil, Imuran, occasionally methotrexate, Cytoxan, IVIG, and occasionally rituxan as indicated.  As in most diseases, early treatment produces the best outcomes.  Consult with us for accurate diagnosis and appropriate treatment.

Dermatomyositis is an autoimmune disease affecting primarily the muscles but also associated with a photosensitive skin rash.  The patient usually has significant weakness of the arm and leg muscles.  Occasionally the typical rash may occur without the muscle involvement (amyopathic dermatomyositis).  If it occurs in patients > 50 years of age, cancer must be excluded. Treatment is initaiated with high dose corticosteroids followed by either Imuran, methotrexate, IVIG, Cytoxan, Ritxuan, or a combination of these therapies.  Consult with us for accurate and appropriate diagnosis and treatment.

Prednisone (corticosteroid) is a pivotal drug that has many and, unfortunately, many side effects (osteoporosis, blood pressure, blood sugar, weight gain, etc.).  Used appropriately it relieves the symptoms of many inflammatory diseases, requiring close supervision for optimum outcome.  Therapy must be individualized but, in general, the target dose should be <10mg/day or less to reduce potential side effects.  If it is taken daily for more than 10-14 days, the prednisone should be tapered under physician supervision.  Every other day dosing reduces side effects but may not provide the best option.  For long term use, alternative (steroid-sparing) drugs should be instituted.  Consult with us for accurate and appropriate diagnosis and treatment.

Diagnosis begins with a thorough history in which the physician may ask about family members with psoriasis, recent stressful events or illnesses, and initiation of new medications.  Next, he/she will perform a physical examination of the skin, hair, and nails to look for red, white, or silvery raised areas of thick, dry, flaky skin on the elbows, knees, trunk, scalp and other areas as well as characteristic nail abnormalities such as thickening, indentations, discoloration, loosening of the nail beds. Finally, to confirm the diagnosis, a biopsy may be performed to look at a small sample of skin under the microscope.

Psoriatic arthritis frequently causes inflammation of the knees, ankles, feet and hand joints.  Typically only a few joints are affected at a time and they may become painful, swollen, hot and red. Inflammation in the fingers/toes may cause swelling of the entire digit, giving them the appearance of a cocktail sausage. Inflammation of the spine and pelvis may lead to pain/stiffness in the back, buttocks, and/or neck, while inflammation of tendon attachments may cause heel/ankle pain (Achilles tendonitis or plantar fasciitis). Rarely, a very destructive form of arthritis called "mutilans” may occur, causing deformity and loss of function in the hands and feet.

In patients with suspected dermatomyositis, evaluation begins with a thorough history and physical examination to assess for muscle weakness and distinctive dermatomyositis-associated skin findings. Next, blood testing may be performed to detect elevated levels of muscle enzymes well as certain antibodies associated with dermatomyositis and other autoimmune diseases. Additional workup may include an electromyogram and nerve conduction study to evaluate the function of the muscles and nerves, a chest x-ray to look for dermatomyositis-related lung disease, or an MRI to detect muscle inflammation. Then, if further workup is indicated, a muscle and/or skin biopsy generally provides a definitive diagnosis.

Dermatomyositis is an inflammatory condition that causes muscle weakness and skin rashes. Although there is no cure for dermatomyositis, treatment options are available to improve the symptoms.  Because autoimmunity plays a role in dermatomyositis, treatment is aimed at altering the immune system.  Initial therapy for muscles weakness usually involves high-dose corticosteroids that are gradually tapered.  After initial improvement, some patients are able maintain disease control with low-dose steroids.  For refractory cases or those concerned about steroid side effects, steroid-sparing agents such as Imuran, Rituxan, or methotrexate are used. For patients with persistent rash, Plaquenil and/or topical corticosteroids may be prescribed.

Skin manifestations occur in nearly one-third of patients with systemic sarcoid, but can occur without systemic involvement.  Erythema nodusum, one of the most common sarcoid skin findings (thought not specific for the disease), appears as tender, red nodules usually on the front of the lower legs.  Lupus pernio, which is sarcoid-specific, appears as reddish/purplish, hard, raised lesions on the nose, ears, cheeks, lips and fingers.  Other skin manifestations include scar-like lesions and ulcers.  Because sarcoid can mimic many skin conditions, diagnosis can be challenging.

Erythema nodusum is inflammation of the fat layer under the skin that results in red, tender nodules that often occur on the front of the lower legs.  The cause of erythema nodusum is usually unknown, but it may be related to certain medications (particularly sufla-drugs, oral contraceptives, and estrogens), normal pregnancy, and infections including strep throat and tuberculosis.  It may also indicate an underlying systemic condition such as sarcoidosis, inflammatory bowel disease, or malignancy. While erythema nodusum usually resolves on its own or after treatment of the underlying cause, NSAIDs or corticosteroids may be used to reduce the inflammation.

Plaquenil (Hydroxychloroquine) is in a class of medications called disease modifying anti-rheumatic drugs (DMARDs), which are used to treat malaria, rheumatoid arthritis, lupus, and other autoimmune/inflammatory conditions. While Plaquenil is a generally safe medication in that it does not require routine lab monitoring like other DMARDs, there is a very small risk that it can cause retinal damage over time. Therefore, an eye exam is required within the first year of starting the Plaquenil and then every 6 to 18 months while taking the medication as recommended by your ophthalmologist.

Corticosteroids are used to treat various inflammatory conditions including  RA, polymyalgia rheumatica, and other autoimmune diseases. They're often very effective in relieving pain and other symptoms of inflammation, but like all drugs they can have side effects. Common ones include insomnia, weight gain, GI bleeding/ulcers, elevated blood sugar, and fluid retention/elevated blood pressure. Steroids can also cause eye problems, osteoporosis, aseptic necrosis, altered immune response, and withdrawal syndrome.  Many side effects can be minimized by limiting the dosage/duration of steroid use. If you have a condition that may benefit from corticosteroids, talk to your physician about the benefits vs. risks.

Gout is a type of arthritis that occurs when uric acid builds up in the blood and causes crystals formations in joints. This can lead to gouty arthritis attacks in which one or more joints suddenly become very painful, red, warm, and swollen. Any joint can be affected, but common ones  include the big toe and other foot/ankle joints as well as hand/wrist joints.  While symptoms usually resolve between flares, some patients develop chronic gout when left untreated. Fortunately, many treatment options are available for gouty arthritis. If you want to learn more, come see us at Madison Medical Rheumatology.

Gout, a condition that causes uric acid crystals to deposit in body tissues, is most commonly associated with painful inflammatory arthritis. However, it can also affect the soft tissues such as skin and cartilage. If uric acid levels remain elevated for a long time, chalky nodules called tophi may begin to form in areas around the elbows, knees, forearms, and ears. As they grow, these nodules can become quite painful and unsightly. Fortunately, treatment with uric-acid lowering drugs such as allopurinol can reverse the development of tophi. If you're interested in learning more about treatment options for tophaceous gout, please call us to schedule an appointment.

Tophaceous gout is a chronic form of gout in which nodular masses of uric acid crystals (tophi) form in soft tissues of the body. Tophi are often unsightly or painful but treatment  is usually very successful and can lead to complete resolution over time; if left untreated, however, tophi can cause irreversible joint erosions. When managing tophaceous gout, the goal is to lower and maintain the blood uric acid level at less than 5 mg/dL.  While several medications (Uloric, robenecid, pegloticase) can be used to do this, allopurinol is considered the treatment of choice for tophi.

Lyme disease is a bacterial infection that is spread by ticks.  It is usually contracted in Northeastern and Midwestern states, not commonly in Mississippi . Early symptoms include fever, headache, and fatigue. Many patients also develop a characteristic rash, called erythema migrans, that appears as an expanding red ring around the the site of the tick bite.   If left untreated, the infection can also cause problems with the joints, heart, and nervous system.  Usually the infection and symptoms can be eliminated by antibiotics. However, delayed/inadequate treatment can cause more serious symptoms which may be difficult to treat.

Erythema chronicum migrans refers to the distinctive skin rash that develops in the early stages of Lyme disease, a bacterial infection spread by ticks.  The rash is often described as a “bull’s eye” because it appears as a small red patch surrounded by a ring of normal skin which is further surrounded by an expanding red ring. This rash usually appears about 7-10 days after the tick bite and may be accompanied by flu-like symptoms. If treated early, erythema chronicum migrans and other symptoms of lyme disease usually resolve; however, if left untreated, arthritis and neurological complications can occur.

Anti-TNFs, or TNF inhibitors, are a class of medications used to treat autoimmune conditions including rheumatoid arthritis, psoriasis, ankylosing spondylitis, and Chron's.  These drugs target an inflammation-causing chemical in the body called tumor necrosis factor (TNF).  Anti-TNF agents are often used in combination with other immune-suppressing drugs such as methotrexate and must be given by injection under the skin or by vein.  Currently, there are five FDA-approved TNF inhibitors: Humira, Enbrel, Remicade, Cimzia, and Simponi. If you have a condition that may benefit from an anti-TNF, talk to a specialist at Madison Medical Group to find out if you're a candidate.

Anti-TNF drugs (Humira and Enbrel) are used to treat inflammatory conditions such as rheumatoid arthritis and psoriasis. While the most common side effect is an injection-site reaction, anti-TNFs can cause other rare but serious adverse effects.  The most significant is an increased risk for infection, particularly fungus and reactivation of latent tuberculosis. Therefore, patients must be screened for TB before starting treatment and should stop taking the drug if fever or signs of infection develop. Because long-term use can also increase the risk of some cancers, it's important to tell your physician about any  personal or family history of cancer.

Anti-TNF medications, such as Humira or Enbrel, can alter the immune system which can lead to reactivation of tuberculosis in a patient who already has the organism in their body.  For this reason, testing for latent (inactive) TB is required before initiating therapy with an anti-TNF drug. Your physician will order a TB skin test, often called a PPD, or a single blood test called a QuantiFERON test to screen for latent TB before prescribing an anti-TNF drug.  He/she may periodically order additional TB tests during treatment since anti-TNFs can also increase your risk of acquiring new infections.

An ANA is a lab test used to evaluate a person for autoimmune disorders by detecting antinuclear antibodies (ANA) in the blood. Your immune system normally produces antibodies to help your body fight infection, but when you have an autoimmune disease your body produces “autoantibodies” that attack your body's own tissues. ANA is a type of autoantibody that specifically targets each cell's nucleus and causes organ and tissue damage.   This test may be ordered if your doctor suspects you have lupus, sjogren's syndrome, scleroderma, polymyositis, or another autoimmune disease.

Though an ANA test is used to help diagnose lupus, a positive ANA does not necessarily mean you have lupus. A positive ANA result simply indicates that your immune system is making antibodies against your body's own cells. There are sub-types of ANA that are specific for different autoimmune diseases such as lupus, sjogren's, scleroderma, and polymyositis. If your ANA is positive, your physician may order additional tests that will help identify the specific autoimmune disorder . It is important to note that about 20% of the normal population will have a positive ANA without showing any signs or symptoms of an autoimmune disease.