Tuesday, November 21, 2006

Suffering from Rheumatoid Arthritis ? .....are you getting a raw deal ?

The sad news is that rheumatologists are still treating RA sub optimally. If this is the scenario with rheumatologists (experts), imagine what orthopaedic surgeons and G.P.'s must be doing ?
Rheumatoid arthritis is a chronic debilitating condition that causes an inflammation of multiple joints. It is an autoimmune disorder, i.e. the body's immune system attacks the joints.

Today RA can be treated effectively and successfully. By current standards patients should have high expectation from treatments and most patients should be doing well. But, in India this is far from true. Literature reveals shocking information. The so called experts are just not delivering the goods.

So, is your rheumatologist doing the right things ? lets find out ...
I've listed ten things any decent rheumatologist should be implementing in his practice.
  1. DAS28 - the disease activity score using 28 joint counts. This score is used to objectively monitor disease activity. It has been extensively validated. At each clinical assessment the doctor fills out a DAS28 form. A DAS28 less than 3.2 means low disease activity, and a score of less than 2.6 means that the patient is in remission. Remission is the goal of treatment. At each visit a scoring is done and if it is high, a positive measure is taken in the form of adding/changing a drug or increasing dosages. With objective assessments remission is achieved faster.
  2. VAS - visual analogue scale. This is part of the DAS28 scoring system. It is used to more accurately measure pain. Attributing adjectives like mild, moderate or severe to a patients pain is not good enough. The patient marks a point on a 100mm line, depending on the severity of his pain. 0 - no pain, 100 - very severe pain. The measurement in millimetres from 0 is the VAS score.
  3. HAQ - health assessment questionnaire. It is another useful way to assess disease activity.
  4. TICORA - tight control of RA improves outcomes. Tight control means a visit to the rheumatologist every month. A DAS28 score is taken at every visit. All with scores greater than 2.4 should have an escalation of drug therapy.
  5. DMARDS - disease modifying anti rheumatoid drugs. Anti inflammatory drugs alone are not effective in RA. DMARD's are drugs that have been found to revert the disease process and induce remissions. Problems include slow onset of action and significant side effects. Methotrexate is the commonest DMARD used. DMARD's are usually used in combinations.
  6. Intra articular steroid shots - This is a very effective treatment modality. It is used as an adjunct to DMARD's to improve DAS28 scores.
  7. Leflunamide - trade name ARAVA. It is a newer addition in the DMARD list. It is a promising new drug.
  8. Biological agents - These drugs are the new happening thing in RA. RA is an auto immune disorder. The immune system causes an inflammation of the joint with the help of pro inflammatory molecules. The biological agents inhibit these pro inflammatory molecules, thus decreasing inflammation in RA. Eternacept and infliximab are the 2 agents available in India. The results of these drugs are very promising. On the downside they are very expensive. As they inhibit the immune system, some serious infections have occurred in patients taking these drugs. But with due care the risk is low.
  9. Exercise - As an adjunct to medicines, the importance of exercise cannot be ignored. Exercises improve outcomes, restore function and add a feel good factor.
  10. Surgery - Last but not the least is surgery. Timely surgery in RA, can help maintain function and relieve pain.
So if your suffering from RA, you can do something about it. If your rheumatologist has no clue about DAS 28, ditch him. But before you go, do the poor guy a favour and teach it to him.

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sachin said...

dear dr. QAED thanks for a very informative article. You must have worked very hard to get this information and be kind enough to share it with us . Do continue with your effort.

inspiratonal-india said...

nice and precise!!!!

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