Rheumatoid Arthritis is not just a destructive disease, it causes significant pain. In UK there are about 350,000 sufferers. The disease develops when the immune system  or defense mechanism turns on the body itself and attacks joints. The joints become swollen, painful and stiff. In time this dreadful disease can leave a person with deformed joints.

There are many drugs available for relief and control. However, pain from rheumatoid arthritis can be debilitating. A new group of drugs called anti-TNF (Tumour Necrotic Factor) has proven effective in treating Rheumatoid Arthritis by blocking TNF, a protein found in excess in the blood and joints of rheumatoid arthritis patients.

One anti-TNF drug is Humira. This drug has to be given by injection once every two weeks at a clinic but a new pen device, recently approved by the NHS, allows patients to self inject. The device is small enough to fit inside a pocket and is fitted with a needle hidden inside.  To use the pen device, you position the pen at the site of the injection usually on the stomach or thigh area and press the button. This releases the needle which then pierces the skin and the humira in delivered. A yellow indicator shows that all the drug has been injected. The device in not much different from the pen device used by diabetics or ones used for urgent delivery of adrenaline.

“The pen has made treatment so much easier. It is designed so there is no worries about patients administering it in the wrong way.” Said Janet Williams, Rheumatology nurse at St. Helen’s Hospital, Merseyside.

A 36 year old, Julie Smyth, was diagnosed with rheumatoid arthritis at the age of 20. She used a variety of drugs and had both shoulders and knees replaced. Four months before her planned wedding, her disease flared up. She was worried she could not walk up the aisle. She was about to cancel her wedding. Doctors decided to treat her with humira via the pen device.

“After just one injection, I noticed a big improvement,” she siad, “I couldn’t believe how quickly I responded. My wedding day was wonderful”

In the UK the pen is only dispensed by the hospital and only through your consultant rheumatologist.

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Weight loss can make a significant difference to the level of pain, stiffness and mobility of arthritic joints. Whatever diet you chose you should incorporate the right exercise. If on your diet, you are not losing weight, then you should include low glycaemic index foods. The glycaemic Index ranks food on the effect they have on the blood sugar and insulin level.

Foods with high glycaemic index includes potatoes, rice, bread and pasta. These foods quickly raise the blood sugar level but after only a few hours, the level drops and you feel hundry and lethargic.

Low glycaemic index foods are vegetables, some fruits, and lentils. These foods keep the blood sugar level up for much longer periods. This means you are not hungry and your energy level stays high.

Selecting low glycaemic index foods is not enough. The portion size is also important. You can ruin an excellent diet by eating too much of the right food. Work out the portions and stick to them.

Studies have shown that it is better to convert the total amount of food you consume in three meals and breaking it up into five or six smaller meals is better way to diet. This will keep the blood sugar level up and the body metabolism high. You also do not have low ebbs during the day.

Dr. Phil Hariram.

Arthritis Guide.

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If you have arthritis and you are looking to control pain without drugs, then the first thing you need to do is  reduce your weight or maintain a normal weight. If you are overweight, weight loss will be the most important thing you can do to improve the level of pain, stiffness and mobility.

A small amount of weight loss can make a significant difference. The best measure of weight in relation to height and general body health is the Body Mass Index (BMI). The normal range is 20-25 and 26-30 is considered overweight and over 31 obese.

Extra weight puts additional stress on weight bearing joints such as knees and hips, and increases the level of pain. It also increases the risk of arthritis. It is not always easy to lose weight if you have arthritis. If your weight remains constant on a particular diet plan, then you are consuming just the right amount of calories to provide for the needs of the body. If you are gaining weight, then you are taking more than your body needs and the extra calories are stored as fat.

To lose weight you need to consume less than your body requires. This way the extra calories needed is obtained from the breakdown of fats stored in the body. Exercise will help you burn fats. it is not as effective as a specific diet plan but will help. It should be incorporated into the whole weight loss plan.

The heavier you are, the more calories you will burn during exercise. Exercise will keep the joints supple, reduce stiffness and tone up supporting muscles. It also makes you feel healtheir and energised.

To assess your progress, evaluate the level of pain, stiffness and mobility before your diet and exercis plan, then make assessmentsat intervals.

Dr.Phil Hariram

Arthritis Guide.

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Gout is caused by high uric acid in the blood. In the past it was known as the Patrician’s Malady and thought to be a disease of indulgence, and until the introduction of drugs that lowered the uric acid level, patients suffered recurrent and frequent acute agonising gout and chronic gout leading to polyarthritis, tophi and other organ damage. Today this is unlikely apart from in non-compliant patients.

Acute gout is a very painful condition. It often occurs during the night and frequently affects the big toe.The joint affected is the metatarso-phalangeal joint. It resolves spontaneously and this can be quickly or can last weeks.

Gout is predominantly a male condition up to the age of 50. It is rare in pre-menopausal women. There are various factors that can affect gout. Once these factors are recognised, and dealt with, if uric acid remains high, then maintenance treatment with allopurinol is used to control uric acid level. This prevents any damage to joints and other organs.

The incidence of gout is increasing globally. In the past, gout was unheard of in some areas of the world especially Asia and Africa but the incidence in these areas are increasing. It is thought that this is due to increased consumption of proteins and fats.

Once gout is diagnosed, it is important that you are aware that it can be associated with other conditions. Make sure you know your cholesterol level and the health of your kidneys.

Dr.Phil Hariram

Arthritis Guide.

Arthritis Treatment

If you have an episode of acute gout, it does not mean you have to be on continuous drug therapy to reduce your blood uric acid level. It simply means that your doctor will look for possible factors that may influence the level of uric acid in your blood and continue to check you uric acid level. From my previous posts you will know that gout can be affected by various factors.

Once all the possible influences on your gout are checked and eliminated or reduced, if your uric acid level remains elevated then your doctor will consider treating you with drugs such as allopurinol. High uric acid if left untreated will lead to urate crystal deposition in other joints causing polyarthritis and on the skin as tophi.

There are times, however, when uric acid levels are high in routine blood tests or a patient may present to the doctor with tophi. Here your doctor will do routine monitoring and as mentioned before, look for other factors that can influence uric acid level.

Management of these patients will include diet restriction to low purine foods and weight loss. Drugs like diuretics are replaced. If the uric acid level remains high, then allopurinol will be started. Allopurinol, gradually increased until the level of uric acid is in the normal range, will stop crystal formation and thereby protect the joints, kidneys and other organs from damage by gout. Side effects of allopurinol are rare but can be serious.

Drugs less frequently used are probenacid, sulphinpyrazone,and azapropazone. Sometimes acute gout can develop while on maintenance therapy. if this happens do not stop your medication. In some cases acute gout can develop after starting allopurinol. If this happens, see you doctor for further treatment.

Dr.Phil Hariram

Arthritis Guide

Arthritis Treatment

Hyperuricaemia is a higher than normal blood level of uric acid. There are individuals with high blood uric acid levels and have never had an attack of gout. Are these people at risk of arthritis of the joints and kidney stones from urate crystals deposits? Yes they are.

Firstly the diagnosis of asymptomatic hyperuricaemia is made more frequently because of more screening, and blood tests for insurance purposes. Secondly you can break it down to primary and secondary types. In the primary type there may be a genetic link. In this case there is a deficiency of an important enzyme leading to excess production of uric acid. When this is severe (Lesch-Nyhan Syndrome), there are severe problems.

Secondary hyperuricaemia results from factors affecting the production and/or elimination of uric acid. These include medical conditions, drugs, metabolic conditions, obesity and alcohol consumption.

Sometimes hyperuricaemia is suspected when patients present to the doctor with tophi. These can be acute or chronic. An acute tophus is usually small and later soften when it becomes chronic. They look like small nodules and as they grow bigger, the skin overlying them looks shiny and feels smooth. Sometimes they can ulcerate and release white chalky stuff. If the patient is treated with allopurinol the tophi usually becomes smaller.

Dr.Phil Hariram

Arthritis Guide.

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In the days before adequate treatment controlled the blood level of uric acid, chronic gout presented with multiple joint involvement and chronic poly-arthritis. Today this is rare and only found in patients who refuse medication or have poor compliance. Here the acute gout attack will become more frequent. Then other joints become involved. The crystals deposited in and around the joints are needle shaped and I suspect this is why acute gout is so painful.

I had an elderly patient who had heart failure and was on large doses of diuretics and ace inhibitors. She developed acute gout. Her medication was looked at and altered. Unfortunately her uric acid level remained very high. She was started on allopurinol.

She developed an allergic rash to allopurinol. In fact everything the consultant prescribed gave her problems. In the end she had no medication and refused any attempt to try anything for her gout because she was worried about side effects. She was put on a specific diet. Eventually she developed poly-arthritis. Her fingers had big nobbles for joints and she had problems walking around her ground floor flat. Tophi developed first on the ear then elsewhere.

A joint badly damaged by chronic gout will on x-ray show erosions, secondary calcium deposits and soft tissue swelling.

Allopurinol is the drug of choice in chronic gout. By maintaining the blood level of uric acid within the normal range, separation of urate crystala into joints and kidneys are prevented.

Dr.Phil Hariram,

Arthritis Guide.

The first explanation of podagra was in the sixteenth century by Burgamer, a German Physician. He said podagra is a pain in the feet with or without swelling which comes from dampness or drought.

Podagra is acute gout affecting the big toe and typically the first metatarso-phalangeal joint. It is as a result of higher than normal uric acid in the blood. Uric acid is mainly excreted by the kidneys. Diuretics and other drugs can affect the function of the kidneys and reduce excretion of uric acid. This can cause elevated level of uric acid in the blood and acute gout.

Over indulgence in alcohol can trigger acute gout. Beer is the worse alcoholic beverage for gout. Port was linked to gout in the eighteenth century. At the time, port was stored in lead lined casks and lead diffused into the port. Lead in the consumed port accumulated in the body and in the kidneys, it affected the ability of the kidneys to excrete uric acid. The imbalance caused high uric acid in the blood. This condition is called Saturine gout.

Sometimes podagra can develop following initiating treatment with allopurinol. Gross over eating especially seafoods and red meat can trigger podagra.

No one knows exactly why podagra is the commonest manifestation of acute gout. Some suggested that the first metatarso-phalangeal is used a lot and takes a lot of the body’s weight when walking.

Dr.Phil Hariram,

Arthritis Guide.

Hippocrates described gout in men and post-menopausal women. Studies have shown that the incidence of potential gout is one in one hundred. Studies have also shown a link between high uric acid blood levels and hypertension and obesity. It is also suggested that the incidence of gout is increasing.

In the past gout was unheard of in the Third World but the incidence is increasing in these areas as a result of dietary changes and consuming more proteins and fats.

Once rich food and alcohol were known to be causative factors, preventative dietary measures were employed.

Colchicum was used for centuries to treat gout. it is an extract from the meadow saffron bulb (Crucus autumnale) but were more commonly used in the nineteenth century. It was found to be very effective.

Cinchopen was introduced early in the twentieth century. This drug in addition to treating acute gout, had pain relieving properties but caused liver damage.

In 1951, probenacid and phenylbutazone were introduced. Phenybutazone had similar properties to cinchopen and was very effective treatment for acute gout. This drug is now withdrawn in most countries because of it’s potential to cause bone marrow depression on long term use. Probenacid speeds up the elimination of uric acid. This significantly decreased the number of acute attacks and formation of tophi.

In 1963 allopurinol was introduced. This is a safe drug and can be used in renal disease. Continuous treatment reduced the blood level of uric acid.

Dr.Phil Hariram

Arthritis Guide.

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In acute gout, the pain is severe, throbbing and unrelenting and can last longer than a week. The affected joint is swollen, shiny and very tender to touch and often contact with the bed sheath can cause agonising pain.

The initial treatment is an optimal dose of an anti-inflammatory drug. The commonest of these is ibuprofen. Non-steroidal anti-inflammatory drugs (NSAIDs) have side effects and risks to patients but treatment is on a short term basis. Side effects can be reduced by using the slow released formulation of the drug or a suppository. The slow release drug will pass through the stomach intact reducing the risk of nausea and vomiting. If there is a history of gastric bleeding or ulcers, NSAIDs are not recommended.

Colchicine was commonly used before the advent of NSAIDs but it is likely to cause nausea and diarrhoea. The dose is gradually increased until effective or to the limit dictated by side effects.

Azapropazone is a vey useful drug for treating gout.

In large joints the fastest relief is achieved by steroid injection into the synovial space. The commonest manifestation of acute gout is in the big toe. Injection into the joints of this toe is not recommended because the joint is small and very painful.

Phenylbutazone was used extensively in the past, and was first choice in gout treatment but the serious side effect of bone marrow depression on long term treatment has led to the drug withdrawal in most countries.

During treatment of an acute episode of gout, your doctor will not start you on allopurinol. Any attempt to reduce the level of blood uric acid during an acute attack will make your gout worse and the episode last longer.

Dr.Phil Hariram,

Arthritis Guide.

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