Early detection, biologics key to treating rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory disorder that affects 1.3 million Americans; women three times more often than men. A disorder of the small joints in the hands and wrists, ankles and feet, RA is currently incurable.

Unlike osteoarthritis, a joint disorder caused by “wear and tear,” RA is primarily the result of inflammation of the synovial membrane, a soft tissue found on the inner layer of affected joints. The condition produces fluid buildup and swelling that results in pain, bone erosion, joint deformity and disability.

Older drugs and newer biologics can offer effective treatment, especially if they are started early. Dr. Arnold Ceponis, a rheumatologist at UC San Diego Health System, says that standard X-rays and blood tests, in conjunction with newer imaging tools, can help to diagnose RA earlier. We asked Ceponis when people should become concerned that their aches and pains are something more worrisome than just telltale signs of aging.

Q: Is rheumatoid arthritis strictly inflammation of the joints?

A: RA is an autoimmune disorder in which one’s own immune system attacks healthy tissue causing chronic inflammation and destruction of joint cartilage and bone. If not properly treated, the damage to the joints can be severe and irreversible. RA often occurs in periodic flares of disease activity.

Fortunately, remission is possible. RA is a “systemic disease,” which means that in addition to causing joint problems, it affects the entire body. The results can be fatigue, dry eyes and mouth, nodules under the skin and eye inflammation. Chronic inflammation caused by RA can accelerate atherosclerotic damage of blood vessels and therefore significantly increase risk of heart disease, such as myocardial infarction. Having untreated or undertreated RA is somewhat similar to having untreated high blood pressure or high blood sugar levels from poorly controlled diabetes.

Q: Why do some RA patients receive ultrasound?

A: In addition to earlier diagnosis, joint examination by ultrasound during a regular office visit can help to individualize treatment. Newer generation ultrasound systems are equipped with tools that can numerically measure the amount of the blood flow within the joint and therefore can objectively measure joint inflammation.

For example, it’s not uncommon using ultrasound to find signs of active joint inflammation in patients who are only partially treated, but thought to have good disease control because there was little or no pain or swelling. Conversely, ultrasound can help to look in more detail into a source of the joint pain that might present as arthritis, but the actual reason for symptoms could be musculoskeletal pain due to sports or overuse injuries, tendinitis or a torn rotator cuff in the shoulder.

Q: What drugs are best for treating rheumatoid arthritis?

A: Most RA patients can successfully be treated with older disease-modifying drugs, such as methotrexate, leflunomide, sulfasalazine and/or hydroxychloroquine. If these traditional disease-modifying drugs aren’t sufficient, I usually prescribe biological medications, such as TNF-inhibitors or medications that modify function of specific immune cells. This strategy targets different aspects of joint inflammation, not only to improve disease symptoms, but also to halt disease progression. Although potential side effects from these treatment strategies can make individuals more prone to infection, these medications have a good safety record and are usually well-tolerated.

Q: Can a patient alter the course of RA on their own?

A: I offer patients four steps: Stop smoking. Floss your teeth. Keep moving. Stay in touch with your rheumatologist.

As paradoxical as it sounds, there is strong scientific evidence to suggest that smoking is a risk factor for RA, and that poor dental hygiene can promote inflammation in the joints. It’s difficult to change habits, but stopping smoking can have multiple benefits, and it appears it can also decrease risk for RA. Certain bacteria in the mouth can trigger an immune response that causes a cross-reactivity and inflammation in the joints. Therefore, gum diseases like gingivitis and periodontitis can promote and make RA more difficult to treat. By maintaining a good oral hygiene, by flossing and brushing, you can actually help to take care of your arthritis.

Contrary to a belief that exercise is bad for your joints, studies suggest that moderate exercise can help to reduce inflammation in RA joints.

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