Red flag arthritis

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Arthritis is not a disease but a symptom indicating pain in joints. Skeletal muscular disorders which mean disorders of joints, muscles, bones and soft tissues account for about 20% of the problems encountered by the general practitioners in their clinical practice.

Arthritis clinically can be divided into two types: Mechanical structural damage, which constitutes 90% of arthritis. This is called green flag arthritis, wear and tear arthritis or mechanical structural arthritis. In clinical terms, it is called osteoarthritis. In 10% of cases, arthritis is red flag dangerous arthritis involving defense system impairment and autoimmune system. It is a systemic disease and not arthritis alone and the commonest form is rheumatoid arthritis.

Following are the points and excerpts of a panel discussion held between Dr. AN Malviya, Dr. Jatinder Maheshwari and Dr. KK Aggarwal.

  • Osteoarthritis of the knee is the commonest arthritis in the body. It is wear and tear arthritis usually seen in patients with obesity, not exercising or in patients who have past injury or in patients who are suffering from rheumatoid arthritis.
  • Extra weight of one Kg extra weight leads to 9 kg extra weight on the knee joint.
  • The causes linked with osteoarthritis are obesity, squatting, sitting cross legged, climbing stairs which are more than 4 inches in height and genetic in origin. Genetics is an important aspect in arthritis.
  • Smoking is not directly linked with arthritis but linked with rheumatoid arthritis. Alcohol and diet are linked with osteoarthritis through obesity.
  • The best exercises for osteoarthritis are – brisk walking, aerobics, cycling and swimming. To prevent arthritis, the best exercise is walking and once arthritis develops, the best exercise is cycling.
  • One should not give painkillers in osteoarthritis for more than three months. It is always better to try methods which can omit painkillers. It is a myth that glucosamine helps. In acute arthritis, one can try cold fomentation and in chronic cases, hot fomentation.
  • Acupuncture may be helpful as it secrets endorphins.
  • Surgery may be required in both early and late stages. In late stages, surgery corrects deformities and in the early stages, surgery corrects the correctable causes of bone disorders which can lead to osteoarthritis.
  • One can also try knee support, braces etc. to pull on the pain of arthritis for some time.
  • In osteoarthritis, one can experience pain in climbing the stairs or climbing down the stairs, especially if the patella joint is involved.
  • Osteoarthritis is common in elderly specifically aged 50 plus.
  • Red flag arthritis involves 1% of population with rheumatoid arthritis with female: male ratio of 4:1. Up to 60-70 lakh people in India may be suffering from deforming rheumatoid arthritis. 70% of them may be in bad shape because of deformity.
  • Rheumatoid arthritis should be diagnosed as early as possible but definitely within 6 months.
  • For diagnosis: 85% history helps, 10% examination helps and only in 5% cases do diagnostic lab tests help. Lab tests involve ESR, rheumatoid factor, ACPA (high specificity).
  • The second type of red flag arthritis is spondyloarthritis (SPA).
  • SPA can be axial involving the spine or peripheral involving the below trunk joints. The peripheral form is usually missed. It is seen in young people with male: female ratio of 2:1. Patients often present with low backache, which is worse in the morning. They have bad nights but as they get up in the morning, they feel better. Immobility is bad for them and mobility is good for them. The age group affected is usually less than 17 years and the disease involves below waist joints which are hip, knee, ankle and feet.  It is asymmetric. Early morning stiffness is present. Smoking worsens the situation.
  • Axial arthritis is called ankylosing spondylitis and has similar features but it involves spines.
  • Inflammatory arthritis is a systemic arthritis, which involves lungs, ear, heart liver and legs. Most people die 20 years prematurely. It impairs the range of motion in spine. It is a systemic illness.
  • Rheumatoid arthritis is treated with methotrexate 20-25 mg every week. The maintenance dose is 12.5 mg. Hydroxychloroquine is a must as it improves lipids and reduces heart attack and improves patient’s symptoms. Leflunomide is to be used if above two combinations fails but it is a toxic drug. Sulfasalazine should be used if other two drugs fail but it is mildly acting drug. TNF blockers are to be used if the patients are refractory and the drugs available are infliximab and etanercept.
  • Three other drugs, which are available for rheumatoid arthritis are abatacept, Abatacept, tocilizumab and rituximab. The last one is broad-spectrum and can be used in many conditions.
    In SPA, NSAIDs are disease modifying drugs and they should be given continuously and not on demand for a period of two continuous years. Etoricoxib is a good choice but naproxen and indomethacin can also be given. IV pamidronate 60 mg + IV 250 mg methyl prednisolone can be given for three days; repeated monthly for six months. Stiffness can be measured clinically or by CRP and ESR. In 66 % cases, the NSAIDs will work and they will fail in 33% requiring lifetime TNF inhibitors. They are to be given every second month (infliximab and etanercept).