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Dr Jessica Chapman

Journal Club

Proven Benefits of a Plant-Based Diet for Rheumatoid Arthritis Relief

March 19, 2024
Can a plant-based diet help relieve rheumatoid arthritis symptoms?

Rheumatoid arthritis (RA) is an autoimmune condition characterized by chronic inflammation of the joints, leading to progressive tissue damage, pain, stiffness, and decreased mobility. In the quest to find more holistic approaches to manage this debilitating condition, recent scientific research has turned attention to dietary interventions, particularly the role of plant-based diets.

A pivotal study, often referred to as “Plants for Joints” (PFJ), has shed new light on this area, providing noteworthy insights into how incorporating plants in the diet could potentially alleviate the symptoms of rheumatoid arthritis.

Understanding the Study Framework

In the meticulously structured ‘Plants for Joints’ (PFJ) study, participants who were randomized to the intervention group embarked on a carefully tailored, multidisciplinary program targeting their rheumatoid arthritis. The initiation of their journey involved individualized consultations with a dietitian and a physical therapist, designed to design the intervention to their specific needs. Over the course of the program, these individuals participated in 10 group sessions that lasted between 2 to 3 hours each, fostering a supportive community environment in which peer education and support were actively encouraged.

Out of the cohort, 17 individuals experienced the entirety of the program through in-person sessions, while another 23 navigated a hybrid model—owing to COVID-19 precautions—with a mix of 2 to 4 live and additional virtual sessions. At the heart of the program was a comprehensive educational component that covered theoretical and practical aspects of a whole-food, plant-based diet, consistent with the 2015 Guidelines on Healthy Nutrition from the Health Council of the Netherlands. Furthermore, participants were guided to establish achievable physical activity targets, aligning with the 2017 Dutch Physical Activity Guidelines, which advocate for 150 minutes of moderate-intensity activity weekly, supplemented by twice-weekly muscle and bone-strengthening exercises.

Addressing Lifestyle with Rheumatoid Arthritis

To address the components of lifestyle influencing rheumatoid arthritis, psychoeducation was provided to elucidate the impact of stress on health, coupled with stress management strategies. Sleep optimization was also a component of the intervention, recognizing its vital role in health and wellbeing. Participants had access to resources including general information, instructional videos, and exercises that could be performed at home. Nourishment for the program was not just theoretical—participants were equipped with a meticulously planned weekly menu, bolstered by daily supplements of the active form of vitamin B12 (1500 mg) and the active form of vitamin D (50 µg) to ensure intake of crucial nutrients commonly deficient in a plant-based diet, such as protein, omega-3 fatty acids, iron, zinc, iodine, and calcium.

In contrast, the control group received standard medical care without any alterations to their existing dietary or lifestyle regimen, thus establishing a baseline against which the intervention’s efficacy could be measured.

Scientific Outcomes of the Intervention

The findings from the PFJ study were both encouraging and scientifically significant. Participants who adhered to the plant-based diet showed a remarkable decrease in RA disease activity, as determined by both subjective measures (such as patient global assessment and tender joint count) and objective measures (including swollen joint count, body composition, and an assortment of metabolic markers).

These improvements suggest a noteworthy improvement of symptomatic expression of RA, potentially attributed to the anti-inflammatory and immunomodulatory effects of the diet.

Furthermore, the holistic nature of the intervention, incorporating physical activity and stress management, underscores the multifaceted approach required in managing rheumatoid arthritis effectively. This aligns with current understanding that RA management should extend beyond pharmacological treatments to include lifestyle modifications to maximize patient outcomes.

Critical Analysis of the Study’s Limitations

While the outcomes of the PFJ study are indeed promising, it is imperative to approach these findings with a critical lens, especially considering the study’s limitations. The sample size was relatively small, and the intervention period lasted only 16 weeks, raising questions about the long-term sustainability and effectiveness of such dietary changes in RA management. Additionally, because the study intentionally combined multiple lifestyle factors, discerning the individual contribution of the plant-based diet versus other interventions (physical activity, stress reduction) to the observed health benefits becomes challenging.

It is also noteworthy that the study reported improvements in both subjective and objective measures of disease activity. However, the degree to which extra attention provided to the intervention group (participant observation bias) influenced these outcomes cannot be entirely dismissed.

Moving Forward: Implications for Clinical Practice and Research

The PFJ study provides a compelling foundation for the potential role of plant-based diets in managing rheumatoid arthritis. Nonetheless, further research with larger randomized controlled trials is essential to fully understand the long-term effects and practicality of implementing such dietary changes. Investigations exploring the specific components of plant-based diets that are most beneficial for RA patients, as well as studies assessing the efficacy of these diets in different RA phenotypes, are needed.

Conclusion

In conclusion, the “Plants for Joints” study provides insightful evidence into the positive impact of plant-based diets on rheumatoid arthritis management. While promising, the complexities of RA and the limitations of the current study necessitate cautious interpretation and further investigation. For individuals living with rheumatoid arthritis, considering dietary changes as part of a comprehensive management strategy could offer additional pathways to alleviate symptoms and improve quality of life. Nonetheless, such decisions should always be made in consultation with healthcare professionals, ensuring a tailored approach that meets each individual’s unique health needs.

Medical Disclaimer

This information is offered to educate the general public. The information posted on this website does not replace professional medical advice, but for general information purposes only. There is no Doctor – Patient relationship established. We strongly advise you to speak with your medical professional if you have questions concerning your symptoms, diagnosis, and treatment.

Diseases and Conditions

Is Knuckle Cracking Bad for Arthritis?

January 23, 2024

Is Knuckle Cracking Bad

The distinct pop and crack of knuckles being pulled and stretched is a familiar sound to many. You may not even realize how often you crack your knuckles until you consciously try to stop the habit. Up to 54% of people report regularly cracking their knuckles, whether for stress relief, simple habit, or just liking the sensation. But is this harmless fidgeting or is knuckle cracking bad for arthritis?

Anatomy of Knuckles

The knuckles are the joints that connect the bones of the fingers. Each finger has three joints called the distal interphalangeal (DIP), proximal interphalangeal (PIP), and metacarpophalangeal (MCP) joints 1. The thumb only has an MCP and DIP joint.

The MCP joints are where the main part of your hand meets your fingers, letting your fingers bend and straighten. The PIP joints are in the middle of your fingers, helping them to move too. The DIP joints are at the very end of your fingers and they let you bend the tips of your fingers. 2

The knuckles are covered by a special pocket of filled with a fluid. This fluid is called synovial fluid and it helps them move without any friction. There are strong bands called ligaments on the sides of the knuckles that keep them in place, and there are also protective plates in front of them. The finger bones are connected to the muscles of the hand and forearm by tendons, which help you move your fingers.

What Creates the “Cracking” Sound

The cracking or popping sound when knuckles are cracked is not caused by the bones themselves cracking, but rather by the gases being released from the fluid inside the knuckle joints. The current theory is that it is caused by the gases rapidly coming out of solution from the synovial fluid inside the joint capsules.

As Dr. Robert Klapper, an orthopedic surgeon at Cedars-Sinai Medical Center explains, “The noise of cracking or popping in our joints is actually nitrogen bubbles bursting in our synovial fluid” (source).

Similarly, according to a Scientific American article, “The cracking or popping sound is thought to be caused by the gases rapidly coming out of solution, allowing the capsule to stretch a little and decompress the joint” (source).

So in summary, the cracking sound comes from the release of gases from the joint fluid, not from the actual bones cracking or breaking.

Short Term Effects

When you crack your knuckles, you may experience some short term effects in the minutes and hours afterwards. One common sensation is a feeling of relief or release after cracking knuckles. This is likely due to the stretching and loosening of ligaments surrounding the joint during the cracking process.

Some research has found that immediately after cracking knuckles, grip strength can increase by up to 25% for a brief period. Castellanos and Axelrod (1990) measured hand strength before and after knuckle cracking and observed this temporary boost in grip force.

However, other short term effects are less beneficial. There may be some mild swelling and inflammation around the joint capsule after cracking. One study using MRI scans found more joint swelling in the knuckles of habitual knuckle crackers compared to non-crackers. This suggests frequent knuckle cracking could irritate the joint tissue.

Long Term Effects

The main question around knuckle cracking is whether or not it increases your risk of developing arthritis over time. There have been several key studies that have looked into this.

One study published in the Journal of the American Board of Family Medicine looked at 215 people ages 45-89 who had cracked knuckles on one hand for many years. They did not find any increased signs of arthritis on x-rays in the hand they cracked vs the one they did not.1

Another study followed 300 people over 50 years. Some were habitual knuckle crackers while others were not. But there was no difference in the incidence of arthritis between the two groups, leading the researchers to conclude knuckle cracking does not appear to increase arthritis risk.2

So the evidence indicates that knuckle cracking itself does not cause or worsen arthritis. However, a study in 1990 and 2018 did find that people who cracked knuckles frequently had more swollen hands and reduced grip strength compared to those who did not crack often. So while it may not directly lead to arthritis, habitual knuckle cracking can increase inflammation and impact hand strength and dexterity over time.

Other Risks

Although habitual knuckle cracking is generally harmless, there are risks with too forcefully or excessively cracking the knuckles. Cracking the knuckles with excessive force can potentially cause ligament or tendon injuries, though this is very rare. Sometimes it can it cause a finger to dislocate but this is very rare.

Additionally, the sound of knuckle cracking can be annoying or disruptive to those around you, especially if done frequently throughout the day. While not inherently dangerous, the noise and habit can be bothersome. According to a study cited by Harvard Health, knuckle cracking is associated with other habits like nail biting, smoking, and drinking alcohol 3.

Conclusion

Overall, research indicates knuckle cracking is not inherently dangerous or harmful when done in moderation. While the sound may be disconcerting, studies show it does not do damage to the joints or increase risk of arthritis. However, those who crack habitually and aggressively should exercise caution, as this can irritate the joints and tendons and lead to reduced grip strength.

Though not conclusively proven to be benign, cracking knuckles generally does not cause serious issues for most people. It appears to be more of an annoying personal habit than a major health concern. However, moderation is still advisable, as excessively forceful cracking could potentially injure joints and ligaments.

Medical Disclaimer

This information is offered to educate the general public. The information posted on this website does not replace professional medical advice, but for general information purposes only. There is no Doctor – Patient relationship established. We strongly advised you to speak with your medical professional if you have questions concerning your symptoms, diagnosis 

Tips and Tricks

How to Get Rid of Your Injections Properly

December 14, 2023

Introduction

Proper injections disposal is a critical aspect of healthcare and public safety. Improper disposal of used needles and other injectable medications can pose serious health risks, including the spread of infectious diseases such as HIV and hepatitis. It is essential to ensure that needles are safely and properly disposed of to protect healthcare workers, waste handlers, and the general public. In this step-by-step guide, we will walk you through the process of safe needle disposal, providing valuable information on how to properly dispose of injection needles and other injections. By following these guidelines, you can help prevent needlestick injuries and promote a safer healthcare environment.

The importance of proper injection disposal

Proper injections disposal is not just a matter of convenience; it is a critical step in ensuring the safety of individuals who may come into contact with used needles and other injectable medications. The risks associated with improper disposal cannot be overstated. Healthcare workers, waste handlers, and even the general public are at risk of needlestick injuries and the potential transmission of infectious diseases when needles are not disposed of correctly.

One of the key reasons for proper injection disposal is to prevent needlestick injuries. These injuries can have severe consequences, including the transmission of bloodborne pathogens such as HIV, hepatitis B, and hepatitis C. By safely disposing of needles, we can significantly reduce the risk of accidental needle pricks and subsequent infections.

Additionally, proper injection disposal also helps protect waste handlers who come into contact with medical waste. These individuals can be exposed to contaminated needles and other sharp objects if they are not disposed of safely. By following the appropriate disposal methods, we can minimize the risk of injury to these workers and prevent the spread of infections.

In the next section of this guide, we will delve into the specific steps involved in proper injection disposal at home. By following these steps, you can play an active role in ensuring the safety and well-being of everyone involved in the disposal process.

Step 1: Prepare the container

Now that you have gathered all the necessary supplies, it’s time to prepare the container for safe disposal. Follow these steps to ensure proper containment and storage:

1. Ensure the container is puncture-proof and leak-resistant: Check the integrity of the container to make sure that it is sturdy and won’t be easily pierced by needles. Look for containers specifically designed for needle disposal, as they are made to withstand punctures and leaks.

2. Place the container on a stable and sturdy surface: Find a location in your home or facility where the container can be easily accessed but out of reach of children and pets. Make sure it is on a stable and sturdy surface to prevent any accidental tipping or spills.

3. Keep the container upright: It is important to maintain the correct orientation of the container. Always keep it upright to prevent any potential leakage or spills.

4. Do not overfill the container: Follow the manufacturer’s instructions on the container capacity and do not exceed the fill line. Overfilling the container can increase the risk of needle sticks and may compromise the integrity of the container.

By properly preparing the container, you are taking the necessary precautions to ensure safe disposal. In the next section, we will discuss Step 2, which involves the actual disposal of your injectable medications. Stay tuned for more information on how to safely discard your used needles and syringes.

Step 2: Dispose of the injections safely

Now that you have properly prepared your container, it’s time to safely dispose of the needles and syringes. Follow these steps to ensure safe and proper injection disposal:

1. Carefully insert the used needles or syringes into the container: Make sure to place the needles in the container with the utmost caution. Do not recap the needles, as this poses a risk of needlestick injuries. Simply drop the them into the container.

2. Securely close the container: Once the injections are inside the container, seal it tightly. Follow the manufacturer’s instructions on how to securely close and seal the container to prevent any accidental spills or openings.

3. Store the sealed container in a safe location: Keep the sealed container in a place that is out of reach of children and pets. Store it in a secure location away from any potential hazards or areas of high traffic.

By following these guidelines, you can ensure the safe and proper disposal of your used needles and syringes. In the next section, we will discuss the importance of considering alternative disposal methods and the environmental impact of improper needle disposal. Stay tuned for valuable insights on how to minimize the impact on our surroundings.

Step 3: Secure the container

Now that you have properly disposed of your injection, it is crucial to take extra precautions to ensure the container is securely stored. This step is essential to prevent any accidental spills or needlestick injuries. Follow these guidelines to secure your container properly:

1. Double-check the seal: Before storing the container, inspect the seal to ensure it is completely closed and intact. Look for any signs of damage or potential leaks.

2. Store in a designated area: Choose a designated area for storing your container. It should be a secure location that is easily accessible, yet out of reach of children and pets.

3. Avoid extreme temperatures: Do not expose the container to extreme temperatures, such as direct sunlight or freezing conditions. These can compromise the integrity of the container and increase the risk of spillage.

4. Keep records: It is a good practice to keep a record of when you dispose of each container. This record can serve as a useful reference if ever needed.

By following these steps, you can ensure the containers are properly secured until they are ready for disposal. In the next section, we will discuss the importance of education and awareness in injectable medication disposal and how to spread the message effectively. Stay tuned for valuable insights on promoting safe disposal practices in your community.

Step 4: Properly label and store the container

Properly labeling and storing the container is another crucial step in ensuring safe needle disposal. It not only helps you identify the contents of the container but also prevents any confusion or accidents. Follow these guidelines to label and store your container effectively:

1. Clear and visible labeling: Use a permanent marker to clearly label the container as “Sharps” or “Biohazard.” This can help others identify the potential danger and handle the container with caution.

2. Store in an upright position: Always store the container in an upright position. This prevents any accidental spills or leaks that may occur if the container is knocked over.

3. Keep out of reach: Store the container in a location that is inaccessible to children and pets. Consider using a lockable cabinet or a high shelf to ensure their safety.

4. Do not overfill: Avoid overfilling the container to prevent protrusion of needles. Once the container is around three-quarters full, it is time to seal and dispose of it properly.

Taking these necessary steps in labeling and storing your container can greatly reduce the risks associated with needle disposal. In the next section, we will delve into the importance of community involvement in proper needle disposal practices. Stay tuned for valuable insights on how to engage your community and create a safer environment for all.

Step 5: Disposal options for containers

Proper disposal of needle containers is an essential part of safe needle disposal. You should never toss a needle container in the regular trash or recycling bin as it poses a serious risk to waste management workers and the environment. Instead, consider the following disposal options:

1. Local drop-off locations: Many communities have designated drop-off locations, such as hospitals, pharmacies, or local recycling centers, where you can safely dispose of containers. Contact your local health department or waste management agency to find out the nearest drop-off point.

2. Mail-back programs: Some companies offer mail-back programs where you can safely return your injection container through the mail. These programs provide pre-paid shipping containers that meet all safety regulations.

Here are a few links to mail back programs.

SafeNeedleDisposal .org

MedSharps.com

Stericycle.com

3. Hospital or Nursing Home: Check if your local hospital or nursing home accepts injection containers for proper disposal. In some states like New York State it is mandated by law.

Remember, always research local regulations and guidelines for needle disposal in your area. By utilizing these proper disposal options, you are taking an active role in protecting public health and maintaining a clean environment.

In the next section, we will discuss the importance of raising awareness about safe needle disposal within your community. Stay tuned for valuable tips on how to educate and engage others in this important topic.

Additional tips for safe injections disposal

While proper injeciton container disposal is crucial, there are also some additional tips to keep in mind for safe needle disposal. By following these guidelines, you can further minimize the risk of accidental needlestick injuries and ensure the safety of yourself and others.

a) Never recap needles: Once a needle is used, do not attempt to recap it. Recapping can increase the chances of accidental needlestick injuries. Instead, immediately place the needle in a container.

b) Do not overfill containers: They should only be filled up to the indicated fill line. Overfilling can lead to spills and potential injuries. If your container is full, seal it and dispose of it using one of the previously mentioned methods.

c) Avoid injection disposal in glass or plastic bottles: Using glass or plastic bottles for disposal is not safe nor recommended. These containers may break, can be easily penetrated, and do not provide the same level of protection as proper injection containers.

d) Educate others: Spread awareness about the importance of safe needle disposal to your friends, family, and community. By educating and engaging others, you can help prevent needlestick injuries and promote responsible needle disposal practices.

Remember, safe needle disposal is a collective responsibility. By taking these extra precautions, you play a vital role in ensuring a safer environment for everyone. In the following section, we will discuss the environmental impact of improper needle disposal. Stay tuned to learn more about the consequences and how we can work together to mitigate them.

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Diseases and Conditions Overcoming Inflammation

Can UV light trigger lupus flares?

July 12, 2017
Can UV light trigger lupus flares?

Now that summer is finally in full swing, I’d like to remind everyone to use broad spectrum sunscreen while enjoying the sun!  This is especially important for people living with systemic lupus erythematosus (SLE). Ultraviolet (UV) light is a known trigger of SLE flares BOTH involving the skin and major organs.  Many people also report joint pain, weakness, and headaches.  These flares can be very serious.

Although we know UV light is a trigger for SLE flares, we still don’t fully know how it happens.  This is what we do know.

  • UV light directly damages the DNA of skin cells.
  • The cells release inflammatory cytokines, most notably interleukin-1α and tumor necrosis factor-α.
  • UV light also increases interferon-α signaling. People with high levels of interferon-α signaling often develop fevers, fatigue, and low white cell count (leukopenia).  Interferon-α signaling is thought to be an important part in the development of SLE.

Take home points

So while you’re enjoying the sun remember to:

  1. Avoid the sun when UV light is strongest, between 10 AM and 3 PM. If you use IFTTT, check out this app.  You will get a notification on your phone when the UV index is high… and it’s free!
  2. Use broad spectrum UVA/UVB sunscreen.  Try to aim for a SPF higher than 30.
  3. Try wearing clothing that have vivid colors and a tight weave. The Skin Cancer Foundation has a great article regarding this topic: “What is Sun-Safe Clothing?”
  4. Wear a broad-brimmed hat when spending time in the sun.

Be safe and please leave your comments below!

References

 Fernandez D, Kirou KA. What causes lupus flares?  2016 Mar;18(3):14. doi: 10.1007/s11926-016-0562-3.

Medical Disclaimer

This information is offered to educate the general public. The information posted on this website does not replace professional medical advice, but for general information purposes only. There is no Doctor – Patient relationship established. We strongly advised you to speak with your medical professional if you have questions concerning your symptoms, diagnosis and treatment.

Diseases and Conditions Featured

Guide to living with rheumatoid arthritis: Part 1

July 5, 2017
Have you recently been diagnosed with rheumatoid arthritis? RheumDoctor presents a guide to living with rheumatoid arthritis

Rheumatoid arthritis…  Your rheumatologist diagnosed you with rheumatoid arthritis and you have a lot questions.  What’s rheumatoid arthritis?  Can I get rid of it or will I live with this disease for the rest of my life?  What should I expect?  How do I fight it?  This week I’ll present to you Part 1 of a Guide to living with rheumatoid arthritis.  I’m going to present this as a three-part series.  Part 1 will cover the basics: what is rheumatoid arthritis, the cause, symptoms, diagnosis, treatment, etc.  In Part 2 I’ll cover prognosis, what to expect, diet and exercise.  In Part 3, I’ll be covering the financial side of rheumatoid arthritis: How to get access to medications and how to deal with insurance companies.

I hope you find this information useful.  Be strong, be brave, and know that you’re not alone.

What is rheumatoid arthritis?

Rheumatoid arthritis is an autoimmune disease that causes inflammation throughout the body but mainly affect joints. Without treatment, rheumatoid arthritis can eventually lead to permanent joint destruction.  Autoimmune diseases occur when the immune system loses “tolerance to self”.  What this means is that the immune system can no longer distinguish between healthy cells and cells that don’t belong like bacteria or cancerous cells.

According to the CDC, about 1% of people living in the US suffer from rheumatoid arthritis.  It tends to occur 2-3 times more often in women and tends to start in your sixties but it can start at any age.  [1]

Some common signs and symptoms include:

  • Pain and swelling in the joints. Particularly small joints like the knuckles, wrists, and toes.
  • Morning stiffness that lasts more than one hours
  • Having difficulty opening jars. Weakness in the hands.
  • Fatigue, fevers, unintentional weight loss.

What causes rheumatoid arthritis?

We’re actually unsure.  We do know that in certain cases there is a genetic link. People that have a certain HLA class II genotype (shared epitope) tend to get rheumatoid arthritis more often.  Especially, if they smoke cigarettes.  Moreover, we know that rheumatoid arthritis tends to run in families.  However, most cases of RA happen spontaneously and not everyone who has a genetic risk factor develops RA.

There’s still a lot of work that needs to be done to fully understand what causes rheumatoid arthritis.  Like most autoimmune diseases, our best guess is that people who have RA probably were born with some sort of genetic predisposition for the disease.  Then they get exposed to something in the environment like a virus, trauma, stress, hormonal change, which then triggers the disease to come online.

What are the symptoms of rheumatoid arthritis?

Usually rheumatoid arthritis presents with pain, swelling, and prolonged stiffness involving small joints, like the ones in your hands or feet.  When I mean prolonged, I mean more than one hour.  But RA can present in many ways. These can be divided into typical (90% of cases) and atypical presentations (10% of cases).

Typical

Insidious (55% – 65%): People develop pain, swelling, and prolonged stiffness mainly involving small joints like the toes and knuckles. This progressively worsens over months.

Subacute (15% – 20%): Again small joints are painful, swollen, and stiff but the this develops over weeks. Usually people experience some fatigue.

Acute (10%): Joints suddenly become swollen and tender over days. Some people have a fever, drenching night sweats, and sometimes can lose weight without trying.

Atypical (10% of cases)

Palindromic pattern: This type of presentation isn’t technically considered rheumatoid arthritis. It’s just that 33% to 50% of people with this type of presentation progress to full-blown rheumatoid arthritis. Typically, one joint is involved. It becomes tender and swollen for a few days then gets better on its own. Then a few weeks to a few months later it happens again. The flare can happen in the same joint but not necessarily. Treatment with hydroxychloroquine can decrease the risk of developing full-blown rheumatoid arthritis, so it’s important to start treatment as this stage.

Insidious onset of the elderly: As the name suggests this type of presentation occurs in the elderly, so people aged greater than 65 years. People experience extreme pain and stiffness shoulders and the hips. Sometimes you can see whole hand or foot swelling. Sometimes it’s very difficult to differentiate from polymyalgia rheumatica or remitting seronegative symmetrical synovitis with pitting edema (RS3PE).  People with polymyalgia rheumatica and RS3PE typically do NOT have any positive antibodies.

Rheumatoid nodulosis: Rheumatoid arthritis can cause nodules and bone cysts on radiographs. Usually people also have joint pain and swelling but sometimes all they have are nodules.

Arthritis robustus: This is rather rare. I’ve only seen it once. It typically occurs in men. Essentially the person develops horrible rheumatoid arthritis hand deformities but experiences little or no pain.  I know it’s hard to believe, but it’s possible!

Untreated rheumatoid arthritis

By James Heilman, MD (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons

How is rheumatoid arthritis diagnosed?

The diagnosis of rheumatoid arthritis, contrary to popular belief, is primarily a clinical diagnosis. Having a positive antibodies like a rheumatoid factor (RF) does not necessarily mean that you have rheumatoid arthritis because MANY conditions can have a positive rheumatoid factor. Some of these include:

Rheumatoid arthritis, mixed cryoglobulinemia types II and III, sarcoidosis, and other autoimmune diseases like Sjogren’s syndrome. Other non-rheumatology diseases that can cause someone to have a positive rheumatoid factor include infections most notably hepatitis C, tuberculosis, syphilis, HIV, and endocarditis. People suffering from cancer and people with chronic pulmonary and liver diseases, can also have a positive rheumatoid factor.

It’s also important to mention that about 5 – 25% of people aged 60 years and older have a positive rheumatoid factor without any underlying causative disease.

This is why my job as a rheumatologist is so interesting 🙂

The American College of Rheumatology classification criteria for rheumatoid arthritis is as follows:

The 2010 American College of Rheumatology/European League Against Rheumatism classification criteria for rheumatoid arthritis[2]

Who to test?

  • People that have at least 1 joint with definite swelling.
  • And the swelling cannot be better explained by another disease.

Classification criteria for RA (a score of ≥ 6/10 is needed for someone to have definite RA)

Category   Score
A Joint involvement

1 large joint

2 – 10 large joints

1 – 3 small joints

4 – 10 small joints

> 10 joints (at least one small joint)

  

0

1

2

3

5
B Antibodies

Negative RF and negative CCP antibodies

Low positive RF or low positive CCP antibodies *

High-positive RF or high positive CCP antibodies #

  

0

2

3
C Inflammation markers

Normal CRP and normal ESR

Abnormal CRP or abnormal ESR

  

0

1
D Duration of symptoms

< 6 weeks

≥ 6 weeks

  

0

1

* Low positive antibodies means any value that is above normal but less than 3 standard deviations above the upper limit of normal.

# High positive antibodies means any value that is 3 standard deviations above the upper limit of normal.

It’s important to note that these criteria were NOT meant for clinical practice but rather, were really meant for research trials. Sometimes, rheumatologists do deviate. Other conditions should be ruled out and let’s face it, not everyone fits perfectly into the mold. The criteria also does not account for musculoskeletal ultrasound testing. This imaging test can detect very subtle inflammation of a joint.[3]

Positive antibodies without RA

Now sometimes the workup is completely negative including x-rays. This is not uncommon. It can mean many things. It could mean that the rheumatoid factor is not clinically significant. 5–25% of the population can have a positive rheumatoid factor without any underlying condition or any symptoms. Typically the rheumatoid factor levels are low. It could also mean that you will develop rheumatoid arthritis in the future. Studies have shown that antibodies associated with rheumatoid arthritis can be present over a decade before onset of clinical disease. [4]Unfortunately, we don’t have the tools to precisely determine who will convert and who will not. In this situation, your rheumatologist can help you watch for any change in your condition.

How is rheumatoid arthritis treated?

We treat rheumatoid arthritis with medications called disease modifying anti-rheumatic drugs (DMARDs).  These medications slow down or stop the natural progression of rheumatoid arthritis.

Except for a few special situations, EVERYONE should with rheumatoid arthritis should be treated with a DMARD as soon as possible because permanent joint damage can happen in as little as 3 months after symptoms start.[5]

The following are the medications used to treat rheumatoid arthritis in the United States.  It’s important to work closely with your rheumatologist because they all have possible risks and what may be good for your neighbor may not be safe for you.

I’ve broken them down into conventional DMARDs, biologic DMARDs, and pipeline medications that have not been approved as of yet.

Conventional

  • Methotrexate
  • Leflunomide
  • Sulfasalazine
  • Hydroyxchloroquine

Biologics

  • Etanercept, TNF inhibitor
  • Adalimumab, TNF inhibitor
  • Golimumab, TNF inhibitor
  • Certolizumab pegol, TNF inhibitor
  • Infliximab, TNF inhibitor
  • Abatacept, Co-stimulation inhibitor
  • Tocilizumab, IL-6 inhibitor
  • Sarilumab, IL-6 inhibitor
  • Tofacitinib – JAK inhibitor
  • Rituximab – B cell depletion

Pipeline

  • ABT 494, a new JAK inhibitor
  • Baricitinib, another JAK inhibitor
  • Sirukumab, another IL-6 inhibitor

Biosimilars

It’s also important to note that we are starting to see biosimilar medications in the States. These are medications that are sort of copied from existing biologic medications.  They are NOT generic medications. The problem with biosimilars is that because of their complexity, it literally is impossible to exactly copy a biologic medication. If you want to learn more about biosimilar medications, please check this article.

Supplements

If you’re interested in supplementing, there is some research that suggests high dose turmeric/curcuma and high dose fish oil/omega-3 fatty acids may also be helpful.[6][7] However, supplementation should be used in combination with FDA approved medications that I listed above.

Is there a cure for rheumatoid arthritis?

I honestly wish I had better news for you. Unfortunately there is no cure for rheumatoid arthritis. Treatment primarily focuses on arresting the natural progression of the disease with the use of disease modifying anti-rheumatic agents (DMARDs). Conventional DMARDs such as methotrexate, leflunomide, sulfasalazine, and hydroxychloroquine, modulate the immune system to decrease rheumatoid arthritis activity.  Biologic medications like etanercept use a targeted approach, i.e., suppress a specific cytokine.

The goal of treatment is to put rheumatoid arthritis into remission and decrease the frequency of flares.

This may seem very pessimistic, but recent advances have really improved the prognosis of people living with rheumatoid arthritis.

Nevertheless, DMARDs do not cure rheumatoid arthritis.

How do we win the war against rheumatoid arthritis? Before we can win the war and find a cure, we need to know exactly what causes rheumatoid arthritis in the first place and we need to understand its exact pathophysiology. Believe it or not, despite all our advances, we still cannot answer these two questions. Don’t despair, researchers are actively trying to answer these questions.

Can rheumatoid arthritis become fatal?

Rheumatoid arthritis is a systemic autoimmune mediated disease that primarily affect the joints. Note the primarily bit. It can affect a host of different organs including the eyes, lungs, heart, skin, and bone marrow to name a few.

Untreated or poorly controlled rheumatoid arthritis can cause serious conditions such as interstitial lung disease (i.e., inflammation of the lungs), pericarditis (i.e., inflammation of the “sac” surrounding the heart), as well as something called Felty’s syndrome (i.e., a hematologic condition that can cause white cells to dramatically decrease and causes the spleen to enlarge). These severe manifestations of rheumatoid arthritis that can lead to death are hardly ever seen anymore mainly because we have many highly effective medications called disease modifying anti-rheumatic medications (DMARDs). These medications have completely changed people’s prognosis.

Cardiovascular disease and infection

The most common cause of death in people with rheumatoid arthritis these days includes cardiovascular disease and infection – primarily from medications.[8]

Rheumatoid arthritis increases cardiovascular risk via the interplay of inflammation and lipid metabolism. Studies have shown that people who receive treatment with methotrexate and or tumor necrosis factor inhibitors reduce their cardiovascular risk.[9] A British study also demonstrated that cardiovascular was not increased regardless of the choice of DMARD provided that rheumatoid arthritis was well controlled.[10]

Infection remains an ever-present problem in the world of rheumatology. To treat autoimmunity you need to suppress the immune system. Not too much, not too little, but just right. In some cases this has the unfortunate result in causing serious infections that can lead to death in extreme cases.

Rheumatoid arthritis can become fatal in many other ways, however, for the most part it is medication induced – although the pharmaceutical companies don’t really want you to know that. Just read a package insert. They’re terrifying.

However, I’ve been talking about rheumatoid arthritis fatalities. Untreated or undertreated rheumatoid arthritis is HIGHLY debilitating leading to a significant drop in your quality of life. Early treatment with a DMARD is the best way to improve your odds. You have to fight fire with fire!

Can I stop my medications if I’m feeling better?

No. Rheumatoid arthritis is a life-long disease.  If you’re feeling better, great!  However, it’s probably your medications that are keeping you that way.  If you stop your medications the rheumatoid arthritis will come back.  Maybe not now but soon.  Rheumatoid arthritis subsides spontaneously in a VERY small subset of people.

If your medication is making you feel sick, talk to your rheumatologist.  They’re there to make you feel better and they want to find the perfect treatment plan tailored for you.

Do not stop your medications without consulting your rheumatologist.

Next steps

We’ve covered a lot of material today and there’s a lot more coming your way!  Stay tuned for Part 2.  I’ll be covering topics such as what to expect, what to eat, how to exercise, and strategies on how to reduce stress.  Please leave your comments below.

References

[1] https://www.cdc.gov/arthritis/basics/rheumatoid-arthritis.html

[2] https://www.rheumatology.org/Portals/0/Files/2010_revised_criteria_classification_ra.pdf

[3] Horton SC, et al. Ultrasound-detectable grey scale synovitis predicts future fulfilment of the 2010 ACR/EULAR RA classification criteria in patients with new-onset undifferentiated arthritis. RMD Open. 2017 Mar 30;3(1):e000394. doi: 10.1136/rmdopen-2016-000394. eCollection 2017.

[4] Brink M, et al. Rheumatoid factor isotypes in relation to antibodies against citrullinated peptides and carbamylated proteins before the onset of rheumatoid arthritis. Arthritis Res Ther. 2016 Feb 9;18:43. doi: 10.1186/s13075-016-0940-2.

[5] Raza K, et al. Treating very early rheumatoid arthritis. Best Pract Res Clin Rheumatol. 2006 Oct;20(5):849-63.

[6] van der Tempel H, et al. Effects of fish oil supplementation in rheumatoid arthritis. Ann Rheum Dis. 1990 Feb; 49(2): 76–80.

[7] Ramadan G Al-Kahtani MA, El-Sayed WM. Anti-inflammatory and anti-oxidant properties of Curcuma longa (turmeric) versus Zingiber officiale (ginger) rhizomes in rat adjuvant-induced arthritis. Inflammation. 2011 Aug;34(4):291-301. doi: 10.1007/s10753-010-9278-0.

[8] https://www-ncbi-nlm-nih-gov.elibrary.amc.edu/pubmed/26472415

[9] https://www-ncbi-nlm-nih-gov.elibrary.amc.edu/pubmed/28455580

[10] https://www-ncbi-nlm-nih-gov.elibrary.amc.edu/pubmed/28160488

Medical Disclaimer

This information is offered to educate the general public. The information posted on this website does not replace professional medical advice, but for general information purposes only. There is no Doctor – Patient relationship established. We strongly advised you to speak with your medical professional if you have questions concerning your symptoms, diagnosis and treatment.

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Recipes

Chive Blossom Butter

June 14, 2017
Chive blossom butter

My mom is what you would call a busy body.  Always out and about: gardening, cooking, cleaning… running a business.  She also happens to be an amazing cook.  This Saturday morning as I was doing my errands, she texted me images of her latest creation.

Beautiful chive blossom's from my mom's garden

Very pretty.  Why aren’t mine like that?

Chive blossoms and lemons

Interesting, show me more.

Unformed chive blossom butter

This does not look appetizing.

Chive blossom butter

Yum!

I can see this tasting great with mashed potatoes, toasted bread, or on a steak.  Although this is not the healthiest recipe, something like this should definitely be shared.

Chive Blossom Butter

Adapted from Popayan www.recettes.qc.ca

50 – 60      Chive flowers with ½ inch of the stem attached, finely minced

1 lb              Unsalted butter, room temperature

1 ½             Lemons, juiced

¼ cup        Extra-virgin olive oil

Salt as desired

  1. In a large bowl, mix the butter, lemon juice, and the olive oil together with a wooden spoon. Then, add the minced chive blossoms.
  2. At this point you can either fill ramequins with the butter-chive blossom mixture or you can mold them into individual sized portions as seen above.

Individual sized portions

  1. Mold the butter-chive blossom mixture into a roll and wrap in wax paper and then in plastic wrapping.
  2. Place in the freezer.
  3. When the mixture has hardened, unwrap, and cut into individual sized portions

 

Makes one pound of butter.

 

Bon appetit!