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When to see a rheumatologist

What Are The Early Signs Of Rheumatoid Arthritis?

October 30, 2019
What Are The Early Signs Of Rheumatoid Arthritis?

What are the early signs of rheumatoid arthritis? Rheumatoid arthritis is one of the more common forms of autoimmune arthritis, affecting about 1% of the adult population.  This may not seem quite common, but in the world of rheumatology this is actually quite common.  Women tend to be affected more than men 2-3:1 and the disease tend to manifest between the ages of 40 – 60.  However, it can also happen in young adults and older individuals.  When it happens in children, we call it juvenile idiopathic arthritis.

Early Signs of Rheumatoid Arthritis

The following are some of the early signs of rheumatoid arthritis.

#1 Inflammatory joint pain

Most of us experience joint pain at some point in our lives.  This is simply a part of being human.  However, most of us experience non-inflammatory joint pain NOT inflammatory joint pain.  Non-inflammatory joint pain typically worsens as the day progresses.  There typically is no swelling, redness, or warmth.  There can be stiffness but typically this last just a few minutes and certainly less than 30 min.  Basically, things quickly get better as you get going.

People that suffer from rheumatoid arthritis present with inflammatory joint pain, which presents very differently.

  • Joint pain that is worse in the morning and improves as the day goes by.
  • There is joint swelling and usually they feel warm.  At times they can look red.

People suffering from rheumatoid arthritis experience stiffness that usually lasts more than one hour.

#2 Involvement of knuckles, wrists, ankles, and toes

Although rheumatoid arthritis certainly affects larger joints, like the knees, hips, and shoulders, it tends to affect smaller joints like the knuckles, wrists, ankles, and toes.

#3 Symmetrical joint distribution

This is pretty self-explanatory.  Rheumatoid arthritis inflames joints symmetrically.  If the second knuckle on the right hand is inflamed, the second knuckle on the left hand most likely will be too.  Maybe not as much, but inflamed nonetheless.  However, it’s important to take this with a grain of salt, particularly early in disease.

#4 Fatigue

People often feel very tired, when they suffer from rheumatoid arthritis.  I’m talking can’t make it through the day tired.

#5 Fevers

This often depends on how quickly symptoms emerge.  Symptoms of rheumatoid arthritis usually develop over the course of months (55 – 65% of cases), but at times can develop over a few weeks (15 – 20%), and even days (10%).  The quicker the onset, the more likely someone will experience low grade fevers.  Some people, particularly those aged greater than 65 years, can present like polymyalgia rheumatica.  These people often present with fevers as well.

What Are Some Other Symptoms of Rheumatoid Arthritis?

Rheumatoid arthritis is a very complex autoimmune disease that can affect many different organs.  We discussed the 5 common early signs of the disease but the following are some other less common manifestations.

Cardiac

  • Pericarditis
  • Myocarditis
  • Coronary vasculitis

Dermatologic

  • Nodules
  • Skin vasculitis

Ocular

  • Scleritis
  • Episcleritis
  • Retinal nodules

Pulmonary

  • Pleuritis
  • Interstitial lung disease
  • Bronchiolitis obliterans
  • Lung nodules

Neuromuscular

  • Nerve entrapment – e.g., carpal tunnel syndrome
  • Neuropathy

Other

  • Severe dry eyes and dry mouth
  • Felty’s syndrome

What Are Some Of The Mimickers Of Rheumatoid Arthritis?

When faced with symptoms that look and sound like rheumatoid arthritis, it’s important to take a step back and consider alternative diagnoses.  Some of these include:

Next Steps

If you think you or one of your loved ones may be suffering from rheumatoid arthritis, I highly suggest you discuss your symptoms with your general practitioner or schedule as appointment with your local rheumatologist.  Although, signs and symptoms are very important, a good history and physical examination in conjunction with specialized bloodwork and x-rays, are essential to either rule in rheumatoid arthritis and rule out other possibilities.

References

Rheumatology Secrets 3rd edition

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.

Overcoming Inflammation When to see a rheumatologist

How to prepare for your rheumatology consultation

October 3, 2017
How to prepare for your rheumatology consultation

Rheumatologists treat well over 100 different types of diseases.  These diseases are complex and affect many organ systems.  Diagnosing a rheumatic disease is like solving a complex puzzle.  Every first consultation includes a detailed history, a physical examination, and a review of past blood work, x-rays, and documentation from your other doctors.  All these help your rheumatologist solve the puzzle.

Preparing for a rheumatology consultation is a bit like preparing for a meeting with your accountant.  You want everything organized in advance: W-2, investment income statements, IRA/pensions distributions, child care costs, etc.  You want everything neatly laid out in advance, so that your consultation is as productive as possible.

Laying the groundwork

Make sure your rheumatologist has all the information at his or her disposal well before your appointment.

  • The progress note from your referring physician. What is the question that’s being asked?
  • Your primary care physician’s (PCP) last progress note.
  • The results of any blood tests.
  • The results of any x-rays or any other imaging.
  • If you had a biopsy that relates to your symptoms (e.g., skin biopsy, kidney biopsy, lung biopsy), your rheumatologist will want to see the pathologist’s interpretation.
  • If you are transferring care from another rheumatologist, your current rheumatologist will definitely want to see that information.

Bring an updated list of your medications and allergies

It’s always a good idea to have a written updated list of all your medications and allergies.  Make sure you bring this along to your first consultation.  Do not assume that your PCP’s updated medication list is up-to-date. Some people see more than one doctor and they’re all making changes independently.

Anticipate questions your doctor may ask

Rheumatologists certainly have access to high specialized blood tests and imaging, but the medical history is by far the most important part of the consultation.  Before your visit, try to expect some questions your doctor may ask and then write them down.  Here are a few that may help you get started.

  • When did you first notice something was wrong or had changed?
  • Describe your symptoms.
  • Has this ever happened before? If so when?
  • Do the symptoms come and go or are they continuous?
  • Is there a particular time of day where they are worse?
  • What makes your symptoms worse? What makes them better?
  • Have you taken any over-the-counter medications for your symptoms? If so, which ones and did they help?
  • Do you think you have other symptoms besides joint or muscle pain that seem connected?
  • Have your symptoms caused you to make changes to your daily routine?

Anticipate questions you may have for your doctor

  • Based on what you know, what could be causing my symptoms?
  • What tests do I need to have done to help decide what my diagnosis is?
  • Are there any symptoms that I should be looking out for?
  • What kind of interventions could I do now, to help ease some of my symptoms?
  • What kind of activities should I avoid at this time? (e.g, get pregnant, run a marathon, prolonged travel, etc.)

Actively listen and participate

You may feel overwhelmed when your doctor is giving you a new diagnosis, let alone giving you a complex set of recommendations.  You’re not alone.  A study looked at how much information (when prescribing a new medication) patients retained after their doctor’s appointment.  They found that only 64% of people were able to recall all the information that they discussed during the visit[1].  Not bad, but not great.

We know that recall of information improves health outcomes in people suffering from chronic diseases like rheumatoid arthritis and lupus.  Another study looked at aspects of doctor-patient communication that lead to higher recall.  They found that active patient engagement and explicit conversations about medications improved recall.[2]  Here are a few tips about becoming a better active listener.

  • Pay attention
  • Show that you’re listening
  • Provide feedback
  • Defer judgement
  • Be candid, open, and honest in your response.

You may also want to write things down in a journal (highly recommended) or maybe you may want to bring an advocate to your consultation.  This could be a trusted friend or family member.

Conclusion

Being ready for your appointment, active listening, and asking questions to understand your symptoms is central to not only making the most of your rheumatology consultation but also, becoming an empowered patient.

Please follow this link to request a rheumatology consultation.

[1] Tarn DM, Flocke SA, New prescriptions: How well do patients remember important information? Fam Med. 2011 Apr; 43(4): 254–259.

[2] Richard C, Glaser E, Lussier MT. Communication and patient participation influencing patient recall of treatment discussions. Health Expect. 2017 Aug; 20(4): 760–770.

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Diseases and Conditions When to see a rheumatologist

10 Warning signs you could have Sjögren’s syndrome

March 1, 2017
Sjögren's syndrome can cause dry eyes and dry mouth as well as many other symptoms. Read on to learn more!

Today is a most bizarre weather-related day.  It’s warm, like you don’t need a coat warm, and there’s a raging thunderstorm.  Did I mention it’s February in upstate New York?  In honor of this most bizarre day, I’d thought I’d write a few words on a somewhat bizarre and illusive autoimmune disease called Sjögren’s syndrome.

Henrich Sjögren gave Sjögren’s syndrome its name.  He was a Swedish physician who first described the disease in 1933.  Sjögren’s syndrome is a common autoimmune disease that primarily causes dryness.  But it’s a lot more complicated than that because Sjögren’s syndrome can involve almost any organ so can present with a myriad of symptoms.  The symptoms arise from infiltration of lymphocytes into glands and affected organs.  Simply put, Sjögren’s syndrome is on the differential diagnosis in any person who has a positive ANA presenting with unexplained symptoms.

10 Warning signs you may be suffering from Sjögren’s syndrome

The following are some of the common manifestations of Sjögren’s syndrome.  Believe me, there are A LOT more but these are some of the common ones.

  1. Dry eyes
  2. Dry mouth
  3. Swollen cheek(s) i.e., parotid gland enlargement
  4. Profound tiredness
  5. Joint pain, sometimes with swelling
  6. Swollen glands
  7. Numbness, tingling, burning of the skin
  8. Raynaud’s
  9. Shortness of breath with minimal work
  10. Having a child that suffered from congenital heartblock

Dry mouth symptoms

The following are some common symptoms of dry mouth.

  1. Difficulty swallowing dry foods
  2. Inability to talk continuously
  3. Change in taste
  4. Burning sensation
  5. Large dentist bill! – Cavities, cracked teeth, loose fillings
  6. Problems with your dentures
  7. Worsening heartburn
  8. Thrush

As you can see the symptoms are a little all over the place and quite frankly are kind of vague.  Furthermore, many different conditions can mimic some of these symptoms: dehydration, depression, various medications, uncontrolled diabetes, multiple sclerosis, hepatitis C, sarcoidosis, etc etc.  Literally.

Classification criteria

Now it’s important to note that the following classification criteria are used for research purposes, and not necessarily for the day-to-day clinic.  Although they are important, there is such a thing called the art of medicine.

As we all know, not everyone fits into a neat little box.

Recently the American College of Rheumatology and the European League Against Rheumatism came up with a new system to classify Sjögren’s.  Basically, a group of hot-shot Sjögren’s specialists got together, looked at the literature, probably had more than one heated discussion, and came up with the following.

To test positive you need to have a score ≥4.  There are five items but they are weighted differently.

  • 3 Points – Anti-SSA/Ro antibody positivity
  • 3 Points – Focal lymphocytic sialadenitis with a focus score of ≥1 foci/4 mm2
  • 1 Point – Abnormal Ocular Staining Score of ≥5 (or van Bijsterveld score of ≥4)
  • 1 Point – Schirmer’s test result of ≤5 mm/5 mi
  • 1 Point – Unstimulated salivary flow rate of ≤0.1 mL/min, each scoring = 1

The sensitivity of this score is 96% and the specificity is 95%.  The sensitivity tells you how likely you are to detect all cases of Sjögren’s syndrome and the specificity tells you how accurate you are with the diagnosis using these set of diagnostic criteria.  These are pretty good figures.

What does this mean?

As you can see, the diagnosis favors objective findings, NOT symptoms.  This is a huge change from the previous set of diagnostic criteria.  You’ll also note that positive ANA, rheumatoid factor, and positive anti-SSB/La antibody positivity are not included in the new classification criteria.

Now I don’t want people thinking that I think symptoms are unimportant.  They are VERY important.  It’s just that symptoms should prompt a workup looking for objective features of the disease.

Now, try to remember the 10 warning signs.  If you find yourself checking a few of these items, check-in to your local rheumatologist.

References

Rheumatology Secrets 3rd edition

Shiboski CH, et al. 2016 American College of Rheumatology/European League Against Rheumatism classification criteria for primary Sjögren’s syndrome: A consensus and data-driven methodology involving three international patient cohorts.Ann Rheum Dis. 2017 Jan;76(1):9-16.

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Overcoming Inflammation

How to boost joint wellness with turmeric

December 19, 2016
Turmeric capsules, supplementing with turmeric can help joint inflammation

A few years back, my mother-in-law brought me a grocery bag full of supplements.  You heard it, a GROCERY BAG of supplements.  To boot, this was her monthly supply.  Not lifetime, not yearly, her monthly supply.  Every month, she was ingesting a grocery bag full pills for various ailments.  That’s a lot pills.  This was very concerning to me.  First, this had to be very expensive and she had very little, if any knowledge of what she actually was taking.  What were some of the potential side effects?  Were any these interacting with each other?  Were these interacting with her prescribed medications for diabetes and thyroid disease?

Now, I don’t know about you but the world of supplements is downright daunting.  How do you know whether a supplement works for its intended purpose and is it safe?  There’s so much conflicting data out there.

Today, I’d like to show you how I approach assessing the efficacy and safety of any supplement, medication, or procedure.

I’m going to use turmeric, also known as Curcuma, as an example.  This is a supplement that is rapidly becoming an important player in the world of supplements.  It’s used to treat various conditions such as osteoarthritis.

Safety First!

First, here are a few safety tips.  The FDA regulates herbal supplements but they fall under a group called dietary supplements.  When it comes to dietary supplements, manufacturers don’t have to seek FDA approval to put their product on the market.  They don’t even need to prove that their product actually works.  Manufacturers must follow good manufacturing practices to make sure that the supplement is processed consistently and meets quality standards.

For example, they aren’t allowed to cut their product with pesticides and heavy metals.  In the event that they do, the FDA can take action against the manufacturer or distributor and have the product recalled.  Basically the FDA has to make sure dietary supplements aren’t harming anyone.

High risk situations

High risk situations include: you’re pregnant or breast-feeding, you’re about to have surgery, you’re younger than 18 or older than 65, or you’re already taking other medications.  Herbal supplements may interact with your other medications and these interactions could be harmful or life-threatening.

The following are items that should always be made available on the labels of all herbal supplements:

  • The name of the supplement
  • The name and address of the manufacturer or distributor
  • A complete list of ingredients
  • Serving size, amount, and the active ingredient

 

When in doubt, ask your doctor or your pharmacist.  I argue that, you should ALWAYS ask your doctor or pharmacist.

Anything you put in your mouth, whether it be FDA approved, regulated, or not, in a way is a medication and has the potential to cause good but also cause harm.

Of note, the FDA regulates American manufacturers and distributors.  If the supplement comes from anywhere else, all bets are off.  Many countries don’t screen for or regulate their manufacturers so it’s impossible to know whether they contain any unwanted and potentially dangerous components.  I’ve included a few websites in the reference section, to help you with your research.

The Efficacy of Turmeric Extracts and Curcumin for Alleviating the Symptoms of Joint Arthritis: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Osteoarthritis is super common.  It affects about a quarter of the worldwide population.  There are no known cures.  Well maybe joint replacement but that’s kind of extreme and even then, it’s not a magic bullet.  Turmeric is a spice used in cooking for a really long time.  Millenia…  This spice has different bioactive components, the most important one being curcuma.

Curcuma is actually really interesting.  It modulates a completely different inflammatory pathway as compared to standard arthritis medications like naproxen, ibuprofen, or celecoxib.  It modifies something called NF-κβ signaling.  This pathway helps maintain normal immunity, but it also is linked to cancer and other diseases such as heart disease, asthma, inflammatory bowel disease, and osteoarthritis.  Don’t get me wrong, abnormal NF-κβ activity DOES NOT cause cancer or osteoarthritis.  It simply appears to be active when these diseases are present.

Methods

That really long header you just read, is the title of a recent study that sought to look at all prospective randomized clinical studies using turmeric for arthritis.  This type of study is a meta-analysis.  The researchers found eight studies: 4 high quality studies and 4 moderate quality studies.  The researchers used the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) to assess arthritis severity.  This is how bad the arthritis is general, how it limits your quality of life.  They then measured pain with the pain visual analogue score (PVAS).  Thankfully the dose of turmeric was similar across the studies: about 1 gram/day without pain killers and about 500 mg/day with pain killers.

Results

What the researchers found was that people receiving turmeric had lower WOMAC scores compared to placebo.  People receiving turmeric reported improved morning stiffness and overall ability to move.  Moreover, the improvement seen in the turmeric groups were similar to those achieved in ibuprofen and diclofenac groups.  These are standard arthritis medications.  The problem with them is that they can cause stomach problems, they can affect the liver and kidneys, and they should not be used when someone has coronary artery disease or is on blood thinners.  The nice thing about turmeric is that it is not associated with any of these nasty side effects.  At high doses it can cause some diarrhea and it has NOT been studied in pregnant or lactating women.

So basically, the study concluded that turmeric or Curcuma more specifically, at dose of 1000 mg per day can help the decrease arthritis symptoms.  They also mentioned that the sample size (i.e., number of people) of the various studies they included were rather small and some of the studies weren’t top notch quality.

“Therefore, turmeric extracts and curcumin can be cautiously recommended for alleviating the symptoms of arthritis, especially osteoarthritis.”

A few words of caution:

  • Always carefully read the packaging.
  • More is not necessarily better. 8 -12 grams of curcumin can cause diarrhea and can cause anemia.
  • Notify your doctor when you decide to start a new supplement.

Are there other natural supplements that block NF-κβ?

So the question is, are there other natural supplements that block NF-κβ?  The answer is yes.  Researchers are actively looking into these potential supplements: green tea, rosehip, and resveratrol.  Whether theory translates into clinical efficacy?  Please stay tuned for more!

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.

References

NIH Dietary Supplement Label Database: https://dsld.nlm.nih.gov/dsld/

National Center for Complementary and Integrative Health: https://nccih.nih.gov/

Office of Dietary Supplements: https://ods.od.nih.gov/

Pubmed: https://www.ncbi.nlm.nih.gov/pubmed

Daily JM, Yang M, Park S. Efficacy of turmeric extracts and curcumin for alleviating the symptoms of joint arthritis: a systematic review and meta-analysis of randomized clinical trials. J Med Food. 2016 Aug;19(8):717-29.

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Diseases and Conditions When to see a rheumatologist

Signs you may be suffering from autoimmune joint pain

December 5, 2016
Signs you may be suffering from autoimmune joint pain

Pretty much everyone at some point in their lives is going to experience some form of joint pain.  But when does joint pain become more than just your typical, “I over did it” joint pain?  When does it become, “I think there is something really wrong” type of joint pain?  Is this joint pain caused by an autoimmune disease?

Here are a few typical scenarios.

Scenario #1

Mr. B is a 65-year-old man who presents to clinic with bilateral knee pain.  He first noticed the pain a few years ago.  He used to take some over-the-counter ibuprofen when it got real bad and that used to relieve the pain.  Over the past few months he has noticed worsening.  His left knee sometimes swells up.  The ibuprofen isn’t really cutting it anymore.  He tells me that the pain is worse after particularly active days.  When he sits down he feels pretty good but when he stands up, he feels pretty stiff but generally loosens up after a few steps.  He used to work construction and played football in college.

Scenario #2

Mrs. M is a 53-year-old woman who comes to the clinic for joint pain.  About 3 months ago, she noticed that she was having a lot of difficulty removing her rings.  She really didn’t pay much attention to it.  She told herself, “I must be eating too much salt”, “I must be getting old”.  Over the course of the next few weeks she began developing pain and swelling involving her knuckles.  The pain is particularly worse first thing in the morning and sometimes wakes her up in the middle of night at times.  She also states, “My hands feel like a claw in the morning”.  The stiffness last well over one hour in the morning and typically, by noon she’s as good as she is going to be for the rest of the day.  She’s tried ibuprofen, naproxen, and acetaminophen but nothing seems to work.  She also remarks that her hot flashes have gone completely out of control recently.

Sounds familiar?

Inflammatory vs. Non-inflammatory joint pain

In scenario #1, we have a man presenting with non-inflammatory joint pain.  This is your common wear and tear arthritis or osteoarthritis.  It can involve pretty much any joint you can think of.  What is important to note, is that it tends to progress slowly over time.  The joint pain tends to worsen with increasing activity and it typically responds, although maybe not completely, to over-the-counter anti-inflammatory medications.  Usually there is no joint swelling, but when it comes to the knees, swelling often does occur. A phenomenon called “gelling” can also occur with osteoarthritis.  This occurs when the joint has been in a resting position for a while and then becomes active.  The joint stiffens up or gels, but then loosens up pretty quickly.

In scenario #2, we have a woman presenting with joint pain that develops over the course of 3 months, or what we call a subacute presentation.  She’s experiencing joint swelling involving small joints and it’s associated with prolonged morning stiffness. What I mean by prolonged is over one hour.  Her symptoms also are worse in the morning.  She also experiences constitutional symptoms, i.e., hot flashes.  These are all hallmarks of inflammatory joint pain.  There are MANY different autoimmune diseases that present with inflammatory joint pain and they all have their own particular flavor.  Some like the knuckles, some like the ankles, some like the knees, some have a symmetrical distribution, and some are simply just random.  But they all share these specific key characteristics.  Rheumatoid arthritis and psoriatic arthritis are two common types.  Please follow the links to learn more about these.

Another important note about autoimmune joint pain.  It doesn’t go away.  This is very important. There are A LOT of different things that can cause a joint to swell, but most of them get better with time.  When it doesn’t, then you have to start wondering.

Summary

The difference between inflammatory versus non-inflammatory joint pain

Why is this important?

So why should you care?  Well, first, walking around with swollen joints isn’t exactly the most pleasant thing in the world.  It turns out that it isn’t exactly healthy for your joints either.  Autoimmune joint disease at times can cause permanent joint damage and it can happen in as little as 3 months.

Early identification and prompt treatment is essential to prevent joint damage.

So if you think that you or someone you know is suffering from autoimmune or inflammatory joint pain, give your local rheumatologist a buzz.

References

Rheumatology Secrets 3rd edition

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.

2 Comments