SYSTEMIC CONDITIONS
Rheumatoid
Arthritis
This disease
causes chronic inflammation and warrants the attention of optometrists.
Rheumatoid arthritis falls into a collective group known as autoimmune diseases. The immune system is a complicated network that normally defends the body against bacteria, viruses and other invading microorganisms. In the case of a patient with an autoimmune disease, the immune system mistakenly attacks the tissues and organs of a person's own body. Rheumatoid arthritis is a disease that causes chronic inflammation of the joints, as well as other organs in the body. In most cases, this condition is a chronic and progressive illness that has the potential to cause joint destruction and functional disability.
Etiology
We still do not know the precise cause of rheumatoid arthritis. Some researchers believe that the tendency to develop rheumatoid arthritis is genetically linked. The theory is that certain infections or factors in the environment might trigger the immune system to attack the body's own tissues in susceptible patients. Regardless of the exact trigger, the result is an immune system that promotes inflammation in the joints and occasionally other tissues.
Signs and symptoms
The course of rheumatoid arthritis varies depending on the severity of the disease. The typical pattern involves alternating periods of flare-ups interspersed with periods of remission. The periods of remission can occur spontaneously or with treatment, and can last weeks, months, or years. When the disease is active, common symptoms include fatigue, lack of appetite, low-grade fever, muscle/joint aches and stiffness. During the active stages, the joints frequently become red, swollen, painful and tender. This occurs because the tissue that lines the joint (synovium) becomes inflamed, resulting in the production of excessive joint fluid (synovial fluid). In many cases, the synovium also thickens with inflammation (synovitis).
Multiple joints are usually inflamed in a symmetrical pattern, with both sides of the body being affected. The small joints of both the hands and wrists are commonly involved. Over time, chronic inflammation can cause damage to bodily tissues, cartilage and bone. This damage leads to a loss of cartilage, and erosion and weakness of the bones as well as the muscles, resulting in joint deformity, destruction, and loss of function.
The inflammation associated with rheumatoid arthritis can affect organs and areas of the body other than the joints. Inflammation of the glands of the eyes and mouth leads to dryness and is referred to as Sjogren's syndrome. As optometrists, we need to question patients with rheumatoid arthritis specifically about this condition.
Other associated conditions:
• Pleuritis. Rheumatoid inflammation of the lung lining can cause chest pain with deep breathing or coughing.
• Anemia, a reduction in the number of red blood and/or white blood cells.
• Rheumatoid nodules, firm lumps under the skin around the elbows and fingers.
• Vasculitis can impair blood supply to tissues and lead to tissue death.
Diagnosis
Diagnosis is based on the pattern of symptoms, distribution of the inflamed joints, and blood and x-ray findings. In many cases, the primary care physician may co-manage these patients with a rheumatologist.
Certain blood tests can also help with a definitive diagnosis. A blood antibody called the "rheumatoid factor" can be isolated in 80% of patients with RA. In addition, citrulline antibody is present in most patients with the disease. Another antibody called "the antinuclear antibody" (ANA) is also commonly detected in patients with rheumatoid arthritis. Lastly, a sed rate, which is a measure of how fast red blood cells fall to the bottom of a test tube, can be helpful. Rarely do abnormalities in these blood tests alone lead to a diagnosis of rheumatoid arthritis. Instead, they are used with other findings to complete the picture.
As the disease progresses, joint x-rays can show bony erosions typical of rheumatoid arthritis in the joints, as well as monitor progression.
Treatment
There is no known cure for rheumatoid arthritis. The goal of treatment is to reduce joint inflammation and pain, maximize joint function, and prevent joint destruction and deformity. Optimal treatment for the disease involves a combination of medica- tions, rest, joint strengthening exercises and joint protection.
Two classes of medications are used to treat rheumatoid arthritis: fast-acting, first-line drugs and slow-acting, second-line drugs, also referred to as Disease-Modifying Antirheumatic Drugs (DMARDs). The first-line drugs are used to reduce pain and inflammation. The second-line drugs promote disease remission and prevent progressive joint destruction.
"First-line" medications
Examples of nonsteroidal anti-inflammatory drugs (NSAIDs) include acetylsalicylate (aspirin), naproxen (Aleve, Bayer Healthcare, Naprosyn and Anaprox, Roche Laboratories), ibuprofen (Advil, Wyeth; Motrin, McNeil and others), and etodolac (Lodine, Wyeth Ayerst Laboratories). NSAIDs are medications that can reduce tissue inflammation, pain and swelling. These agents are safe and well-tolerated in most patients. The most common side effects of aspirin and other NSAIDs include stomach upset, abdominal pain, ulcers and gastrointestinal bleeding. In order to reduce stomach side effects, NSAIDs are usually taken with food. Some patients may require additional medications to help protect the stomach from the ulcer effects of NSAIDs. These medications include antacids, sucralfate (Carafate, Axcan Scandipharm), proton-pump inhibi- tors like Prevacid (lansoprazole, TAP Pharmaceutical Products) and others, and misoprostol (Cytotec, G.D. Searle).
Corticosteroid medications can be given orally or injected directly into tissues and joints. They are more potent than NSAIDs in reducing inflammation, and in restoring joint mobility and function. Corticosteroids are useful for short periods of active disease, or when the disease is not responding to NSAIDs. However, corticosteroids can have serious side-effects, especially when given in high doses for long periods of time. These include weight gain, facial puffiness, thinning of the skin and bone, easy bruising, cataracts, risk of infection, muscle wasting, and destruction of large joints, such as the hips.
"Second-line" drugs
The "second-line" or "slow-acting" medicines may take weeks to months to become effective. They are used for long periods of time to help promote remission, thereby retarding the progression of joint destruction and deformity.
• Hydroxychloroquine (Plaq-uenil, Sanofi-Synthelabo) is used over long periods. Possible side-effects include upset stomach, skin rashes, muscle weakness and vision changes. While vision changes are rare, monitor patients taking hydroxychloroquine regularly, including annual fundus photography and 10-2 visual field with red stimulus.
• Sulfasalazine (Azulfidine, Pharmacia & Upjohn) is typically used for conditions such as ulcerative colitis. However, it is often used in combination with anti-inflammatory medications in the management of rheumatoid arthritis. This agent is well-tolerated with side effects related to rash and upset stomach.
• Methotrexate (Rheumatrex, STADA Pharmaceuticals) is an immunosuppressive drug. Other immunosuppressive medicines sometimes used in the management of rheumatoid arthritis are azathioprine (Imuran, GlaxoSmithKline), cyclophosphamide (Cytoxan, Bristol-Myers Squibb), chlorambucil (Leukeran, GlaxoSmithKline), and cyclosporine (Sandimmune, Novartis). Due to potentially serious side-effects, immunosuppressive medicines are generally reserved for patients with very aggressive disease, or those with serious complications of rheumatoid inflammation, such as vasculitis.
Advancements
Newer "second-line" drugs for the treatment of rheumatoid arthritis include leflunomide (Arava, Aventis Pharmaceuticals), and the "biologic" medications etanercept (Enbrel, Amgen and Wyeth), infliximab (Remicade, Centocor Pharmaceuticals), anakinra (Kineret, Amgen), and adalimumab (Humira, Abbott Laboratories).
• Leflunomide blocks the action of an important enzyme that has a role in immune activation. Therefore, it can have a powerful effect on halting progressive joint damage. However, side-effects include liver disease, diarrhea, hair loss, and/or rash in some patients.
• Etanercept, infliximab, and adalimumab are biologic medications that intercept a protein in the joints before it can act on its natural receptor to "switch-on" inflammation. Patients who respond to these agents see significant improvement. Etanercept must be injected subcutaneously once or twice a week.
• Infliximab is given by infusion directly into the vein. Adalimumab is injected subcutane- ously either every other week or weekly. Injection of each is currently recommended after other medications have been proven ineffective.
Dr. Gupta practices full scope optometry in Stamford, Conn. He's also clinical director of The Center for Keratoconus at Stamford Ophthalmology. E-mail him at Deegup4919@hotmail.com.
Ms. Gupta is a clinical pharmacist who has years of both retail and hospital pharmacy experience.