By Dr Ananya Mandal, MD
As rheumatoid arthritis affects not only physically but also emotionally and socially, therapy should be aimed at management of every aspect of the disease and not merely pain and deformity. It is to be remembered that rheumatoid arthritis has no absolute cure. The disease progresses with near complete joint damage and loss of function. There may be several severely painful flare ups as the disease progresses leaving the patient crippled and consequently anxious and depressed as well.
Management aims at relieving symptoms, preventing and halting progressive joint damage and maintenance of optimum joint function.
Treatment of symptoms
The characteristic feature of rheumatoid arthritis is pain, swelling and inflammation of the joints. Pain relievers and anti-inflammatory agents are the primary mode of therapy to relieving join pain and inflammation.
Pain relievers that reduce pain but do not act on inflammation include opioids like codeine and fever relievers like paracetamol. Rather than these agents Non-steroidal anti-inflammatory drugs (NSAIDs) are the drugs used widely to control symptoms of rheumatoid arthritis. These agents can reduce local inflammation and ease the symptoms to a great extent.
Management of flare ups and sudden inflammation
Glucocorticoids or steroids have been used in rheumatoid arthritis for years. These agents are anti inflammatory agents that reduce the inflammatory markers. Glucocorticoids are useful in acute flare ups of rheumatoid arthritis. There is rapid improvement and this allows time for more slowly acting agents like DMARDs’ actions to set in. Glucocorticoids can be used here in oral or injectable forms.
Preventing progressive joint damage
Progressive joint damage is prevented by the use of Disease-modifying anti-rheumatic drugs or DMARDs. These agents are the mainstay of therapy for rheumatoid arthritis. These agents include methotrexate, sulfasalazine, leflunomide, Hydroxychloroquine and Chloroquine, Gold salts and Ciclosporin.
These agents may be used alone or in combination. For example methotrexate, sulfasalazine, and hydroxychloroquine are used as triple therapy. DMARDs act on the pathology of the condition and thus can provide long term prevention of complete joint damage and bone erosion.
Similar to DMARDs are newer agents like TNF inhibitors or biologicals. These agents include etanercept, infliximab, adalimumab and certolizumab. There are several monoclonal antibodies like abatacept, rituximab, and tocilizumab that are also effective in rheumatoid arthritis.
Surgeries are often performed to retain joint function or prevent loss of joint function. For example, in rheumatoid arthritis affected hands the ligaments and tendons may be released (carpal tunnel release surgery for example) to ease the deformity. In severe cases the affected joints of the hips or knees may be replaced partly or completely to prevent further damage. This is called arthroplasty.
Physiotherapy in management of rheumatoid arthritis
Physiotherapy also plays an important role in maintaining optimum joint flexibility and strength. Guided exercises and movements help keep the joints supple and prevent or at the most delay deformities as well.
Physiotherapy may also be used to provide pain relief. Pain relief may be offered using heat or ice packs, massage, or transcutaneous electrical nerve stimulation (TENS). TENS uses a machine that applies a small pulse of electricity to the affected joint, which numbs the nerve endings and relieves pain. Physiotherapy also encompasses use of crutches and other medical devices that help in maintaining mobility.
Treating coexisting ailments
Management also involves treating coexisting ailments like heart disease, bone diseases, lung disease, vasculitis, eye complications, kidney disease, anxiety and depressive disorders.
This involves provision of adequate care and support to patients. As the joint functions deteriorate capability of performing daily tasks independently also declines. Supportive management involves occupational therapy to help patients maintain their independent living for as long as possible.
Patient education forms a greater part of this approach. For example, many elderly patients with rheumatoid arthritis fail to prepare and consume their food by themselves. This leads to severe loss of weight and under-nutrition. Aids to help them prepare and eat food can help prevent malnutrition. There are counsellors, behavioural therapists and psychiatrists who can provide care for the mental health of these patients.
Dietary advice and management
Diet is an important measure in the management of rheumatoid arthritis patients. Maintenance of an optimum weight by consuming a healthy balanced diet according to energy expenditure helps keep the symptoms in check. Obesity and weight gain predisposes one to inflammation worsening rheumatoid arthritis.
Becoming underweight is also common among patients with rheumatoid arthritis due to multiple reasons including loss of appetite, inability to feed oneself or prepare food as the disease progresses, side effects of the medications or side effects of depression associated with disability.
Several important nutrients must be supplemented and included in diet. This includes Omega 3 fatty acids present in oily fish such as tuna, salmon, sardines, anchovies, herring, mackerel etc. as well as in flaxseed, walnuts, canola oil etc. Omega 3 fatty acids also relieve joint pain and stiffness in rheumatoid arthritis.
Diet should also incorporate fruits and vegetables that contribute to antioxidants in food. Antioxidants can help fight inflammatory processes. Minerals like Calcium and Vitamins like Vitamin D are very essential for joint and bone health. Iron and folic acid are important for prevention of anemia (iron).
Regular vaccination for influenza and other diseases like pneumococcal pneumonia helps protects rheumatoid arthritis patients who generally are prone to infections. Regular follow ups for disease progress and treatment related side effects are similarly important.
Alternative and complementary therapies
There are several alternative and complementary therapies that have been used in rheumatoid arthritis. In most cases there is little or no evidence that these actually provide benefits in the treatment of rheumatoid arthritis. Some of these include acupuncture, acupressure, osteopathy, cupping, hydrotherapy, electrotherapy, nutritional supplementation with glucosamine sulphate, chondroitin and fish oil etc.
Reviewed by April Cashin-Garbutt, BA Hons (Cantab)