Winning the War Against Rheumatoid Arthritis
By Nathan Wei
RA is a condition that forces half of patients to become disabled
from the work force within five to ten years… and reduces life expectancy by
as much as 18 years. RA affects about one per cent of the world’s adult population,
most commonly women between the ages of 30 and 50.
The good news is that a tremendous amount of progress has been
made within the last ten years in identifying patients earlier and treating
the disease more aggressively. Patients with RA, if treated appropriately, can
lead a relatively normal life. This is in stark contrast to the wheel-chair
bound existence common as recently as 20 years ago!
Experts in the field consider early rheumatoid arthritis to
be a medical emergency with mortality and morbidity equal to that for diabetes,
asthma, heart disease, and other life-threatening conditions.
Rheumatoid arthritis attacks the joints in a symmetric fashion
(both sides of the body affected equally) with the most common areas being the
hands, wrists, ankles, knees, and feet. In addition to the swelling and pain,
patients with RA often have profound fatigue and stiffness.
Rheumatoid arthritis is an autoimmune disease that attacks not
only joints, but internal organs such as the blood vessels, lungs, heart, and
eyes. Patients with RA are at increased risk for heart attack, stroke, and lymphoma.
Since many other types of arthritis such as gout, lupus, and
osteoarthritis can look like RA a careful diagnostic approach is needed.
Laboratory testing has its pitfalls. The rheumatoid factor,
a blood test found to be positive in about 80 per cent of individuals with RA,
may also be positive in other disease conditions. Couple that with the fact
that 20 per cent of patients with RA will be rheumatoid factor negative, then
it becomes clear a diagnosis should not hinge on the results of blood tests
alone.
Imaging procedures can also be misleading. Conventional x-rays
often miss the erosions found with early disease. Newer imaging technologies
such as magnetic resonance imaging (MRI) and ultrasound are much more sensitive.
After the diagnosis is made, there is even more hope for a patient
today. In the past, non steroidal anti-inflammatory drugs (NSAIDS) used to be
considered a cornerstone of therapy. That is no longer true.
Disease-modifying anti-rheumatic drugs (DMARDS) are being used
earlier. Among the DMARDS currently being used are methotrexate, leflunomide
(Arava), azathioprine (Imuran), sulfasalazine (Azulfidine), cyclosporine, and
hydroxychloroquine (Plaquenil). These drugs attack the immune cells responsible
for chronic inflammation. While DMARDS alone in combination are effective, they
are relatively non-specific. Often, combinations of DMARDS are required.
Biologic Response Modifiers (BRMS) can target the disease more
specifically than DMARDS. RA is a disease that is dependent on the signaling
that occurs between immune cells. The signaling takes place through the use
of special chemical messengers called cytokines. BRMS act at both the cytokine
(chemical messenger) as well as the cellular level allowing the disease to be
better controlled and in some instances put into remission.
Biologic response modifiers, which include drugs that suppress
tumor necrosis factor (TNF), appear to be particularly effective.
Tumor necrosis factor is a protein that is produced by the immune
cells. TNF is the major culprit responsible for inflammation-inducing damage.
By block the effects of TNF, better control of RA can be achieved.
Three anti-TNF drugs are currently available: etanercept (Enbrel),
adalimumab (Humira), and infliximab (Remicade). Another biologic drug, anakinra
(Kineret) blocks interleukin, a different cytokine.
These drugs allow patients to have their disease controlled
to such an extent that most are able to enjoy a normal work and leisure existence.
On the horizon are other biologic drugs that work at different
points in the immune system- on different cytokines and on different pathways-
to allow even greater as well as more specific control of disease. Since rheumatoid
arthritis is a disease with many different cytokine and cellular mechanisms
responsible for damage, attacking the disease at different points makes sense.
In the future it may be possible to identify patients through
specific tissue signals (called “biomarkers”). These biomarkers will allow physicians
to type patients and give patients the specific therapy that will work best
for them. Once that is achieved, the possibility of a cure becomes a reality.
Everything, though, starts with early accurate diagnosis. If
damage is allowed to occur the chances for remission drop dramatically!
Dr. Wei (pronounced “way”) is a board-certified rheumatologist
and Clinical Director of the nationally respected Arthritis and Osteoporosis
Center of Maryland. He is a Clinical Assistant Professor of Medicine at the
University of Maryland School of Medicine and has served as a consultant to
the Arthritis Branch of the National Institutes of Health. He is a Fellow of
the American College of Rheumatology and the American College of Physicians.
For more information on arthritis and related conditions, go to: http://www.arthritis-treatment-and-relief.com
