Clinical Immunology & Rheumatology

Introduction

What Does a Rheumatologist Treat ?
A rheumatologist is a physician, who is further trained in the diagnosis and management of musculoskeletal diseases and systemic autoimmune conditions. Patients with rheumatic diseases commonly present with pain, swelling & stiffness of the joints or low back pain. If untreated this arthritis can lead to deformities and disability. While Orthopaedicianstreat joint disease surgically, Rheumatologists treat joint diseases medically.
Apart from the common arthritis like, rheumatoid arthritis, osteoarthritis, a Rheumatologist also treats gout, chronic back pain, tendinitis, osteoporosis, fibromyalgia etc. Autoimmune diseases can have multi-system involvement and can affect any organ depending upon the underlying disease. Autoimmune conditions occur when the immune system attacks its own cells and tissues leading to unwanted inflammation and organ damage.

When Should I See a Rheumatologist ?
Most of us experience joint or muscle pain at some point in our lifetime. Though most of the joint symptoms resolve by itself, some may persist. If your pain is not resolving in 1-2 weeks it is better to take an expert opinion. If joint symptoms are associated with any of other symptoms like more stiffness in morning, joint swelling, fever, weight loss, skin rash etc then it important for a patient to see a rheumatologist as early as possible.
Earlier referral should be made if you have relatives with autoimmune or rheumatic disease (as these conditions can run in families) or if the symptoms are significantly worsening over a short period of time. Joint damage can occur if the symptoms of joint pain are ignored or not treated properly over a period of time. This damage cannot always be reversed with treatment and may be permanent. Do not delay appropriate evaluation.

What Should I Expect From a Rheumatology Visit ?
Rheumatic diseases are occasionally complex in nature and difficult to diagnose, so rheumatologists will gather a complete medical history and perform a physical exam to look for signs and symptoms of inflammation throughout the entire body and musculoskeletal system.
A rheumatologist may order additional laboratory tests to confirm the diagnosis. All of these results will be combined to determine the appropriate diagnosis and develop a personalized treatment plan for a particular patient.

Services provided

  • • Arthritis and Pain Management
  • • Rheumatoid Arthritis Treatment
  • • Connective tissue disease(lupus,Sjogren syndrome) Management
  • • Gout Treatment
  • • Psoriasis and psoriatic arthritis Treatment
  • • Scleroderma Treatment
  • • Myositis treatment
  • • Systemic Sclerosis (Scleroderma) treatment
  • • Treatment of vasculitic disorders and their mimics
  • • Sarcoidosis treatment
  • • Treatment of Ankylosing Spondylitis ,Reactive arthritis and IBD associated arthritis
  • • Treatment of osteoporosis and disorders of bone metabolism
  • • Treatment of fibromyalgia
  • • Osteoarthritis management
  • • Treatment of autoimmune diseases in children such as juvenile arthritis, juvenile lupus and myositis
  • • Management of primary immunodeficiency disorders in children
  • • IVIG and Biologic therapy
  • • Intra-articular injections (steroids, PRP)
  • • MSGB(Minor salivary gland biopsy), synovial, kidney and nerve biopsy
  • • Synovial fluid analysis including crystal examination for gout and CPPD
  • • MSK Ultrasound

Treatments

Ankylosing spondylitis (AS)

What is Ankylosing spondylitis (AS)?
It is a type of autoimmune disease which causes arthritis of the spine predominantly. It belongs to spondyloarthritis group of diseases.

What is the cause of Ankylosing spondylitis?
Exact cause is unknown. Most autoimmune disease have genetic risk factors and environmental triggers which dysregulate immune system. The immune system starts attacking the joints & other structures. In AS, it attacks the sacroiliac joints, joints of the spine, hip & occasionally the other joints. It may also cause inflammation in eyes which is called as iritis or uveitis, presenting with pain, redness and blurred vision.

What symptoms occur in Ankylosing spondylitis ?
Main symptom of AS is low back pain. It is associated with early morning stiffness. Back pain of ankylosing spondylitis usually is severe at rest and gets better with activity. It is more severe in the nights and is associated with a stiff back early in the morning for atleast more than 30 minutes.AS can also cause joint pains usually in the lower limbs. Heel pain, sole pain are also common.How is Ankylosing spondylitis different from other types of arthritis like Rheumatoid arthritis?

In Rheumatoid arthritis, inflammation of small joints is the hallmark whereas in AS the sites of inflammation is predominantly spine and entheses which are sites of attachment of ligaments and tendons to bones.

How is Ankylosing Spondylitis diagnosed ?

Rheumatologist assesses your medical history, examines the musculoskeletal system and based on the clinical scenario orders for blood tests, X ray or MRI. HLA B27 genetic testing may also be ordered as a part of diagnostic work up.

If I have HLA B27 positivity, does that mean I have AS ?
Definitely No. Not all persons with HLA B 27 will AS. So it is important this test is interpreted by your Rheumatologist in conjunction with the clinical scenario and imaging evidence.How does Ankylosing spondylitis progress?

Over a period of time with persistent inflammation, calcium gets deposited on ligaments of the spine. The vertebral joints fuse & become stiff. This leads to difficulty in bending, turning the neck.

Can Ankylosing spondylitis be cured ?
Early treatment which relieves symptoms and prevents progression of disease can help a person lead near normal life. There is no permanent cure without treatment.How is Ankylosing spondylitis treated?

The first line of treatment are the NSAIDs (non-steroidal anti inflammatory drugs) like indomethacin, diclofenac, naproxen etc. No NSAID is superior to another. These drugs give relief from pain for most patients. For joint and tendon related pains local injections of steroids (localized joint pain, tendon sheaths) or oral steroids (multiple joint pains) are effective. If there is no response to the above treatment, disease modifying antirheumatic drugs (DMARDs) such as sulfasalazine, methotrexate, leflunomide may be useful. If there is no response to DMARDs, then biological injections like TNF alpha blockers or IL-17 blockers can be used. Biologics like TNF alpha blockers are the most effective drugs available in treating the spinal and peripheral joint symptoms. Examples of TNF alpha blockers available in our country are infliximab (administered as Intravenous infusion), etanercept, adalimumab, golimumab (administered under the skin).

Is there any role for physiotherapy in ankylosing spondylitis?
Yes. A very important role. Patients must do regular exercises that promote spinal extension and mobility as advised by the doctor and physiotherapist. Activities like aerobics, walking, swimming, cycling etc are encouraged

What are the problems other than joint pain that are seen in ankylosing spondylitis ?
Uveitis :Inflammation of a part of eye called uvea causing redness, pain and blurred vision. Eye examination by ophthalmologist as and when suggested by your Rheumatologist is a must for AS patients.
Psoriasis : Any changes in skin, nail and scalp must be reported to your Rheumatologist in the form of Patches, scaly plaques, discolored nails,excessive dandruff could be psoriasis which is seen in some patients with AS and vice versa. Psoriasis is managed in conjunction with a dermatologist.
Gastrointestinal symptoms : diarrhea and constipation could be due to intestinal inflammation which need further evaluation by Rheumatologist in conjunction with gastroenterologist.
Osteoporosis : Long standing AS and those with fused spine are at risk for developing osteoporosis which needs evaluation by the Rheumatologist. You may need to take calcium and vitamin D supplements and anti-osteoporotic as prescribed by Rheumatologist

I have AS. I have heard that it runs in families. Should I plan a family?
If you are HLA B 27 positive & your child inherits the gene, there is only 5- 20% chance that he/ she will develop AS. If you are HLA B 27 negative, then the chance of your child developing AS is even lower. Hence AS should not deter you from starting a family.

Is stem cell therapy useful for ankylosing spondylitis?
No. Stem cell therapy for AS is in experimental stages & is currently not approved/ proven to be useful for AS.

Does smoking affect ankylosing spondylitis?
Yes. Smoking has been shown to increase the inflammation of AS & also reduce the responsiveness to therapy.
Rheumatoid Arthritis (RA)

1.What is Rheumatoid Arthritis (RA) ? What are the common symptoms?
Rheumatoid arthritis is an autoimmune disease which means that immune cells of body are attacking its own cells and damage them. In RA they are attacking lining of the joints called as synovium leading to joint pain, swelling and redness. Patients experience joint pain, stiffness. The disease generally affects small and large joints in a symmetrical fashion. Misfiring of immune cells is not limited to the joints and there are other manifestations as well, like long standing cough when lungs are affected or nodules or dryness of mouth or eyes.

2. What symptoms should alert you?
• Four or more joints involved
• Early morning stiffness of more 30 minutes or stiffness after a period of rest
• Presence of other symptoms like nodules or dry cough or breathlessness
• Dryness of mouth or eyes or tingling / numbness or an ulcer3. How common is the disease?

It affects around 1% of population worldwide. It affects females more commonly and can affect any age group from children to adults to old aged individuals.

4. What causes RA? Can we prevent it or predict it?
There are multiple reasons which have been explored but none alone can explain this complex disease. Genes, infection and environmental factors all play a role. Smoking definitely increases risk, worsens the disease and decreases the effect of the medications.

5. Is it familial? Can it run in families?
There is a genetic component to disease but it does not really predict the chances your relative might get the disease. In fact, even in identical twins, chances of getting RA in other twin, if one has the disease, is only 15-20%. So it is not necessary that you will transfer the disease to your future generations.

6. Does diet influence disease activity?
One must take a healthy diet. Avoid high fats, high sugar and refined and processed foods. If one particular food item worsens your joint pain every time you consume, you may stop it. Certain food are considered anti-inflammatory like those rich in omega 3 fatty acids. These are avocado, flax seeds, chia seeds, almonds walnuts, soyabean and fish.

7. Is there role of stress?
Some people recollect a period of stress or trauma before the advent of these symptoms or may relate to disease flare during periods of stress. It is not clear whether such stressful events are more common or is it a recall bias.

8. How long does one need to take medications?
This is another difficult question and there is no straight to answer. Generally, it is lifelong like any diabetes or hypertension. But with early diagnosis, treatment and after a period of sustained remission, it is possible to come down to minimum number of drugs(s). In a few patients medicines can be stopped completely also.

9. What is remission or low disease activity?
Remission or low disease activity means your disease is under control with no or minimal pain or swelling in the joint and normal blood reports.

10. What is the importance of physiotherapy?
Entire world is realising the importance of yoga and physiotherapy in general. It boosts your immune system, unnerves and relaxes it. In fact, it forms the most important part of your treatment. It is free of cost but needs lot of discipline as we often neglect this mode of treatment. Yoga, aerobics, deep breathing exercise are all very important.

11. Is there a cure?
Management can help attain a state similar to cure.Currently there is no cure but remission or low disease activity with available drugs are achievable. What is most important is timely diagnosis and management.

12. What are other complications I should be aware about?
As discussed briefly, RA can affect other internal organs in the body. Discuss your symptoms with your doctor. Remember to check your blood pressure, sugar and cholesterol as long standing disease can affect your general health. With good disease control and monitoring, these can be prevented or very well taken care of.

13. Can I plan my pregnancy with Rheumatoid Arthritis?
Yes, you can get pregnant but discuss your medications with doctor. Some drugs like methotrexate, Leflunomide are not safe during pregnancy. Ideally disease should be in remission or a low disease activity status for six months before you conceive. Monitoring of fetal growth should be done.
Systemic Lupus Erythematosus (SLE/Lupus)

What is Systemic Lupus Erythematosus (SLE/Lupus)?

Systemic lupus erythematosus (SLE/Lupus) is an autoimmune disease. Normally, immune system helps to protect our body from many bad things like infections and cancer. In autoimmune diseases like lupus, one’s own immune system starts attacking its own cells and tissues. It can occur at any age (mostly 15 to 45 years but can occur in children too). It is seen more in women than in men. SLE / Lupus mean the same disease.

What is the cause of SLE / lupus?
The exact cause of SLE is not known. The risk of lupus is associated with some genes present in one’s body. It has also been found to be associated with environmental factors like sunlight exposure, certain medications, viruses, stress etc. However, in most patients, we don’t find any single gene or environment factor. Mostlikely,it is a combination of many things which causes someone to have SLE.

What are the symptoms of Lupus?
SLE can affect any system or organ of the body. Lupus patients can develop many different types of symptoms.
The most common lupus symptoms are,

  • • • Fatigue or tiredness
  • • Skin rashes, which get worse on exposure to sunlight. Many patients have a butterfly shape (malar) rash on face.
  • • Joint pain, stiffness more in mornings and joint swelling
  • • Frequent ulcers (or sores) in mouth or nose
  • • Hair fall / loss
  • • Lupus patients can also have following symptoms or problems
  • • Weight loss
  • • Frequent fevers without any infections detected
  • • Headaches and brain problems (like fits or seizures, mood swings, difficulty to think clearly, sudden psychotic or unusual behavior, stroke or paralysis)
  • • Swelling and puffiness of hands, feet or eyes
  • • Eye problems – redness, vision problems
  • • Muscle weakness
  • • Recurrent miscarriages, blood clots etc
  • • Vomiting, loose stools
  • • Get cold hands and feet, which change color to white or blue, especially when exposed to cold
  • • Passing less urine

Also, having above symptoms doesn’t itself mean one surely has lupus. Many of these symptoms like hair fall, fatigue, oral ulcers, swelling etc. are pretty common in people without having lupus. A Rheumatologist makes sure that a patient is not having these symptoms due to other common causes.

Are there any long-term risks in Lupus?
Lupus is a variable and unpredictable disease and can be life threatening for a minority of patients whose vital organs like kidneys, brain, heart, blood etc. are affected. However, with modern treatments and careful monitoring of the condition the disease can be brought under control in most patients.

How is SLE diagnosed?
When one thinks that a patient has lupus, it is best to get the patient evaluated by a Rheumatologist. They go into details of symptoms, examine, and after various investigations (blood tests, X ray, urine tests etc.), can make or reject a diagnosis of SLE. SLE investigations can be very difficult to interpret and no single test can confirm it. Hence, only an expert should make a diagnosis of SLE. Once it is confirmed that a patient has SLE, we may have to do more investigations to find which organs are involved.

How is Lupus managed?
Lupus cannot be cured but it can very well be controlled. A number of different drugs may be needed depending on which symptoms you experience

What types of medications are used in treatment of SLE?
Different types of drugs can be used to treat lupus. These are advised according to how severe the disease is and what organs are involved in the patient. The main aim of treatment is to bring lupus disease under control and prevent organ damage. The drugs used in lupus are to control the overactive immunity which is attacking patient’s own body. They also help to decrease the inflammation in various organs.
• Non-steroidal anti-inflammatory drugs (NSAIDS) : These are drugs like ibuprofen, naproxen etc, especially given if patient has joint pains.
• Medicines like hydroxychloroquine and chloroquine :They were originally discovered to treat malaria, but can help a lot in lupus patients.
• Steroids and other medications (like methotrexate, azathioprine, mycophenolate, cyclophosphamide, rituximab etc.): These help to control or suppress the overactive immune system. Steroids are usually used only at start when disease is moderate to severe. They are very helpful to control disease to give relief and prevent organ damage. Later we use other medications and decrease steroids to maintain the control.Experts in treating SLE use the drugs given below in best possible way to avoid or minimize the side effects.

Can SLE affect my chances of getting pregnant ?
There are higher chances of problems in pregnancy in SLE females as compared to normal female pregnancies. It is important to let your treating Rheumatologist know if you want to plan a pregnancy in near future. The expert can guide you and take proper measures to avoid problems in pregnancy. For example, they will advise avoiding pregnancy if your disease is active. However, once your disease is well controlled for at least 6 months, pregnancy can be safely planned under doctor’s advice.

What can I do on my part to keep lupus under control?
• Have a healthy lifestyle: It can help lupus patients a lot. Eat healthy diet - lots of vegetables, fruits, nuts, dairy products, avoid sugar and refined foods etc. Stay active. Even mild home based exercises, walking and using stairs whenever possible etc are good ways to stay active – It helps Lupus patients to keep muscles and bones strong. Avoid smoking or other addictions. Try to avoid / manage mental and physical stress. One can consider doing relaxation exercises – like meditation or mindfulness etc.
• Avoid excess sun exposure: Sunlight can cause a lupus rash to flare and may even trigger a serious flare of internal organs itself. Use a good sunscreen with sun protection factor (SPF) of at least 30 or take doctor’s advice.
• Show an expert in lupus (like a rheumatologist) : Follow their directions
• Get educated about SLE: It is very important for patients to have good information and be educated about their disease, so that they can take better treatment decisions. They should ask their doctor to provide with patient information material.

Fibromyalgia

What is Fibromyalgia?
Fibromyalgia (Fibromyalgia) is the most common cause of chronic widespread musculoskeletal pain, often accompanied by fatigue, cognitive disturbance, and multiple somatic symptoms.

What causes Fibromyalgia?
Fibromyalgia is shown to be a syndrome of low pain threshold and altered pain perception. The exact cause of Fibromyalgia is not known. It is likely to be multifactorial. Genetic predisposition with disease running and families is well recognised. Environmental insults including viral infections, stress (both emotional and physical) and depression in some cases can contribute to the onset of illness. Fibromyalgia can coexist with rheumatic disease like rheumatic arthritis, systemic lupus erythematosus and Sjogren’s syndrome.

How common is Fibromyalgia?
It is very common. Upto 3% of the population suffers from it. It is most common around the 4th decade. Fibromyalgia is more common in women but it can occur in men and children too.

How is Fibromyalgia diagnosed?
The diagnosis is based on the combinations of symptoms, physical examination. Widespread aches and pains affecting both sides of the body are the hallmarks of Fibromyalgia. Neck pain and back pain are the common symptoms. Extreme fatigue, early morning stiffness, non-refreshing and non-restorative sleep, subjective feeling of swelling of limbs and joints, numbness of peripheries are also common. Migraine like headaches, abdominal symptoms like bloating, heart burn, tendency to visit toilet frequently, particularly after food ( irritable bowel syndrome ) and urgency to pass urine frequently (irritable bladder) are other associated symptoms. Fibromyalgia patients also have multiple tender points over the body, which the doctor can identify on examination. So it is the combination of symptoms and the presence of tender points that lead to the diagnosis of Fibromyalgia. As mentioned earlier, there are no laboratory tests in the diagnosis of Fibromyalgia. Many patients are suspected to have other diseases and are investigated extensively before Fibromyalgia is diagnosed.

How is Fibromyalgia treated?
Usually Fibromyalgia symptoms are mild and patients mange to lead a normal life in spite of the pain. In some cases, pain can be severe. There is no cure. But the symptoms can always be helped. Unlike the pain of arthritis, the pain of Fibromyalgia usually does not respond to pain killers. Different types of medicines may be needed . Antidepressant drugs used in doses much lower than what is needed to treat depression are useful is correcting sleep disturbance and in improving pain threshold. Drugs commonly used are Amitriptyline, nortriptyline, Duloxentine, milnacipran. Anti convulsant drugs like pregablin and gabapentin also help the pain of fibromyalgia. Cognitive behavioural therapy (CBT) will help patients to take control of his of her illness. This is usually done by trained pain psychologists.

What exercises are recommended for Fibromyalgia?
Exercise recommend for fibromyalgia patients is cardiovascular fitness training, usually with low-impact aerobic exercise. This approach is supported by various studies in fibromyalgia patients. Exercise can be of significant benefit for pain and function, and may be of benefit for sleep. However, in practice, it can be difficult for fibromyalgia patients to start exercises because patients generally perceive that their pain and fatigue will worsen as they begin to exercise. The specific cardiovascular fitness program should be individualized based upon patient preference and physical status. Before recommending a particular program, it is useful to assess the patient's current level of physical activity, exercise tolerance, and fitness; and preferences or interest in self-directed versus therapist-directed stretching and strengthening exercise and in techniques such as yoga and tai chi. Low-impact aerobic activities such as fast walking, biking, swimming, or water aerobics are most successful among the interventions that have been studied. The type and intensity of the program should be individualized and should be based upon patient preference and the presence of any other cardiovascular, pulmonary, or musculoskeletal comorbidities. Physical therapists or exercise physiologists familiar with fibromyalgia can provide helpful instruction. Some patients need to start with a low level and shorter duration per exercise session and to very gradually increase the intensity and frequency of exercise as tolerated over a number of weeks to months. Optimal cardiovascular fitness training generally requires a minimum of 30 minutes of aerobic exercise three times per week in a range near target heart rate. However, even with gradual increases in exercise, some patients may not achieve this goal, and patients should be encouraged to continue exercising regularly. Additional forms of exercise that have shown some benefit in fibromyalgia but that are not primarily directed at developing aerobic fitness include tai chi and yoga. The more intense the level of physical activity and a lesser amount of sedentary time correlate with better scores for pain and improved quality of life in women with fibromyalgia. Mixed exercise programs that utilize a variety of techniques, including aerobic and strength training, may be better tolerated, although there are insufficient studies to demonstrate superior efficacy over any single exercise modality.

Systemic Sclerosis (Scleroderma)

What is Systemic sclerosis (Scleroderma) ?
Scleroderma literally means "hard skin," which is a common finding in this disease. It occurs due to the abnormal growth of connective tissue. There are broadly two categories of scleroderma: localized scleroderma ( affects skin and rarely muscles ) and systemic sclerosis ( affects skin and internal organs like heart, lung, intestines etc). Localized scleroderma generally remains limited and does not progress to the systemic form. Localized scleroderma further can two types; morphea and linear. Systemic sclerosis affects the skin, muscles, blood vessels and internal organs. It is often divided into diffuse and limited disease. Diffuse systemic sclerosis is a rare disease that can be severe and sometimes life-threatening.

What causes it ?
The exact cause of scleroderma is not known. However, it has been known that body makes too much of collagen ( substance that heals and gives us scars ) that gets deposited in the skin and other body organs, causing the skin to tighten and harden and the organs to dysfunction. Another component is abnormal function of cells in the lining of blood vessels, which leads to Raynaud's phenomenon which is discoloration of fingers or toes on cold exposure (pallor, blue fingers or toes) and telangiectasias (red spots). These abnormalities are triggered by abnormal functioning of our own immune cells.

Symptoms Localized Scleroderma
The symptoms of localized scleroderma are isolated to the skin and underlying tissues. Two types are recognized: morphea and linear scleroderma.
Morphea : These are local patches of hardened skin. Red patches of skin develop white centers with purplish borders. Lesions remain active for weeks to several years. Spontaneous softening that leaves a darkened area of skin often occurs. It may be localized or generalized.
Linear: A single line or band of thickened and discolored skin develops. The line usually runs down and arm or leg, but sometimes it runs down the forehead.

Systemic Sclerosis
This disease affects not only the skin and underlying tissues, but also affects the blood vessels and major organs of the body. Two types of systemic disease are recognized: limited and diffuse.
Limited: In this form, skin thickening is generally limited to the fingers, forearms, legs, face and neck. Raynaud's phenomenon ( fingers turning blue or pale on cold exposure) may be present for years before any other symptoms develop. People with this form are less likely than people with diffuse disease to develop severe organ involvement.
Diffuse: In this form, skin thickening may occur everywhere on the body, including the trunk. Only a short interval of time will elapse between the onset of Raynaud's phenomenon and significant organ involvement. Damage typically occurs over the first three to five years, after which most patients enter a stable phase that varies in length. During this phase, your skin will stay about the same and the rate of damage to internal organs slows or stops. After the stable phase is over, your skin will start to soften and more serious damage to internal organs is unlikely to occur.

How to confirm the diagnosis?
A diagnosis could take months as the disease unfolds and as the doctor is able to rule out other possible causes of your symptoms. Diagnosis is made clinically by the doctor familiar with the disease. There is no direct blood test that can confirm the diagnosis. Special tests may be ordered to evaluate your lung status ( such as a chest X-ray, pulmonary function tests) and gastrointestinal tract function.

What is the Treatment?
Several treatments are effective at preventing and/ or reducing organ damage from this disease. While treatments are not able to reverse the disease, they may actually prolong life. So treatment decisions are made on a symptom-by-symptom, organ-by-organ basis.

Raynaud's phenomenon
Don't smoke. Smoking narrows blood vessels, making Raynaud's worse.

Avoid the cold as much as possible.
Dress warmly, in layers. Mittens are warmer than gloves. Use drugs prescribed by your doctor to improve your circulation ( Calcium channel blockers, angiotensin receptor blockers, ACE inhibitors etc.) Skin sores and ulcers can be treated with nitroglycerin paste or antibiotic cream. Narcotic analgesics may be necessary to treat the pain of these ulcers.

Skin problems
Apply moisturizing creams and lotions frequently, especially after bathing. Apply sunscreen before going outdoors. Use only warm water in your bath or shower ( hot water is too drying) Avoid harsh soaps, household cleaners and caustic chemicals. Use rubber gloves if you cannot avoid harsh chemicals. Itching can be treated with oral antihistamines, topical analgesics and topical corticosteroids.

Stiff muscles and joints
Get regular exercise to maintain range of motion and muscle strength. Use pain killers or arthritis medicines as prescribed by your doctor.

Dental problems
Practice good oral hygiene - brush and floss regularly. Use fluoride rinses or prescription toothpastes. See your dentist regularly. Keep your mouth moist by taking frequent sips of water, chewing sugarless gum or using saliva substitutes. Perform facial exercises to help keep your mouth and face flexible.

Gastrointestinal problems
Eat small, frequent meals. Remain standing or sitting at least one hour after eating. Avoid late-night meals. Chew food well. Proton pump inhibitors, such as omeprazole and lansoprazole, can be taken for heartburn. Promotility agents may help move food through the gastrointestinal tract. Antibiotics may relieve diarrhea caused by bacterial overgrowth. Vitamin supplementation may be needed

Lung disease
Immunosuppressive drugs such as cyclophosphamide and azathioprine, along with low-dose steroids can be used to treat interstitial lung disease. Vasodilators such as tadalafil, prostacyclin, Bosentancan be used to treat pulmonary hypertension. Get regular check-ups with your doctor and have lung function tests performed often so that lung disease can be caught early and treated. Get flu and pneumonia vaccines.

Kidney disease
Measure BP regularly and alert your doctor if it is high. Angiotensin- Converting Enzymes (ACE) inhibitors, including captopril, enalapril and ramipril can effectively manage acute renal crisis by lowering high blood pressure.

Heart disease
Treatments for heart disease vary according to the way the heart is being affected by systemic sclerosis.

Who is at risk of getting this disease ?
Anyone can get scleroderma at any age. Women are more commonly diagnosed with scleroderma than men. In fact women with the disease outnumber men with it by about four-to-one. Localized scleroderma is more common in children and young women. Morphea usually appears between the ages of 20 and 40. Linear scleroderma usually occurs in children or teenagers.Systemic sclerosis, whether limited or diffuse, typically occurs in people 30 to 50 years of age.

Life expectancy
Localized scleroderma is not life-threatening. Systemic sclerosis patients are at risk of serious complications, kidney disease, Pulmorary Arterial Hypertension (PAH) (high blood pressure in the arteries around the lugs), alveolitis ( inflammation of the lungs), Gastro-intestinal ( GI ) disease and heart damage that can be severe and adversely affect the quality of life.

Pregnancy
Any female diagnosed with scleroderma needs to check with her physician and obstetrician to discuss possible complications associated with having children. If scleroderma has stabilized, then the physicians are better able to determine if the body can handle pregnancy and childbirth. The genetic risk of transmission of disease to children is negligible.

Osteoarthritis

What is osteoarthritis ?
Osteoarthritis (OA) is one of the commonest arthritis seen in general population. It is a painful condition that can involve one or more of the joints in the body. It is commonly a disease which occurs with increasing age.

What actually happens in osteoarthritis ?
Major joints in the body are formed by two end of bones coming together. This end of bones are covered by a cushion, which is known as cartilage. These bone ends along with the cartilage in between forms the joint. This cushion of cartilage is very important in normal functioning of the joint. However in osteoarthritis,there is degeneration and wearing out of the out of this cushion or cartilage. In OA the cartilage thins out along with some other changes in the surrounding bone of the joint and this leads to various problems of osteoarthritis.

What are the most common joints involved in osteoarthritis ?
OA most commonly occurs in knees, hips, spine hands,and feet.Osteoarthritis can virtually affect any joint Of the body.

What causes osteoarthritis in the joints ?
OA is strongly associated with increasing age. Hence age related degeneration of the joint plays a major role. But it is not as simple as that. Many people can develop osteoarthritis at an early age. Many people with osteoarthritis do not have much pain. Many people have osteoarthritis which is much more advanced at an unexpected age. Different patients have variable levels of pain even with same amount of osteoarthritis. Family history is important as well. We arestill trying to understand many of these factors.

What are the risk factors associated with osteoarthritis ?
As mentioned above, we don't totally understand what causes osteoarthritis. However we do know that certain factors play a role in increasing risk of having osteoarthritis.
Age : Advancing age is one of the most commonest risk factors for osteoarthritis. In general public above 60 years of age, at least 80% have some evidence of osteoarthritis, in at least one of their joints. This may be just seen on X rays and patient may or may not have pain. However as mentioned above, not everyone with the same degree of osteoarthritis will have the same amount of pain.
Gender : For some unknown reasons, females have more chances of osteoarthritis than males. Females also tend to have more pain compared with same degree of osteoarthritis in men.
Obesity and weight : Osteoarthritis occurs more frequently in people who are obese (weight is well above required for that age and height). There is also some evidence that people who reduceweight can decrease the risk of developing osteoarthritis in the future.
Sports and rigorous physical activity : There is evidence that playing excessive injury sports like football, wrestling or repeated kneeling and squatting jobs can increase the risk of osteoarthritis. Having any injury in the ligament in the knee or any other joint can also crease the risk of osteoarthritis in the future . There is good evidence to suggest that routine, non-competitive running or exercises done for personal fitness does not increase the risk of osteoarthritis.
Previous ligament or meniscus injury : Any person who has had a history of injury to their supporting structures in joints like ligaments, meniscus etc at a young age, have higher chances of osteoarthritis in future. This is commonly seen in knee joint ligament and meniscus injuries. Even if one undergoes surgery to repair same, they are still at higher risk for developing osteoarthritis of respective joint in the future.
Family history: Osteoarthritis, particularly, nodal OA, can have remarkable familial predisposition.

Do all patients with age get Osteoarthritis?
No, not all patient get OA and it depends on multiple other factors, some of them have been outlined as above. We don’t have exact figures from India, but OA is more common in women and increases after an age of 50 years and plateaus at 70 years. Western literature shows increasing prevalence over time due to longer life expectancy, obesity and sedentary life style. It is estimated that 10% and 18% men and women are affected respectively.

What are the symptoms associated with osteoarthritis?
Pain : Pain is the most common symptom associated with osteoarthritis. When osteoarthritis starts, the pain can be intermittent and variable. It might be aggravated by certain activities. Often it is more common in late afternoon and evening.The patient can have good days without pain and bad days with pain. For example : The first symptom of osteoarthritis in the knee is usually having some discomfort or pain while patient is climbing or coming down the stairs.
Site of Pain: Pain more commonly occurs around the joint line except in hip and shoulder when pain can occur away from the joint
Stiffness or gelling phenomenon : The osteoarthritis patients can have stiffness which is usually aggravated when the patient takes rest in a certain position for more than few minutes. The patients are stiff in the morning but the morning stiffness is usually less than 30 minutes and not very intense like rheumatoid arthritis. For example : When the patient sits too long with knee osteoarthritis, after getting up, initial few steps are painful. But after walking few steps patient is fine.
Swelling : Some patients with osteoarthritis can have mild to moderate swelling in the joint. This swelling might be soft and compressible due to collection of some fluid in the joint. This can also be hard swelling due to formation of bone spurs (extra new bony protrusions) in the osteoarthritic joint.
Crepitus or crackling sound : In osteoarthritic joint one can have some crackling noise for crackling sound when the joint moves. This is known as crepitus.
For example : Patient with knee joint osteoarthritis can feel crackling or crepitus from their joints, especially when they keep palms over their joint while movements. In most young – middle aged patients, clicking sounds heard from joints without much pain is normal and one should not start fearing osteoarthritis due to same.

How is osteoarthritis diagnosed ?
There is no single test which can diagnose osteoarthritis on its own. Age, weight, family history and pattern of symptoms aid in diagnosis. Other types of inflammatory arthritis, though less common, needs to be ruled out. Blood tests for osteoarthritis : There is no specific blood test to diagnose OA. Most blood tests done in patients with suspected OA are usually done to rule out other arthritis. Imaging methods for OA: Sometimes X rays, ultrasound and MRIare helpful in confirming osteoarthritis, but they are not required in most patients. Also, X-ray can be normal in most patients with early OA. Clinical history is most important in early OA. Imaging methods are most useful to identify degree and severity of OA in a particular joint. And it is important to note that pain or clinical findings may not correlate with X-ray findings. The diagnosis of osteoarthritis is usually made by expert like a Rheumatologist or Orthopedician doctor after collectively taking into account various factors.

How can osteoarthritis progress and affect daily life ?
Most people will have mild to moderate osteoarthritis with progressive age. In most cases it will lead to mild to moderate pain and usually this pain is intermittent. Most of the osteoarthritis patients can function with good quality of life without doing much interventionsexcept for exercises, assistive devices or being physically active. How ever many patients will have moderate or progressive osteoarthritis, which can lead to pain and deformities in the future. In some patients osteoarthritis will lead to disability due to progression. How ever, there are many non-surgical and surgical treatment options available, even if one has advanced osteoarthritis with disability.

What is treatment for Osteoarthritis ?
General principle of osteoarthritis treatment : Osteoarthritis is a chronic disease and there is a component of age-related wear and tear (degeneration) of the cartilage in the joint. Because age is a factor, osteoarthritis usually progresses with advancing age. The progress is gradual in most cases and it takes years for patients with early osteoarthritis to develop advanced osteoarthritis and disabilities. There is no treatment for osteoarthritis which can reverse the damage to the cartilage. But the process can be slowed down. Most important is to loose weight. Most treatment of osteoarthritis is to make the patient symptoms better and to give them a good quality of life. Osteoarthritis treatment can include a range of options, which can include non-medication based treatment and medication based treatment and surgery. It is important to understand that every patient is different and every patient with osteoarthritis can have different issues and joints involved. Treatment depends on patient’s exact problems, daily activity demands and their desired expectations from treatment.
Treatment of osteoarthritis without medication is recommended as a first line of treatment. This line of treatment can be helpful to all patients without any side effects and should be a part of treatment of all OA patients.
Controlling excessive weight or planning weight loss : We have already mentioned that obesity or excessive weight can increase the risk of osteoarthritis. If the patient has already developed osteoarthritis in a particular joint, weight loss may help to slow down the progression. If Knee or hip joint OA patient loses weight by 10%, there is evidence to suggest that they can have 50% decrease in pain. If one is serious about weight loss, one should strongly consider showing a dietitian who can guide them accordingly with the weight loss program.
Physical exercises and physiotherapy : Exercises are very important part of management of osteoarthritis. They don't improve or stop the progression of the worn-out joint. However they keep to help the surrounding muscles strong and may decrease the pain. So a patient with osteoarthritis who continues to exercise, is more active compared to those who do not exercise. Consider starting exercise gradually and take advice from a trained physiotherapist. They can give specific exercises for affected joint. Exercise may not give immediate relief and it may take some weeks for exercises to show its benefits. Also, exercises may increase the pain in initial few weeks before they show benefits. The general rule one should follow is any increase in pain after exercise should reach to pre-exercise levels within 24 hours. If that is not the case, one should be more gradual in building up to a desired exercise regimen or take help of a trained physiotherapist to modify the exercises. Also any form of physical activity in these patients keeps their muscle strong and can be very helpful to help their comorbidities like diabetes, heart disease, hypertension, osteoporosis etc.
Splints and assistive devices : Some patients with osteoarthritis, especially osteoarthritis in the base of the hand can be helped by using hand splints.This splint does not prevent the progression of osteoarthritis in thumb base. However it is helpful inpreventing excess deformity of the thumb base joint. It also helps decreasing the pain at thumb base while movements. Patients with foot and ankle osteoarthritis may have some specific benefits with some specific insoles. This is generally true if patients have specific issues like flat feet or deviated ankles. Usually knee braces or stockings are not advisable as they make the muscles surrounding the joints weak (patients muscles are not used and loading is taken by the supportive device). The weak muscles surrounding the joint can further increase the pain and may lead to instability in patient’s movements. However, one might use the supportive devices for intermittent use to provide stability while walking, for short term use before surgery or in cases where surgery is not feasible. Always take advice of a clinical specialist (like a doctor, physiotherapist or occupational therapist). In patients with advanced osteoarthritis, use of walkers, walking cane or sticks for support etc may be helpful and will prevent falls.

Osteoarthritis treatment with medications/ Pharmacological treatment of osteoarthritis
Most patients with osteoarthritis can be managed with non-pharmacological measures of weight loss, exercise, splints etc. These things should be a part of patient’s management even if any medications are given to them. Some patients do require medications for management of osteoarthritis. Please understand that there is no medication conclusively proven to halt or slow down the progression of osteoarthritis. Whatever medications we have available right now, are to manage the symptoms of osteoarthritis, so that the patients have better quality of life with less pain and more mobility. We again re-emphasize that it is very important for the patient to concentrate on exercise and weight loss in most cases, without which the pharmacological interventions maynot have much benefit.

Topical NSAID lotion / gels / therapies for osteoarthritis joints-
Topical anti-inflammatory gels / lotions contain drugs called as nonsteroidal anti-inflammatory drugs (NSAIDs).Thesedrugs when applied to the skin over the joint can help in relieving the pain of osteoarthritis. This isespecially true in the hands, knee and other superficial joints. They cannot be usedin relieving pain of hip osteoarthritis as it is a deep joint. Usually topical gels contain very low quantity of NSAID drugs with very low absorption and hence they usually do not have any major side effects. However, in patients with blood pressure, kidney or heart issuesone should discuss safety issues with their doctors.

Nonsteroidal anti-inflammatory drugs (NSAIDs)
Nonsteroidal anti-inflammatory drugs (e.g.: ibuprofen, diclofenac, Naprosyn, indomethacin etc) are commonly known as pain killers by general Indian public. Theynot only help relieve pain but can also help to decrease inflammation (redness, swelling etc). They are very effective drugs in relieving the pain and inflammation associated with osteoarthritis. However, one should always discuss their use with doctor as their consumption in patients with acidity (heartburn), heart, kidney, blood pressure issues etc can be harmful. NSAIDS gels (discussed in topical therapies above) have very low doses of these drugs and are absorbed in very little quantities when applied over joints. They are generally much safer to use than NSAID tablets.

Paracetamol
Paracetamol is generally very safe in elderly population of osteoarthritis. The maximum total daily dose of paracetamol is 3 to 4 gram per day. Paracetamol is not as effective as NSAID drugs (discussed above) as it does not have an anti-inflammatory and dramatic pain-relieving effect. However, it is much safer if given for prolonged periods also and can give decent relief to OA patients. In recommended doses it doesn’t tend to affect heart or kidneys. Paracetamol is commonly used in dose of 500 milligram (mg) for fever 3-4 times per day. However, 500 mg is not usually effective for pain. One should use doses of 650mg-1gm two to three times a day for pain relief in OA. One should be careful with paracetamol doses and should not exceed a dose of 3gram – 4 gram of paracetamol in a day. One should always talk to their doctor before trying to find their maximum possible dose of paracetamol which can be taken safely, and one should take it with regular checking up of liver parameters.

Non NSAID pain relieving drugs
Opioid drugs like tramadol (or tapentadol) tablets or capsules, buprenorphine patches etc are used quite frequently in Indian context. However, there is quite strong evidence that these drugs may cause dependence, can cause a variety of issues including constipation, giddiness, nausea etc. They are generally considered to be unsafe in elderly people and should only be use very sparingly. They are generally not recommended to relieve OA pain routinely.

Neuromodulators for relieving pain:
Pain in osteoarthritis and any other disease can be multifactorial. There is some evidence that some patients with OA have over sensitisation of their nerves and this may lead to increase pain. Some experts recommend a trial of low dose neuromodulator drugs like duloxetine, pregabalin, gabapentin etc to give symptomatic relief in OA patients. They might be especially useful in patients with osteoarthritis of spine, especially if there is some compression of nerves. Technically these are not pain relievers, but they possibly work by modulating the pain carried in nerves. Again, these drugs should always be taken under expert guidance.

Joint injections
Glucocorticoid or steroid injections can be useful in certain patients with osteoarthritis. They are especially useful in those with some amount of inflammation in the form of swelling and warmth. They are generally considered to be safe.However, some evidence says that repeated steroid injections in the knee may lead to slightly faster progression of the osteoarthritis. Hence, usually doctors don't give more than three to four injections in a year for a given osteoarthritic joint.

Platelet rich plasma injections in the knee:
In this procedure, patients own blood is collected and platelets are separated and injected in the affected joint (mostly knee). It is uncertain if it has any significant benefits. Many patients claim relief but again its uncertain whether they would have got relief anyways from conventional therapies.

Stem cell injections in the OA joints:
Off late many centres in India have been propagating use of patients own stem cells to be injected into the OA joint. These are expensive, there is no conclusive benefit, there is no clear-cut guideline or regulatory authority for such kind of procedures. One should at this moment refrain from using these kinds of injections. In most cases utilising the expenses meant these kinds of procedure on replacement surgery is far more beneficial. This is especially true in cases of advanced knee and hip OA.

Glucosamine and other similar supplements:
Various tablets / supplements containing glucosamine and chondroitin sulphate are routinely prescribed to or used by patients with osteoarthritis. Many practitioners also prescribe diacerein for patients with osteoarthritis. However, there is no conclusive evidence that any of the above supplements work in relieving the pain of osteoarthritis. There are some good trials which have shown benefit and some good trials which have not shown benefit. There is generally no major harm in using them, but again one should consult their doctor.

Herbal remedies and natural substance supplements for OA:
A lot of herbal / natural therapies are there in the market which are claimed to give miraculous relief in osteoarthritis patients. Some patients also claim a lot of relief with these therapies.The list includes many supplements.For example: Turmeric tablets, curcumin tablets, fenugreek tablets, chinese herbal therapies, herbal topical agents, boswellia extract, rose hip extract, Ayurveda therapy tablets or oils etc. These therapies are usually expensive and there is no proven conclusive benefit. However, since they are generally safe the doctors generally do not aggressively discourage the patients from taking these supplements. One should always be careful of herbal therapies which have the potential to damage liver or kidneys. Many of them claim to have no side effects which can be untrue. Patients should always discuss / disclosetheir herbal therapies they with their respective expert doctors.

Osteoarthritis surgery
Surgery is usually used as a last resort in osteoarthritis patientsspecially who have advanced osteoarthritis and are not benefited by conservative management. The patients with advanced osteoarthritis have severely worn out cartilage, deformities of the joint and the pain is much more severe. The various type of surgeries available:

Replacement surgeries:
The most common surgery done is knee and hip replacement surgery which can be a partial replacement of a complete replacement. Replacement is usually done after 55 to 60 years of age as usually replaced joints last for an average of 15 years. Patient’s usually requires a repeat replacement after that. Generally speaking,repeat replacement surgeries are more difficult. As the average Indian age lifespan is around 70-75 years of age, doctors recommend surgery to osteoarthritis patient at around 60 years of age or later. This is so that they are less likely to require another surgery on the same joint in their lifetime.

Fusion surgery:
Fusion surgery (medically known as arthrodesis) is recommended in very severe osteoarthritic joint where there is no possibility of a replacement and there is lot of pain.Fusion surgeries are usually done in ankle joint OA where. In fusion surgeries joint margins are fused so that this leads to restriction of joint movement and much lesser pain. However, the movements are obviously restricted after fusion surgery. Such surgeries are more for pain relief at the cost of flexibility of the joint. They can be very helpful in properly selected patients.

Gout

What is gout?
Gout is a common and complex form of arthritis that can affect anyone. It is characterized by sudden, severe attacks of pain, swelling, redness and tenderness in the joints, often the joint at the base of the big toe. An attack of gout can occur suddenly, often waking the person up in the middle of the night with the sensation that your big toe is on fire. The affected joint is hot, swollen and very tender.

How does acute gout present?
Gout symptoms may come and go, but there are ways to manage symptoms and prevent flares. Symptoms The signs and symptoms of gout almost always occur suddenly, and often at night. They include:
• Intense joint pain. Gout usually affects the base of your big toe, but it can occur in any joint. Other commonly affected joints include the ankles, knees, elbows, wrists and fingers. The pain is likely to be most severe within the first four to 12 hours after it begins.
• Inflammation and redness. The affected joint or joints become swollen, tender, warm and red.
• Limited range of motion. As gout progresses, you may not be able to move your joints normally.

When to see a doctor ?
If you experience sudden, intense pain in a joint, call your doctor. Gout that goes untreated can lead to worsening pain and joint damage. Seek medical care immediately if you have a fever and a joint is hot and inflamed, which can be a sign of infection.

What are the causes of gout?
Gout occurs when urate crystals accumulate in your joint, causing the inflammation and intense pain of a gout attack. Urate crystals can form when you have high levels of uric acid in your blood. Your body produces uric acid when it breaks down purines — substances that are found naturally in your body. Purines are also found in certain foods, such as steak, organ meats and seafood. Other foods also promote higher levels of uric acid, such as alcoholic beverages, especially beer, and drinks sweetened with fruit sugar (fructose). Normally, uric acid dissolves in your blood and passes through your kidneys into your urine. But sometimes either your body produces too much uric acid or your kidneys excrete too little uric acid. When this happens, uric acid can build up, forming sharp, needlelike urate crystals in a joint or surrounding tissue that cause pain, inflammation and swelling.

What are the risk factors of gout?
You’re more likely to develop gout if you have high levels of uric acid in your body. Factors that increase the uric acid level in your body include:
• Diet. Eating a diet rich in meat and seafood and drinking beverages sweetened with fruit sugar (fructose) increase levels of uric acid, which increase your risk of gout. Alcohol consumption, especially of beer, also increases the risk of gout.
• Obesity. If you’re overweight, your body produces more uric acid and your kidneys have a more difficult time eliminating uric acid.
• Medical conditions. Certain diseases and conditions increase your risk of gout. These include untreated high blood pressure and chronic conditions such as diabetes, metabolic syndrome, and heart and kidney diseases.
• Certain medications. The use of thiazide diuretics — commonly used to treat hypertension — and low-dose aspirin also can increase uric acid levels. So can the use of anti-rejection drugs prescribed for people who have undergone an organ transplant
• Family history of gout. If other members of your family have had gout, you’re more likely to develop the disease.
• Age and sex. Gout occurs more often in men, primarily because women tend to have lower uric acid levels. After menopause, however, women’s uric acid levels approach those of men. Men are also more likely to develop gout earlier — usually between the ages of 30 and 50 — whereas women generally develop signs and symptoms after menopause.

What are the complications of gout?
People with gout can develop more-severe conditions, such as:
• Recurrent gout. Some people may never experience gout signs and symptoms again. Others may experience gout several times each year. Medications may help prevent gout attacks in people with recurrent gout. If left untreated, gout can cause erosion and destruction of a joint.
• Advanced gout. Untreated gout may cause deposits of urate crystals to form under the skin in nodules called tophi. Tophi can develop in several areas such as your fingers, hands, feet, elbows or Achilles tendons along the backs of your ankles. Tophi usually aren't painful, but they can become swollen and tender during gout attacks.
• Kidney stones. Urate crystals may collect in the urinary tract of people with gout, causing kidney stones. Medications can help reduce the risk of kidney stones.

How to prevent gout?
During symptom-free periods, these dietary guidelines may help protect against future gout attacks:
• Drink plenty of fluids. Stay well-hydrated, including plenty of water. Limit how many sweetened beverages you drink, especially those sweetened with high-fructose corn syrup.
• Limit or avoid alcohol. Talk with your doctor about whether any amount or type of alcohol is safe for you. Recent evidence suggests that beer may be likely to increase the risk of gout symptoms, especially in men.
• Get your protein from low-fat dairy products. Low-fat dairy products may actually have a protective effect against gout, so these are your best-bet protein sources.
• Limit your intake of meat, fish and poultry. A small amount may be tolerable, but pay close attention to what types — and how much — seem to cause problems for you.
• Maintain a desirable body weight. Choose portions that allow you to maintain a healthy weight. Losing weight may decrease uric acid levels in your body. But avoid fasting or rapid weight loss, since doing so may temporarily raise uric acid levels.