Friday, 06 Dec 2019

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The Best Kind of Arthritis

I was recently asked, “what is the best kind of arthritis to have?”

Only a rheumatologist would ruminate on such a quandary and recall many patients who were easily diagnosed and treated and some who were not. Some rheumatoids are recalcitrant and impossibly hard to manage, and there are other challenging conditions like scleroderma, ANCA+ vasculitis or fibromyalgia that are problematic. Yet, there are many with joint pain who are easy to diagnose and manage, even if you’re not a keen-eyed rheumatologist.

To address this question fairly, I used three criteria: 1) the diagnosis should be easily and readily made (by rheumatologists and others) on clinical more so than laboratory findings; 2) the chance for remission and avoidance of damage must be high; and 3) drug exposure and risk is limited. Based on these - here are my top 5 answers. 

1. Polymyalgia Rheumatica – also called “PMR”, this condition affects nearly 400,000 geriatricians in the USA. It almost exclusively occurs in Caucasians over the age of 60, with most being over 70 yrs old. This is a great diagnosis because a) the symptom onset is rapid and distinctive as these patients just feel miserable, achy, sore, stiff in the shoulders and legs; b) the ESR and C-reactive protein are dramatically high; and (the best part) C) the response to low to modest doses of prednisone (10-15 mg per day) is equally dramatic. With a correct diagnosis, these geriatricians turn from weeks or months of misery (losing weight, achy joints, new anemia) to a quick return to function and can be seen playing Frisbee and running  under sprinklers. The only downside is it often takes up to five years to get off the prednisone. 

2. Gout – Gout affects 8.3 million Americans, making it 8 times more common than rheumatoid arthritis and 50% more common than fibromyalgia. Why, then, do I see tons more FM and RA than I do gout?  Wait…I know why…. most gout occurs in men and men are clearly the invincible imbeciles of healthcare. Instead of tackling their health issues, men tend to backslide into wishful thinking when it comes to their future medical plans. 

Nevertheless, all MDs believe they can diagnose and treat gout. If the diagnosis of gout was entirely dependent on elevated uric acid level, then every stethoscope would be one lab order away from a timely diagnosis of gout. Unfortunately ~50% of all acute attacks will present with a normal serum uric acid and only after the attack will the hyperuricemia be revealed. Gout remains an easy diagnosis because once gout starts it is likely to recur and gives the doc more than once chance to get it right. What’s great about gout is that once diagnosed, it can be prevented (by lifestyle or drug) or easily managed. Another amazing observation is as long as you do something to treat gout, the patient will benefit; NSAIDs, steroids or colchicine for the acute attack or any urate-lowering therapy (allopurinol or febuxostat) for the worrisome hyperuricemic periods in between. Lastly, gout is a condition that gives you what you deserve. If you don’t smarten up and manage it, your neglect will be rewarded with a gimpy gait, shoes with cut out holes to accommodate that damn big toe and the promise of damaged, deformed, foot-stool dependant foot to accompany you into old age.

3. Bursitis or Tendinitis – What most people and physicians don’t know is that most “joint pain” does not come from arthritis or the joints but instead, comes from inflammation or damage to the bursa (bursitis) or tendon (tendinitis). These two conditions often coexist, involving adjacent structures and hence these can be considered together as the culprits underlying many common complaints. In this category are conditions that most commonly affect the shoulder (like rotator cuff syndrome), hip (trochanteric bursitis), wrist (deQuervains tenosynovitis) and knee (anserine bursitis). Bursae and tendons are supportive structures  that lie in close proximity to the joints and often bear much of the strain or trauma when a joint is stressed. These structures become painful when used repetitively (over use or repetitive movement syndromes) thereby leading to inflammatory or degenerative changes. Infection and overt damage (strains, tears) are less frequent but more dramatic causes of bursitis/tendinitis. The frequency of bursitis/tendinitis is not officially known but is highly prevalent, common with age or physical activity and will affect nearly everyone in their lifetime.  Knowledge of anatomy, common sites of bursal or tendon inflammation can facilitate a rapid diagnosis. These disorders benefit greatly from the Graucho Marx diagnostic method - if it “hurts when I do this”, then "don’t do this”.  Overuse aggravates, while time and rest is often curative.  Some will benefit from ice applications, immobilization/splinting or the use of steroid injections to hasten the relief and repair in some.

Early arthritis of the hand

4. Pauciarticular Juvenile Arthritis – This is also known as oligoarticular (meaning few joints involved – usually less than four) juvenile idiopathic arthritis. The pauciarticular form of JIA is the most common form and accounts for over half of all children with JIA. It may occur as they enter school years or late into their teens.The onset of 1, 2 or 3 swollen joints, even when associated with some inflammatory tests or antinuclear antibodies, may be distressing to the parents and child, but the good news is that many of these children will go into remission and thus the risk of chronic disease, damage or long-term drug use is favorably low.  These swollen joints still need to be treated aggressively so as to avoid damage and growth disturbances. 

5. “No arthritis at all” – This answer comes from a wise friend who may have been trying to be a “wise guy”. But while this answer may seem flippant or impossible according to what we currently don’t know, the notion of prevention should be one that doctors discuss with their patients – especially those with affected family or those concerned they may have either bad luck or bad genes.  Rheumatologists are frequently asked how to avoid arthritis or how to prevent it from getting any worse.  There are no proven formulas for this challenge. Instead there is a large amount of population-based lifestyle research that says the following: a) reduce weight and avoid obesity – it’s a risk factor for many kinds of arthritis and increases the odds of non-response to medications; b) stop or avoid smoking – it promotes gingivitis, systemic inflammation and is another risk or amplifying factor for arthritis;  c) avoid gingivitis – on this one, your mother was right, brush your teeth, floss and see the dentist; d) consider an antiinflammatory diet (low/no carbs, low/no gluten); and e) use good footwear – even if not preventative or curative, you’ll look good and your feet will thank you!

Disclosures: 
The author has no conflicts of interest to disclose related to this subject
Dr. Cush is the Director of Clinical Rheumatology at the Baylor Research Institute and a Professor of Medicine and Rheumatology at Baylor University Medical Center in Dallas, TX. He a Professor of Clinical Medicine at the University of Texas Southwestern Medical School.
 
Dr. Cush is the Executive Editor of RheumNow.com and also Co-Edits the online textbook RheumaKnowledgy.com. 
 
Dr. Cush's research and interests include novel drug development, rheumatoid arthritis, spondyloarthritis, drug safety, pregnancy and Still's disease/autoinflammatory syndromes. He has published over 140 articles and 2 books in rheumatology.
He can be followed on twitter: @RheumNow.