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Rheumors Volume 3, Number 2: Spring 1992

EXTRA-ARTICULAR FEATURES OF RHEUMATIC DISEASES OR "WHY ARE MANY RHEUMATIC DISEASES SYSTEMIC?"
by Robert L. Rosenberg, M.D

We all tend to think of arthritis and rheumatic diseases as affecting only our joints. While this is mostly true for osteoarthritis, many other types of arthritis pose the risk of multiple organ system (systemic) involvement.

Systemic involvement can manifest as medical problems occurring in one or more of the organ systems. The skin, muscles, kidney, lungs, heart, stomach, nerves and other body parts can become diseased causing organ malfunction and illness. Indeed, the fevers and fatigue often seen in arthritis are due to the systemic nature of the diseases. It is not unusual to feel like you have "the flu" when your arthritis is active.

Rheumatoid arthritis may cause skin nodules, eye inflammation, salivary gland malfunction (resulting in mouth dryness), nerve entrapment with numbness and severe fatigue. Fortunately, involvement of the heart, lungs, kidneys and blood forming elements in the bone marrow are less frequent, but potentially severe nonetheless. Commonly, rheumatoid arthritis and other inflammatory diseases such as systemic lupus erythematosus (SLE) and ankylosing spondylitis can cause osteoporosis with subsequent thinning of bone and increased risk of bone fracture. SLE can also cause severe kidney damage, blood vessel changes and central nervous system disturbances. When these occur, they must be treated aggressively.

Ankylosing spondylitis is sometimes associated with heart, blood, and lung problems. Any chronic inflammatory disease may lead to the later development of Amyloidosis - a rare accumulation of abnormal proteins in internal organs that may cause these organs to malfunction and fail. Patients with longstanding arthritis should be observed for these potential complications. Last, but certainly not least, there are potential systemic risks for many of the medicines we use to treat severe arthritis. The anti-inflammatory drugs, steroids, Methotrexate, Plaquenil, Imuran, pain relievers, Gold, Depenicillamine and Cytoxan all are capable of systemic side effects. Modification of drug dose and even stopping a drug may be necessary on occasion.

You may think we rheumatologists are just looking at your joints - actually we are looking at all of you, listening for hints and searching for signs that you may be experiencing some of these systemic problems. Only by carefully anticipating problems can we treat them early, hopefully preventing later complications.

Although arthritis means "inflammation of joints" - it may signal that other parts of the body are likewise involved. Extra-articular involvement, "outside the joints", can lead to major illness and disability. Thorough examination and treatment will help keep systemic involvement to a minimum.

RHEUMINATIONS

WHAT KIND OF DOCTOR WOULD YOU SEE FOR . . . . .

In today's world of medical specialization patients often do not know what kind of doctor to see for specific problems. A short QUIZ follows. For each of the following medical problems, decide which specialist you would consider consulting.

Who would you consult if you were concerned about . . .
Arthritis?
Back Pain?
Tendonitis?
Bursitis?
Osteoporosis?
Lupus?
Carpal tunnel syndrome?

The answer to all the above is your rheumatologist! At ARA we have extensive experience treating all the above conditions, as well as a variety of other musculoskeletal disorders. Often we can help patients avoid surgery for problems such as carpal tunnel syndrome. Our special interests lie in the treatment of arthritic conditions and osteoporosis, and we now offer even greater patient access to therapies on the leading edge of technology.

RHEUMINATIONS

CONGRATULATIONS, DR. SIEGEL!

Arthritis & Rheumatism is the definitive journal of Rheumatology in our country and the world. Rheumatologists recognize it as the leading information source for current research and treatment for their specialty.

Our own Dr. Evan L. Siegel is co-author of the lead article in the May issue of Arthritis & Rheumatism. His research involved looking at the effects of the nervous system on inflammation.

Arthritis & Rheumatism Associates is proud of Dr. Siegel's contribution to rheumatology research.

QUESTION & ANSWERS SECTION

GENERAL INFORMATION SECTION
Arthritis & Rheumatism Associates have developed the Osteoporosis Treatment Section. We have vast experience in diagnosis of the disorder of osteoporosis using the latest techniques both by bone mineral densitometry using DPX (dual photon xray), advanced chemical studies, and general xrays. Vast experience has been gained in using those therapies that have been cleared by the Food & Drug Administration for treatment and we are presently gearing up for a number of studies using experimental medications for the treatment of osteoporosis.

NEWER MEDICAL TREATMENTS OF ARTHRITIS
Herbert S. B. Baraf, M.D.

Experienced readers of Rheumors have learned that there are more than one hundred different types of arthritic conditions. The two principle forms of arthritis, Osteoarthritis (OA) and Rheumatoid Arthritis (RA), have similarities in the way they are treated. However, there are some treatments that are quite specific for certain forms of arthritis.

The Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) have been the mainstay of the medical therapy of arthritis and both OA and RA patients are treated with these agents. The first NSAID was aspirin, originally marketed by Bayer Pharmaceuticals in the late 1890's. The second available NSAID was released for use in the early 1950's. By the mid-1970's the number of available NSAIDs proliferated as Naprosyn, Clinoril, Nalfon, Tolectin and others were released. The last ten years has seen at least ten more new NSAIDs come to market.

This wide variety of NSAIDs has given the Rheumatologist an opportunity to tailor treatment to the specific requirements of his or her patients - differences in dosing, interaction with other medications or toxicities, etc., and is one of the great advances in treatment of recent years. It has been found that there is no one superior drug for a given condition. The individual patient may unpredictably vary in his or her response to these agents. Thus, each time a new drug is introduced, patients who have failed to respond to old medications have reason to be hopeful.

In the past few years, four important new NSAIDs were released; Lodine (etodolac), Voltaren (diclofenac), Ansaid (flurbiprofen) and Relafen (nambutone). We are proud that we participated in the clinical trials that were essential in getting three of these agents approved. As physicians actively involved in clinical research, we have a unique perspective on present and future therapies. Those patients that have assisted in this process also have reason for a sense of accomplishment in their role of advancing treatment of the rheumatic diseases.

Unfortunately, in RA, NSAID therapy alone is usually not enough to keep joint pain and swelling under control. Patients who fail to respond adequately to a series of trials with NSAIDs must often be treated with second-line therapies collectively referred to as DMARDs (Disease Modifying Anti-Rheumatic Drugs). The traditional DMARDs include injectable gold therapy and anti-malarial agents. Gold remains today as one of our most effective therapies for active RA.

Hydroxychloroquine (Plaquenil) is a drug originally developed for use in treating malaria. In the 1950's a series of reports indicated that related anti-malarial compounds were useful in both RA and Lupus (SLE). Anti-malarial drugs have proven to be among the safest and best tolerated DMARDs presently in use.

Perhaps the most significant advance in recent years has been the introduction and general acceptance of Methotrexate as a treatment for RA. In the first several years after its introduction in 1948 it remained primarily a "cancer drug" used to treat a variety of solid tumors and bone marrow malignancy. In the 1960's its use in psoriasis, a troublesome skin condition, became widespread. By the late 1970's its use in RA was reinvestigated. Rheumatologists around the world have been using this drug with increasing frequency for the past ten years with remarkable results and an excellent safety record.

Other anti-cancer drugs have been used in RA, notably azathioprine (Imuran) and cyclophosphamide (Cytoxan). These drugs are presently reserved for patients who have not responded to the above treatments.

A number of experimental arthritis treatments continue to be investigated. Our practice was engaged in clinical trials of Azulfidine, an agent in widespread use for inflammmatory conditions of the intestines, and Therafectin, a drug of low toxicity that may eventually prove to be useful.

Immunology advances have led to new agents that interfere with the immune response potentially offering benefits in RA & SLE. Experimental manipulations of lymphocytes, the cell central in causing and perpetuating inflammation, will likely yield new treatments for the Rheumatic Diseases.

We have come a long way to ease pain and suffering and to control Rheumatic Diseases. We have even greater hope for the years ahead. Continued research is the key to finding new treatments, and possibly cures, for the various forms of arthritis.