Treating the Fire of Rheumatoid Arthritis
Fire season in California has some similarities to treating inflammation of the joint-called arthritis. The leading cause of inflammatory joint disease is Rheumatoid Arthritis (RA). Just like any fire, one is better off catching this painful condition early before it gets out of control. As a wildfire rages out of control, the flames consume property, buildings, trees, and worse. The destruction of RA can be just as devastating. The inflammation destroys joint cartilage, soft tissue and bones. If left unchecked, a joint affected by RA can be totally destroyed and rendered useless. In order to minimize destruction, the firefighters rely on a strategy of early detection and aggressive initial attack. Physicians and patients should approach Rheumatoid Arthritis with the same vigor.
High up in the lookout towers are dedicated people (usually volunteers) who radio in a “smoke report” when a column of smoke is spotted. This early detection process is a very efficient alarm system. Early detection is also utilized in the medical world and is especially important for spotting Rheumatoid Arthritis early.
Joint pain can be so many different things: fibromyalgia, RA, systemic lupus erythematosus (aka: Lupus ot SLE), reactive arthritis, trauma, seronegative spondyloarthropathy, sarcoidosis, infectious arthritis, gout, osteoarthritis, and paraneoplastic syndrome (to name a few). A clinician has to rely on good diagnostic skills to sort out the actual cause of a painful, swollen, hot joint. The physical exam can be critical in detecting RA early. Morning stiffness that last more than 30 minutes should be a big red flag. Multiple, “boggy” joints is also an indicator of possible RA. Some rheumatologists recommend a “squeeze test” for the MCP and MTP joints in the hands and feet. Clinician should not rely on the presence of radiographic evidence, nodules, or even the Rheumatoid Factor for the detection of early RA. Additionally, the Rheumatoid Factor (RF), which is a blood marker, is not necessarily positive even in someone with Rheumatoid Arthritis. Because false negatives can be very misleading, an additional blood test called the anticyclic citrullinated peptide antibody assay (CCP) is recommended along with the RF. The CCP has less risk for a false negative and is very specifically found in RA. If both the RF and CCP are positive, the patient definitely has Rheumatoid Arthritis. When in doubt with a clinical picture suggestive of RA, a rheumatologist should be consulted.
Is it smoke or just some dust from heavy equipment? When in doubt, the lookout still calls the “smoke report” into the dispatch crew to launch the attack of firefighting equipment just in case. Better to be safe than sorry.
Aggressively attacking a fire when it is small pays off in less property damage and less risk to human lives. Planes, helicopters, fire engines, hand crews, and heavy bulldozers are all launched at once when the fire danger is high. Putting the fire out as early as possible is the best strategy and is best accomplished with a full arsenal of firefighting equipment. If the attack is delayed, the fire has a chance to spread up a hill with the wind and evolve into a firestorm of destruction.
The best weapon against the fire of Rheumatoid Arthritis is the disease-modifying antirheumatic drugs (DMARD), not anti-inflammatories (NSAID) or Tylenol. NSAID do not alter the RA disease evolution; they just mask the potential clues of detection. And Tylenol can lead to disaster. Experts in RA recommend that treatment with DMARD for early RA begin within the first three months of symptoms. If symptoms have been present for more than 12 months, the DMARD attack has less chance of minimizing joint destruction. That is a very narrow window of opportunity to change the course of this devastating inflammatory firestorm.
Attacking a fire early gives firefighters the chance to get the upper hand right away. Missing a window of opportunity can mean the difference between 20 acres and 10,000 acres. Given the right conditions, every fire has a chance to ruin lives.
Fighting California wildfires and putting out the fire of Rheumatoid Arthritis have a lot of similarities. Both require an early detection system and an aggressive initial attack to minimize damage. In this day and age of managed care, many primary care providers are too slow to ask for a consultation and sometimes only treat a painful joint with NSAID without knowing the exact cause. This delay of proper treatment can lead a person unnecessarily down a lifetime of chronic pain and disability. Even though the availability of a rheumatologist may be limited, a trip to the specialist can be a good investment in time and money. If you think you have RA, sound the alarm and launch an attack on the early signs of rheumatoid arthritis before it is too late.
Christina Lasich, M.D., wrote about chronic pain and osteoarthritis for HealthCentral. She is physiatrist in Grass Valley, California. She specializes in pain management and spine rehabilitation.