A RHEUMATOLOGIST

A rheumatologist is a physician who is qualified by additional training and experience in the diagnosis (detection) and treatment of arthritis and other diseases of the joints, muscles and bones.

Rheumatology is a subspecialty of internal medicine. Doctors who specialize in rheumatology are referred to as rheumatologists. They diagnose and focus on non-surgical treatment of arthritis and related problems involving joints, soft tissues, auto-immune diseases, vasculitis, and heritable connective tissue disorders. Many of these diseases are now known to be disorders of the immune system, and rheumatology is increasingly the study of immunology.

Rheumatism is a colloquial term referring to any painful disorder affecting the loco-motor system including joints, muscles, connective tissues, soft tissues around the joints, and bones.

Rheumatologists are MD or DO medical degree doctors dealing with arthritis and disorders such as rheumatoid arthritis, rheumatic fever, ankylosing spondylitis, gout, lupus erythematosus, osteoporosis, back pain, osteoarthritis, and many other related diseases. There are more than 200 types of these diseases. Some of these are very serious diseases that can be difficult to diagnose and treat.

Rheumatology training involves a bachelor’s degree followed by 4 years of medical school, 1 year of internship in internal medicine, 2 years of internal medicine residency, and 2 years of rheumatology fellowship. The American College of Rheumatology oversees the board certification of qualified rheumatologists.

Arthritis patients, especially early in the course of their disease, want to know if it is necessary to go to a specialist in rheumatology. They likely already have a rapport with a good doctor- so can’t that doctor diagnose and treat arthritis? If you have osteoarthritis or fibromyalgia, these common conditions can usually be managed by your primary doctor, especially if you have a mild case. There are some cases that become advanced and require a rheumatology consultation.

For more complicated types of arthritis, a rheumatology consult can be extremely helpful since a rheumatologist deals with the complexities of rheumatic disease and treatment options on a daily basis. It is always best to get good advice sooner than later.

ANKYLOSING SPONDYLITIS
Ankylosing Spondylitis is a type of inflammatory arthritis that attacks the spine, and can also attack the joints of the arms and legs, the skin, intestines and eyes. Low back pain and prolonged morning stiffness are usually the first symptoms, often in young males. It can lead to fusion of the spine by causing inflammation at the entheses, the site where a tendon or ligament attach to bone. Diagnosis might require x-rays and possibly MRI scan of the sacroiliac joints of the lower back and a HLA-B27 blood test is commonly positive. Treatment is with stretching exercises to prevent loss of flexibility and NSAIDs. If there is not improvement, Sulfasalazine and anti-TNF biologic medications (Enbrel www.enbrel.com, Humira, Cimzia www.cimzia.com, Simponi www.simponi.com, Remicade www.remicade.com, and Simponi Aria www.simponiaria.com) can be helpful treatments. Surgery for the spine is rarely needed unless there has been an injury, but hip joints might need to be replaced in late disease. Other problems can be osteoporosis, uveitis or painful inflammation of the eye(s), aortic valve inflammation is rare, psoriasis is a patchy scaly skin disease, and inflammation of the gut which can cause excessive stools and possibly blood and mucous. It is important to exercise with stretching and to not smoke tobacco, which can speed up the rate of spinal fusion. The Spondylitis Association of America www.spondylitis.org has further information available.
BACK PAIN
Back pain is second only to the common cold as an affliction of mankind. It is pain which may or may not radiate below the knee (sciatica) and is usually gone in 1-2 weeks, 90% is gone within 2 months. It is usually caused by mechanical disorders from overuse of the back, aging, injuries, weight, and infrequently by disease. These diseases include osteoporosis, ankylosing spondylitis, tumors and spinal infections. Imaging tests such as x-rays and MRI scans are reserved for patients that do not respond to initial treatment. Treatment does not include bedrest. Instead, patients should continue their normal lifestyle while holding on any excessive exercises. Initial treatments include ice packs, heat, over-the- counter pain-relieving meds, and muscle relaxants if motion is limited. Narcotics are discouraged, and surgery is only needed if there is increasing weakness or loss of control of the legs or bowel and bladder function. Smoking increases back pain and should be stopped. Resting or switching positions frequently and exercises to maintain motion and strength are important, physical therapy and NSAIDs can be helpful. Chronic pain treatments and disability may be needed.
CARPAL TUNNEL
Carpal tunnel syndrome causes numbness and usually weakness of the fingers, especially the thumb, index, and middle fingers, due to compression of the nerve passing through the wrist. There is often a feeling of swelling, but none is present. It can slowly progress from mild and intermittent to permanent nerve and muscle damage if not treated. Other problems that can mimic carpal tunnel are arthritis, tendonitis, and other nerve problems. Carpal tunnel syndrome is more common with pregnancy, obesity, thyroid disease, diabetes, wrist fractures, middle-aged to older people, females, and possibly repetitive hand activities. The physician may be able to reproduce the pains on examination. A nerve conduction test may be needed. NSAIDs, splinting at night, occupational therapy, cortisone injections, and control of underlying diseases like hypothyroidism or rheumatoid arthritis may be able to prevent needing surgery to open the carpal tunnel to relieve pressure on the Median nerve.
CPPD DISEASE OR PSEUDOGOUT
Calcium pyrophosphate deposition disease or pseudogout is due to crystals of calcium pyrophosphate salt that developed inside the cartilage being released into the lining of the joint and triggering severe inflammation. It is similar to gout in the pattern and severity of the joint swelling. Attacks can last for days to weeks, often after injury or overuse of a joint. Eventually it can become chronic inflammation and cause joint destruction. Usually we do not know why the crystals build up in the cartilage, but may be due to excess iron, low magnesium, overactive parathyroid disease, or severe hypothyroidism. It is more common with aging, 3% of people in their 60s and 50% of people in their 90s. Diagnosis can require using a needle to remove fluid from the joint, x-rays and blood tests. Treatment for attacks can include NSAIDs and cortisone injections or pills and might require physical or occupational therapy. Prevention of recurrent attacks can include NSAIDs, Plaquenil, Methotrexate and Kineret. The crystals cannot be removed from the cartilage, and surgery is for repairing and replacing damaged joints.
FIBROMYALGIA
Fibromyalgia is a common cause of diffuse body pain and tenderness of the muscles, chronic fatigue, sleep that does not restore energy, and problems with memory and thinking clearly. It is not a form of arthritis and does not damage the joints or muscles. The diagnosis is based on the presence of these symptoms and is no longer based on the number of tender points. There is no test to detect or prove this disease, but blood and imaging tests can be done to rule out other health problems. There is no cure for fibromyalgia, but patients can feel better with medications and lifestyle choices. Fibromyalgia is associated with depression, anxiety, migraine or chronic tension headaches, irritable bowel syndrome, irritable bladder, pelvic pain such as endometriosis, sleep apnea, multiple sclerosis, spinal stenosis of the neck, or any chronic arthritis disease. Fibromyalgia can run in families but the genetics are unknown and is more common in females. It is usually triggered by chronic pain, stress or lack of sleep. It is thought that the brain becomes hypersensitive to the signals coming in from the body causing them to be interpreted as pain. Treatment includes Cymbalta and possibly Effexor, Elavil, and Flexeril, as well as Lyrica or Neurontin. Tramadol may be used, but opiate narcotics increase the sensitivity to pain and make the fibromyalgia worse. At least as important as medications is regular modest walking, swimming, water aerobics and stretching exercises and staying active without excessive activity as well as a regular sleep pattern of going to bed and waking up at the same time every day. Endurance is diminished, so frequent short rest periods may be needed to prevent exacerbations. The National Fibromyalgia Association www.fmaware.org/ is available for more information.
GOUT
Gout is more than the occasional attack of intensely painful joint swelling that often begins in the foot joints. Gout is also the chronic disease that slowly accumulates crystals of uric acid over many years due to a genetic difficulty getting rid of excess protein. Gout can lead to the destruction of joints and kidney stones due to the burden of uric acid crystals that develop even if there are few attacks. Uric acid is a break down product of purine proteins, one of the two types of proteins in our food. Different foods have different concentrations of purines, so a change in diet to limit purine protein can be helpful for controlling gout. Gout attacks are triggered by excess alcohol, low dose aspirin, and diuretics, as well as injury or overuse of a joint. Treatment of attacks include colchicine, NSAIDs, cortisone and anakinra. Prevention of attacks include avoidance of the above triggers, minimal purine protein diet, colchicine, and NSAIDs. Control of the disease is a combination of minimal purine protein diet and using Allopurinol, Uloric, Probenecid, or Krystexxa www.krystexxa.com if the serum uric acid cannot be kept below a level of 6 which is needed to deplete the uric acid crystals from the body. People with chronic gout usually require a lifetime treatment with drugs to lower uric acid levels. Gout is associated with high blood pressure, heart and kidney disease, and gout is rapidly increasing in frequency with metabolic syndrome associated with obesity.
GIANT CELL ARTERITIS OR TEMPORAL ARTERITIS
Giant cell arteritis, or GCA, is a disease of the blood vessels becoming inflammed in older adults, usually over the age of 60. GCA usually affects the blood vessels of the scalp and head, especially the arteries over the temples, and can affect the blood flow to an eye and loss of vision can occur rapidly after temporary blurring, double vision, or partial blindness. For an older adult, a new persisting headache, especially if together with flu-like symptoms, marked fatigue, loss of appetite, weight loss, pains of the face, throat and jaw with chewing, and/or fevers could be due to GCA. GCA can occur with Polymyalgia rheumatica about 50% of the time. Blood tests show evidence of high inflammation tests. A biopsy of the temporal artery on the affected side is desired to establish the diagnosis. Usually treatment with high dose corticosteroids begins before the biopsy and diagnosis is known to help preserve eyesight. Prednisone is usually started at 60 mg/day and tapered when symptoms are controlled. Most patients are down to 5-10 mg per day after a few months and continue this for 1-2 years. GCA rarely returns. Treatment with cortisone can cause higher blood sugar, weight gain, anxiety, sleeplessness, osteoporosis, cataracts, muscle weakness, bruising and thinning of the skin. DEXA scan testing for osteoporosis and checking for complications during therapy with corticosteroids is important. If corticosteroids cannot be lowered adequately, other medicines are added, such as Imuran or Actemra to help minimize the corticosteroid dose and side effects. The Vasculitis Foundation www.vasculitisfoundation.org/education/forms is available for more information.
HEPATITIS C ARTHRITIS
Hepatitis C virus, or HCV, is the leading cause of liver failure and needing a liver transplant. The virus can also cause inflammatory arthritis, muscle pains and weakness, and vasculitis, which can cause skin and kidney failure problems. Painful joints and muscles with fatigue are the first complaints for HCV associated arthritis. Cryoglobulinemia is when abnormal proteins change shape and interfere with blood flow in the cold. This can cause Raynaud’s phenomenon with finger tips turning white. HCV is now commonly spread through sharing needle for intravenous drug abuse or sharing instruments to snort cocaine. It is now rare to obtain it from blood transfusions, and unlikely through unprotected sex with an infected partner. The diagnosis is made by finding antibodies against the virus on blood tests. A test to determine the amount of HCV confirms the diagnosis and shows how active the virus is. Liver function tests are followed, and the patient should stop all meds that could hurt the liver. HCV can be treated with good success to try to minimize the chronic complaints of living with this infection. Treatment of rheumatoid arthritis with anti-tumor necrosis factor drugs (Enbrel www.enbrel.com, Humira, Cimzia www.cimzia.com, Simponi www.simponi.com, Remicade www.remicade.com, and Simponi Aria www.simponiaria.com) seems to be safe in HCV patients.
LUPUS
Systemic lupus erythematosus, called SLE or lupus can cause inflammation in many parts of the body and can imitate many different diseases. Lupus mainly affects the joints, kidneys and skin, but can also attack the lungs, brain and nervous system, blood and heart. It affects women 10 times more than men, usually in their 20s and 30s. African and Asian heritage is associated with worse disease. It is often a disease of flares, but can be chronic as well. The symptoms include fevers, fatigue, rashes of sun exposed skin (including the butterfly rash on the cheeks or the raised scarring patch of skin), recurrent mouth or nasal sores, swollen and tender joints, swelling of the lungs or heart linings causing a sharp pain or difficulty on breathing deeply, blood or protein in the kidneys, neurological problems (such as seizures, stroke, or psychosis), blood problems such as low blood cell counts, coagulation problems (such as miscarraiges, blood clots causing stroke or lung injury and memory problems), a positive ANA and other antibodies that show immune system problems. It is common to have a positive ANA blood test and not have lupus, so you may need more testing if you have some of the other symptoms above. Treatment of lupus depends on the severity of the disease. NSAIDs, Plaquenil, Prednisone, Imuran, Cellcept, Rituxan, Benlysta, Acthar www.acthar.com and Cytoxan are used for lupus. Danger signs include high blood pressure, swollen feet and hands or eyes and changes in urination as well as angina or breathing related chest pains or neurological problems. Pregnancy should be prevented until the lupus is well controlled. Estrogen can exacerbate lupus so it is discouraged for birth control or hormone replacement. The Lupus Foundation of America http://www.lupus.org/ is available for more information.
LYME DISEASE
Lyme disease is named after the town of Old Lyme, Connecticut, where it was discovered. Lyme is an infection of Borrelia burgdorferi bacteria spread by deer ticks. Most of the time a red ring like or bullseye rash develops at the bite. Later, other similar rashes develop elsewhere and there may be fever, headache, and joint and muscle pains. Prompt treatment with antibiotics prevents the chronic problems with fatigue, poor sleep, and muscle and joint pains that can continue even after the infection has been treated successfully if there is a delay in diagnosis. Failure to treat the bacterial infection can lead to further damage to the joints and nervous system that can be severe. There is high risk of infections with deer tick bites from Virginia to western Pennsylvania and northeast of that line and around Wisconsin. There is low risk in the southern seaboard states lower Mississippi river valley and along the west coast and minimal to no risk elsewhere in the USA. People who live, travel, or camp where they could be expose to deer are at risk, so this is a rural and suburban disease. Risk of being bit is low in late summer and winter. Laboratory tests for Lyme disease are often wrong with false positives and also false negatives, so only patients with possible symptoms should get lab tests for Lyme disease. Early stage infections should have 2-3 weeks of antibiotics, but arthritis requires 4 weeks and may requrie IV antibiotics, which heart or nervous system involvement requires. Post-Lyme disease syndrome with fatigue, poor sleep and muscle and joint pains is more likely if antibiotic treatment is delayed, even if it is successful as it usually is at eradicating the infection. Treatment with more antibiotics does not help post-Lyme disease syndrome. Beware a treatment program of long term IV antibiotics for chronic symptoms. To prevent tick bites, stay on open paths or cut grass and away from brush and tall grass where ticks can brush against you. Wear closed shoes and tuck long pants into the socks to block skin access. Use an insecticide with DEET and check for ticks after being outside. Remove the head of any tick using fine tipped tweezers. There is no vaccine for Lyme disease yet.
NECK PAIN
Pain in the neck which may or may not radiate to the arms (radiculopathy) is usually an mechanical overuse problem and rarely is due to an illness, such as polymyalgia rheumatica, ankylosing spondylitis, rheumatoid arthritis, tumors and infections. Neck pain usually improves in 1-2 weeks, and 75% within 2-3 months. Old injuries such as whiplash injuries are common as a cause. Muscle strains from prolonged physical activity such as extended computer work, sleeping in an awkward position, osteoarthritis with disk disease and spurs that cause nerve irritation and compression or herniated disks and spinal stenosis. Imaging tests with x-rays and MRI scans are reserved for patients that do not respond to initial treatments. Treatment includes encouraging movement and stretching of the neck exercises, while neck braces and smoking tobacco are discouraged as they aggravate neck pains. Ice and/or heat, NSAIDs, muscle relaxers for muscle tightness, physical therapy and massage are helpful. Laying down frequently for 5 minutes with heat and gentle stretching can be helpful to prevent severe exacerbation with headaches and arm pains. Stress reduction may be needed. A small minority will need surgery of the cervical spine.
OSTEOARTHRITIS
Osteoarthritis, or OA, is the wear and tear of the joints associated with middle and advanced age or injuries that hasten the damage of the weight bearing joints of the body. Half of Americans will develop OA of the knee and a quarter of their hips during their lifetime, so it is a major cause of disability of older people. There is no cure for the disease, so the goal is to reduce pain and improve function to maintain an independent lifestyle. OA is the most common form of joint disease and is common in the hand joints, spine, hips, knees, and great toes and causes pain, stiffness, knobby swelling, cracking or grinding, and decreased motion and function of the joint. Risk factors for developing osteoarthritis include older age, family members with OA, obesity, past injury, repetitive use and overuse, and joint deformities such as unequal leg length, bowlegs or knocked knees. Examination and x-rays establish the diagnosis. Treatment includes weight loss, exercises possibly learned in physical therapy, assistive devices such as a cane or brace, heat or cold therapy, massage, and integrative medicine treatments such as tumeric, glucosamine/chondroitin, calcium and vitamin D, omega-3 fatty acids, cinnamon, garlic, ginger, and antioxidants. Medications include topical, oral, and injection pathways with capsaicin cream and Lidocaine or Voltaren gel, Acetaminophen, NSAIDs, Cymbalta, and injections of cortisone or hyaluronic
OSTEOPOROSIS
Osteoporosis is the common weakening of bones, mainly as we grow older, that can lead to eventual fractures and disability. In addition to aging, risk factors include: non-Hispanic white or Asian ethnic background, small bone structure, family history of osteoporosis, prior fracture with little trauma, low levels of sex hormone, eating disorders, low calcium and vitamin D intake or absorption, lifestyle choices (such as sedentary or immobility, cigarette smoking, and alcohol abuse), diseases (such as hyperthyroidism, hyperparathyroidism, Cushings disease and inflammatory arthritis diseases such as rheumatoid arthritis), and medications (such as cortisone, excess thyroid replacement, breast and prostate cancer treatments, and heparin). Osteoporosis is a silent condition and not associated with bone pain until there are fractures. For people over age 50, half of women and a sixth of men will have an osteoporotic fracture during their lifetime. Osteoporosis is diagnosed by measuring the concentration of calcium in the lumbar spine, hip and distal forearm bones with a DEXA scan and comparing that to a young healthy member of the same sex. Bone density better than 1 standard deviation less than the ideal is considered normal bone density. Bone density worse than 2.5 standard deviations less than ideal is considered osteoporosis. Between normal and osteoporosis is a mild form of bone weakening called osteopenia that is less severe than osteoporosis. Treatment includes calcium supplementation (1,200 mg a day), vitamin D supplementation to obtain an adequate blood level, weight bearing physical activity to induce the bones to strengthen, and a medication if sex hormone is diminished. Medications include the bisphosphonates (Fosamax, Actonel, Boniva, and Reclast), as well as Miacalcin, Evista, Prolia www.prolia.com, or hormone replacement. All of these medications reduce the turn over and loss of bone, so they could possibly lead to complications with osteonecrosis of the jaw or atypical femoral fractures which are both very low to rare risk. Teriparatide stimulates bone formation instead, but requires a daily injection. If osteoporosis is present, prevention of falls can be as important as treatment of the bone density. A cane or walker if the patient is unstable, removing hazards from the home and ensuring adequate lighting at night, help for lifting and carrying heavy things, and wearing sturdy shoes could prevent premature fractures. The National Osteoporosis Foundation https://www.nof.org/ is available for more information.
POLYMYALGIA RHEUMATICA
Polymyalgia rheumatica, or PMR, is a common cause of aching and stiffness in older adults over the age of 50 which has evidence of inflammation on blood testing. The aching and stiffness is in the neck, upper arms, buttocks and thighs, and is worst in the mornings. It usually starts rapidly and affects both sides of the body equally. It is often uncomfortable to raise the arms above the shoulders. The stiffness can interfere with sleep and make it difficult to get dressed or get in and out of a car in the mornings. The cause is unknown and there is no evidence of damage to the muscles or the shoulder and hip joints where the pain starts and is then referred to the upper arms and legs where it is felt. PMR is in older patients with a high ESR and CRP and responds very well to corticosteroids, while fibromyalgia is in younger patients with normal labs and little response to corticosteroids. NSAIDs are not effective. Usually 10 – 15 mg a day of Prednisone can quickly relieve the pain and stiffness in PMR and allow normal activities. No response after 2-3 weeks makes PMR unlikely. Patients with PMR are usually tapered slowly to a much lower dose that they may need to take for 1-3 years. Even low dose cortisone can cause higher blood sugar, weight gain, anxiety, sleeplessness, osteoporosis, cataracts, muscle weakness, bruising and thinning of the skin. DEXA scan testing for osteoporosis and checking for complications during treatment with corticosteroids is important. PMR can occur with a much more serious condition, giant cell arteritis, about 10% of the time. See your rheumatologist right away if you have PMR and develop headache, rapid changes in vision and/or unexplained fever. The Vasculitis Foundation www.vasculitisfoundation.org/education/forms is available for more information.
MYOSITIS- POLYMYOSITIS, DERMATOMYOSITIS
Myositis is a muscle disease when the immune system damages the muscles and make them weak. Weakness is usually in the large muscles around the neck, shoulders and hips. There is trouble climbing stairs, getting up from a seat, or reaching for overhead objects. There is usually very little pain in the muscles. Severe disease can cause choking while eating, shortness of breath and breathing food into the lungs. Polymyositis and Dermatomyositis have muscle inflammation and weakness, while patients with Dermatomyositis also have a rash. The rash is usually purple or red spots on the upper eyelids or upper chest which is worse with sun exposure, and they can also have scaly red bumps on the knuckles, elbows or knees. Amyopathic dermatomyositis has only the skin involvement. There can also be inflammation in the lungs with cough and shortness of breath or in the blood vessels which can cause skin damage. Myositis is rare, about 1 person in 100,000 and can occur at any age, but often between ages 5 – 10 and 40 – 50, and women are affected twice as often as men. To determine the cause of weakness, blood tests for evidence of muscle damage and immune system tests are done, and then an electromyogram, muscle biopsy or MRI scan can establish the diagnosis. Treatment is started with oral corticosteroids and blood tests should improve in 4-6 weeks while muscle strength should return in 2-3 months. To help lower the dose of corticosteroids, Methotrexate, Imuran, IVIg, Neoral, Prograf, Cellcept and Rituxan can be used. Physical therapy to improve range of motion and strength is important for preventing contractures of joints and maintaining function. Dermatomyositis more than Polymyositis may be related to an underlying cancer which should prompt appropriate testing. The Myositis Association www.myositis.org is available for more information.
PSORIATIC ARTHRITIS
Psoriatic arthritis occurs in about 15% of patients with psoriasis and can lead to damage of any joint in the body. It can occur in patients without psoriasis, particularly if they have relatives with psoriasis. It can attack one, several or many joints in the body, usually in an unequal or nonsymmetric distribution. Affected fingers and toes can swell like sausages, called dactylitis, which is diagnostic if present. The site of inflammation is at the enthesis or where tendon and ligaments attach to bones near joints, and persistent enthesitis can destroy the joint over time. Heredity plays a role as 40% have a family member with psoriasis or psoriatic arthritis. Infection might trigger the activation of the immune system attack, but there is no persistent infection. It often starts between the ages of 30 and 50, but can start at any age, and is equally in women and men. Children with psoriatic arthritis have a higher risk for uveitis than adults. Imaging tests can help establish the diagnosis, while blood tests are used for looking for other possible diseases. A skin biopsy might be needed to establish psoriasis. Treatment is determined by the inflammation level of the joints involvement. NSAIDs are the initial treatment, but usually Azulfidine, Methotrexate, Neoral, Arava, Plaquenil, Imuran, Otezla www.otezla.com, Enbrel www.enbrel.com, Humira, Cimzia www.cimzia.com, Simponi www.simponi.com, Remicade www.remicade.com, Simponi Aria www.simponiaria.com, and Stelara www.stelarainfo.com can be used to control the disease. Corticosteroid injections can help swollen joints, and hopefully damaged joints that need surgery can be prevented. Psoriatic arthritis patients are slightly more likely to develop metabolic syndrome, which should be treated. Exercise and therapy are important to maintain function and good range of motion in the joints. The National Psoriasis Foundation www.psoriasis.org is available for more information.
RHEUMATOID ARTHRITIS
Rheumatoid arthritis, or RA, is probably the most disabling type of arthritis, but good treatments are now available. RA is the most common type of autoimmune arthritis which is a chronic disease causing pain, stiffness, swelling and destruction of the nonspinal joints, primarily in the hands and feet. Stiffness for more than an hour in the morning is a clue for RA, along with loss of energy, low fevers, loss of appetite, dry eyes and mouth, and rheumatoid nodules on the elbows or hands. The site of inflammation is the synovium or lining of the joint, but also can cause damage in the eyes, lungs, and bone marrow. Most patients are women, and usually starting in middle ages. The diagnosis is based on evidence for inflammatory disease while excluding other possible diseases. Laboratory tests show anemia, inflammatory markers and immune serology including a rheumatoid factor and antibodies to cyclic citrullinated peptides or pieces of proteins from the destruction of the joints. X-rays are usually normal at the onset, but can be used to follow the progression of the disease. Treatment begins with NSAIDs and low dose corticosteroids for comfort and starting DMARDs, disease modifying anti-rheumatic drugs, as soon as the diagnosis is established. Common DMARDs include Methotrexate, Arava, Plaquenil, Azulfidine, Imuran, and Neoral. Failure to control the rheumatoid arthritis to a low disease state within months of starting the DMARDs will prompt adding “biologic” medications such as Enbrel www.enbrel.com, Humira, Cimzia www.cimzia.com, Simponi www.simponi.com, Remicade www.remicade.com, Simponi Aria www.simponiaria.com, Orencia www.orencia.bmscustomerconnect.com, Actemra, Rituxan and Xeljanz while continuing the DMARD. Frequent evaluations and lab testing may be needed to maintain the rheumatoid arthritis in a low disease state. It is very important to stop smoking tobacco and there is a higher risk for heart disease and stroke, and a slightly higher risk for cancer with rheumatoid arthritis. It is important to remember that the primary reason for treatment is not pain control, which is a benefit, but to prevent destruction of the joints over the many years ahead. Patients who can tolerate great pain levels still need to be aggressive at controlling the inflammation in their joints. The Arthritis Foundation www.arthritis.org is available for more information.
SCLERODERMA OR PROGRESSIVE SYSTEMIC SCLEROSIS
Scleroderma is a disease of the skin and many other organs where the connective tissues crowd out the working tissues of the organ. In the skin, the collagen multiplies so that the hair follicles and moisture glands are replaced and the skin becomes leathery and thicker. This can be very dangerous in the vital organs such as the lungs, heart, kidneys and gut. The cause is unknown, but the fibroblasts start to grow the connective tissues of the involved organ without regard for the working tissues, and produce abundant scar tissue. Unfortunately, there is still no cure or reliable treatment for scleroderma. Scleroderma is rare, affecting about 100,000 in the USA, most of whom are women, and most often it starts in middle age, but can affect any age. There are two main types, localized (affects the skin on the face, hands, and feet) and systemic (affects skin as well as blood vessels and major internal organs). Localized scleroderma can spread locally from the skin to involve muscles, joints and bones. Discolored and thickened patches of skin is Morphea, while bands of thick hardened skin is called linear scleroderma, or coup de sabre if on the face or forehead. CREST syndrome can also involve Raynauds and difficulty swallowing as well as the skin changes above. Systemic disease will eventually produce symptoms of deteriorating organ function as the vital and major organs are scarred. Diagnosis is established by confirmation of specific symptoms and signs of scleroderma, such as Raynaud’s phenomenon, skin thickening swelling and tightening, heartburn, high blood pressure from kidney problems, difficulty swallowing, weight loss, shortness of breath, and joint inflammation. Pulmonary function testing and echocardiogram for right heart function can find early evidence of systemic involvement. Treatment is oriented to treating the symptoms and complications of the patient since there is not a treatment to control the disease. Hopefully research will find a treatment for the disease soon. There are effective treatments for some of the complications of severe disease such as acute kidney disease, pulmonary hypertension and fibrosis, lung inflammation, and gastrointestinal problems. The Scleroderma Foundation www.scleroderma.org is available for more information.
SJOGRENS
Sjogrens disease is named after the Swedish doctor who discovered a form of arthritis with dryness of the eyes and mouth 100 years ago. The dryness is due to the immune system attacking the moisture producing glands like the tear and saliva glands, and it can also affect the nose, throat, skin and vagina. Besides attacking the joints and causing arthritis, it also can attack the blood vessels, lungs, liver, kidneys and nerves. Usually the first problem is difficulty eating dry foods or dental problems, and in the eyes it can be an irritation or gritty feeling. Half the patients with this already have some other autoimmune disease, like rheumatoid arthritis or lupus. Blood tests can support the diagnosis, but sometimes a biopsy of the inner lip is needed to confirm the diagnosis. Treatment for dryness can include plugging the lower eyelid tear ducts or using Restasis eye drops for the inflammation. Frequently sipping water and using Evoxac or Salagen can minimize dryness of the mouth. Good dental hygiene and regular cleanings can preserve the teeth and medications for fungal infections or acid reflux may be needed. Treatment for the disease includes Plaquinel, low dose corticosteroids, Methotrexate, Imuran, Cellcept, Rituxan, or Cytoxan. The vast majority of Sjogrens patients remain very healthy and without serious complications. Complications include lung problems that seem like pneumonia, worsening liver and kidney function, skin rashes of the small blood vessels, and nerve damage. Sjogrens may be associated with lymphoma, a cancer of the lymph glands. The Sjogren’s Syndrome Foundation www.sjogrens.org is available for more information.
VASCULITIS
Vasculitis is inflammation of the blood vessels and there are many types. The rash from being allergic to a medicine is a type of vasculitis. Most types are rare, but some can cause severe damage to the parts of the body the blood vessel supplies with blood. Some types of vasculitis are associated with autoimmune diseases, medicines, and infections, but we do not know the causes. Some types only occur in children, some only in the old. The diagnosis is usually established with a biopsy, although blood tests and angiography x-ray tests can help. The types of vasculitis are based on the size of the blood vessels involved. The large artery types are Giant cell arteritis, Takayasu’s arteritis, and aortitis, which can be associated with Cogan’s syndrome or spondyloarthropathies. Medium sized artery types are Kawasaki’s disease and Polyarteritis nodosa. Small to medium sized artery types are ANCA associated, Granulomatosis with polyangiitis, Microscopic polyangiitis, Eosinophilic granulomatosis with polyangiitis, and Primary angiitis of the central nervous system. Small artery types are IgA vasculitis, Vasculitis of rheumatoid arthritis, lupus, Sjogrens and other autoimmune diseases, Cryoglobulinemic vasculitis, Anti-glomerlular basement membrane disease, and drug induced vasculitis. Vasculitis of arteries and veins of various sizes are Behcet’s disease and Relapsing polychondritis. There are other forms of vasculitis related to infection and cancer that are not listed. Treatment is with corticosteroids, often at high dose. Other drugs are used to minimize the dose of corticosteroids such as Methotrexate, Imuran, Cellcept, Cytoxan, Rituxan and some patients need plasma exchange of their blood (plasmapheresis) or intravenous immunoglobulin infusions, IVIg. Vasculitis can be brief or life long and damage to organs may require surgery for grafting arteries to replace blood suppy. Side effects from the corticosteroids or other medicines require monitoring for complications. The Vasculitis Foundation www.vasculitisfoundation.org/education/forms is available for more information.

INTEGRATIVE RHEUMATOLOGIST

ENHANCING THE VALUE PROPOSITION & THE PATIENT JOURNEY THRU INTEGRATIVE RHEUMATOLOGY

WHAT IS INTERATIVE MEDICINE AND INTEGRATIVE RHEUMATOLOGY?

Following my fellowship at the University of Arizona Center for Integrative Medicine (AZCIM), the premier global training program in the newly branded subspecialty of Internal Medicine with its own board certification through American Board of Internal Medicine (ABIM,) the urgency of adding this essential whole person approach to our rheumatology approach became essential and clear to me. Simply stated and following the definition the AZCIM, “integrative medicine is the application of both evidence based principles and all appropriate approaches to treat the whole person relying on the therapeutic relationship between patient and healer and encompassing the mind, body and spirit approach to health” (www.azcim.edu.\)

WHAT IS INTEGRATIVE RHEUMATOLOGY?

My definition as the first Jones-Lowell Rheumatology Scholar recipient at the AZCIM and first formal rheumatologist trained there, is the application of said principles stated above, rigorously applied to the inflammatory rheumatic patient irrespective of disease entity or treatment paradigm with the focus on improving and optimizing that patient’s individual journey in their healing path. To this end, The Oasis Institute ( www.theoasisinstitue.com) has been charged with creating the competence for the AARA physician, by way of education, vetting appropriate modalities and disciplines, implementation and partnering with both AARA and Bendcare (www.bendcare.com), in optimizing the rheumatic patient journey and enhancing the value based proposition in areas the current system has fallen short. All healthcare stakeholders now demand or need this approach. During the past 18months as I have had the opportunity and privilege to meet rheumatologists across our nation while lecturing on The Patient Journey in the Bendcare Educational Summits, physicians have repeatedly come up to me and said they feel lacking in knowledge in these areas of nutrition, lifestyle, etc and that their patients are demanding more information and guidance from them, the treating rheumatologist. Obviously, these areas were not taught in medical school, residency, or fellowship trainings in the past but are beginning to be in some programs now. The Oasis Institute Professional Education tract in the areas of nutrition, supplements, mind-body medicine, exercise, whole body systems (TCM, Ayurveda, Homeopathy) and energy medicine concepts all appropriate for the rheumatology patient will be provided to the AARA physician in the future utilizing evidence based approaches. By way of support and implementation now, the AARA designated nutraceutical product line called Oasis Health, designed for and dedicated to the complex inflammatory rheumatic patient, has been created and vetted for evidence based formulations, outstanding purity in sourcing of raw materials, chain of custody confirmation, and licensed packaging for our consumer arthritis patient, and finally for convenience and ease of implementation by the AARA offices. This is another example of the collaborative win-win situation of consumer driven demand that AARA will lead in collaboration with The Oasis Institute and Bendcare. This activity will provide a disruptive, needed and branded approach for this essential consumer driven demand where physician supervision through a trusted source of high quality nutraceuticals is interfaced with the AARA physician work flow and leveraging our technology superiority in the marketplace.

As an AARA physician I take pride in enhancing my own patients experience by providing them with the services listed above in addition to the most appropriate conventional therapies including biologics, DMARDs, oral small molecules and injectable complex meds for all their rheumatic needs, blending them with an appropriate evidence based rationale that in some instances helps reduce side effects, improves patient satisfaction many times and in some cases reduces the complexity of the medical regimen.

Finally, the interface of Oasis Health product line and the educational opportunities through The Oasis Institute will both segue well with our AARA RESEARCH also being launched, called ENROLL, and headed by Dr Jeffrey Alper. This opportunity will help AARA assess individual natural products in future research settings answering questions in a more detailed ways leveraging our varied rheumatic population amongst our growing national network.

If any AARA physician is interested in becoming part of the Oasis concept, in trainings, education and implementation, and in supporting this exciting movement within AARA, please don’t hesitate to contact me and get involved.

OSTEOPOROSIS

Osteoporosis is the common weakening of bones, mainly as we grow older, that can lead to eventual fractures and disability. In addition to aging, risk factors include: non-Hispanic white or Asian ethnic background, small bone structure, family history of osteoporosis, prior fracture with little trauma, low levels of sex hormone, eating disorders, low calcium and vitamin D intake or absorption, lifestyle choices (such as sedentary or immobility, cigarette smoking, and alcohol abuse), diseases (such as hyperthyroidism, hyperparathyroidism, Cushings disease and inflammatory arthritis diseases such as rheumatoid arthritis), and medications (such as cortisone, excess thyroid replacement, breast and prostate cancer treatments, and heparin). Osteoporosis is a silent condition and not associated with bone pain until there are fractures. For people over age 50, half of women and a sixth of men will have an osteoporotic fracture during their lifetime. Osteoporosis is diagnosed by measuring the concentration of calcium in the lumbar spine, hip and distal forearm bones with a DEXA scan and comparing that to a young healthy member of the same sex. Bone density better than 1 standard deviation less than the ideal is considered normal bone density. Bone density worse than 2.5 standard deviations less than ideal is considered osteoporosis. Between normal and osteoporosis is a mild form of bone weakening called osteopenia that is less severe than osteoporosis. Treatment includes calcium supplementation (1,200 mg a day), vitamin D supplementation to obtain an adequate blood level, weight bearing physical activity to induce the bones to strengthen, and a medication if sex hormone is diminished. Medications include the bisphosphonates (Fosamax, Actonel, Boniva, and Reclast), as well as Miacalcin, Evista, Prolia www.prolia.com, or hormone replacement. All of these medications reduce the turn over and loss of bone, so they could possibly lead to complications with osteonecrosis of the jaw or atypical femoral fractures which are both very low to rare risk. Teriparatide stimulates bone formation instead, but requires a daily injection. If osteoporosis is present, prevention of falls can be as important as treatment of the bone density. A cane or walker if the patient is unstable, removing hazards from the home and ensuring adequate lighting at night, help for lifting and carrying heavy things, and wearing sturdy shoes could prevent premature fractures. The National Osteoporosis Foundation https://www.nof.org/ is available for more information.