Short Stories in Rheumatoid Arthritis

I wanted to take you through a consultation of a patient I have recently seen. He was 41 years old, married with 2 children, but felt like he was 80. He had noticed painful joint swelling and stiffness 2 months ago, affecting his fingers, knees and feet. A variety of anti-inflammatories were taken with short-lived benefit. There were no other chronic conditions, but he did report digestive issues. He was a smoker since his high-school days. His work was very physically demanding, and the joint symptoms were causing difficulty in this regard.

When I examined this gentleman, I noticed redness of the eyes. He had a number of dental implants and fillings. There were already joint deformities of the fingers, so I asked him if the symptoms were present for longer. As expected, the joint pain actually began 18 months prior, but had drastically worsened in the preceding 2 months. Prominent swelling of the small joints of the hands were present, with milder swelling of the knees and feet. The chest was clear. However, the upper abdomen was tender, perhaps due to all the anti-inflammatories.

The referring general practitioner, had already requested the necessary lab tests, which revealed strongly positive results for the Rheumatoid Factor (RF). I went through all the results with the patient which included a full blood count, kidney function, liver tests and inflammation markers.

Finally, the treatment plan was discussed. Since the arthritis was moderately active, I prescribed a combination of therapies, in order to gain quicker control of this autoimmune condition. He asked about the potential side effects which were explained.

Before the patient left, he asked me: “Doc, how did I develop arthritis?  No one in my family has it.” Hence, I am writing this article today.

Is arthritis hereditary?

The most widely known gene associated with Rheumatoid Arthritis (RA), is the HLA-DR4 gene. First degree relatives of patients with RA, do have a higher risk of developing the condition compared to the general population. However, RA is not always transmitted from one generation to another and, many patients do not have a family history. In the latter group, there is a strong interaction between lifestyle and the environment, which alters the structure of a particular gene, and then changes the way it is expressed. In the case of RA, this gene expresses itself, by stimulating joint inflammation.

Prearthritis

In this phase, certain health and lifestyle factors alters the structure of a gene’s DNA, altering the way the gene is expressed, as noted above. These lifestyle factors include smoking, and health-related factors include periodontitis and gut health. Once gene expression is altered, there is loss of the body’s tolerance to itself, and auto-antibodies are generated. These are antibodies, that attack the body’s own tissues. This is the crux of auto-immunity.

Transition phase

After the auto-antibodies develop (e.g. RF and anti-ccp), certain triggers then lead onto the clinical phase of RA. These triggers are infections, vaccines, psychological stress, air pollution (which notably has a mix of second-hand smoke, carbon monoxide and ozone).

Clinical phase

Finally, the joints become swollen, the cartilage wears out, and the bone becomes eroded with joint deformities – this can be prevented with timely treatment.

Of interest, the chronic inflammation does not only affect the joints. The blood vessels also become inflamed leading to heart disease; the bones start to weaken and leads to osteoporosis; neuro-inflammation causes brain fog; and depression may develop for many reasons.

Summary

I advised my patient of all the above. And then he gave me further clues in understanding his diagnosis. We know his problems began in high-school, when he started smoking. His family home was actually close to a highway. He has always had digestive issues. Then 2 years ago, he underwent several dental procedures along with a number of oral infections. It was the same year, that he had taken 2 doses of the Covid vaccine.

In current times, our approach to treating RA, is the same regardless of the cause. However, this will change in the future.

Overall, to reduce your risk of developing RA, improve oral health with assistance from a dentist; pay attention to gut health – probiotics may play a role in balancing the bacterial load; have a balanced diet, and avoid processed food; and of course, avoid smoking.

Should you develop symptoms of RA, the best window of opportunity is within the first 6 months of symptom onset. We still have treatment options beyond that though.