October 6, 2023
I wanted to introduce you to the World of arthritis – the Old, the New and the Modern.
The Old World of Medicine is reflected in visual art; Egyptian mummies who underwent X-rays; as well as verses and writings of brilliant poets and authors.
Artists, like Antoni Gaudí and Renoir, vividly captured the pain, the suffering, malaise, and immobility in their paintings. We would expect them to depict the people surrounding them at the time. But they may have also been illustrating their own illnesses. If arthritis was their affliction, it’s interesting to see how their brushstrokes were affected!
Home remedies were made from the Willow Bark, containing Salicin, which is now in the modern-day Aspirin. The Far East applied acupuncture. Attempts were made at “blood-letting” to remove the inflammation. Afflicted patients were placed in confinement. Physiotherapists would hoist immobile patients and lower them into a thermal pool.
Then in 1948, a “wonder drug”, changed the face of arthritis. It was called “Rayos”, now known as prednisone. This opened the door to the New World of arthritis. In the same decade, Salazopyrine came in to use, and in 1957, Chloroquine was released for joint inflammation. Then heavy metals like Gold in injection form were used, with variable benefit doubled with much side effects. Major success came through in the 1980s, when Methotrexate was discovered as a promising disease modifying agent, and it remains the anchor therapy for many forms of arthritis in every country.
The Modern World of arthritis, began in the 1990s, when the first biologic was engineered, called Infliximab. And ever since, many more biologics have come onto the market.
You may ask, how did they diagnose arthritis in the old days. Well, they labelled all patients as having gout initially. Over time, they realised there was a difference, because not all patients had elevated uric acid in the urine. With keen observation, examinations and paintings, differentiating features were found, and led to the subtyping we have today.
There are over 100 different forms of arthritis, each with a distinct pattern of joint involvement, or extra-articular manifestation, or defining laboratory test, or X-ray appearance. When you consult us, as rheumatologists, we will make every effort to give you the exact diagnosis in terms of form of arthritis, degree of activity and joint damage.
The common types of arthritis we see are – Osteoarthritis, Gout, Rheumatoid Arthritis, Lupus Arthritis, Psoriatic Arthritis, Spondylarthritis e.g., Ankylosing Spondylitis, Reactive Arthritis, Enteropathic Arthritis.
Osteoarthritis takes months to years to develop; tends to affect the hips and knees (with a creaking sensation), joints that have undergone trauma, or manifests as bony swelling of the fingers. X-rays aid in the diagnosis when the arthritis is more established, but blood tests are unhelpful.
Rheumatoid Arthritis develops over weeks to months; primarily affects the small joints of the hands and feet; and displays a soft, spongy swelling. Auto-immune antibodies can be detected on a blood sample to confirm the diagnosis.
Gout actually develops over hours and can be quite incapacitating. It has a predilection for the cooler area of the body, and therefore starts in the big toe, working its way up to the ankles, knees etc. There is classically redness overlying the joint in an acute gout attack, and after 10 years of having gout, crystals can appear in the form of chalky tophi. The uric acid levels are elevated in between attacks but can be normal during an acute attack.
Lupus has distinct skin rashes with or without other organ manifestations and tends to favour the small joints of the hands. Positive autoimmune testing assists in the diagnosis.
Psoriatic Arthritis is usually preceded by the psoriasis rash for many years. The distribution of arthritis can be quite variable with 5 recognised subtypes.
The Spondyloarthropathies generally affect the spine, sacro-iliac joints in the pelvis or large joints of the lower limbs, in a variable combination. The HLA-B27 gene may or may not be positive.
So, what are the plans for the future? Our researchers are developing nanoparticles, to deliver drug therapy to specific areas in the body, and in this way reduce the side effects. Targeted therapies tailored to individual patients based on their blood-work profiles, are also to be developed. Laboratory diagnostics will become more refined and assist us in choosing the best treatment regimen for each patient.
I hope I have enlightened you, on how the Modern Age has come to understand the natural history of arthritis, and Medicine in general. As you can see, our current practices are based on tried and tested therapeutics from the 1940s, mixed with novel therapies. As rheumatologists, we are skilled in applying new and old concepts in treating our patients. There are many more therapeutics to follow.
Dr Amritha Budhoo
Specialist Rheumatologist & Physician
November 22, 2023
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