Common Myths about Rheumatology- to be banished-Dr. Vishal Kaur Aggarwal, Consultant, Rheumatology, BLK Super Speciality Hospital
Rheumatology is a sub-specialty of medicine dealing with diagnosis and treatment of diseases predominantly affecting the joints and connective tissues. Various auto-immune disorders affecting multiple organ systems also fall under its purview. This sub-specialty provides diagnostic facilities and therapy for disorders such as rheumatoid arthritis, ankylosing Spondylosis, gout, osteoarthritis and critical auto-immune diseases such as lupus, scleroderma & dermatomyositis.
There are many myths related to rheumatologic diseases and their treatment in public as well as medical fraternity. This is detrimental as patients with rheumatologic diseases reach the rheumatologist very late with deformities and other systemic complications.
The first myth that these diseases are just bone and joint disease needs to be clarified that these are systemic autoimmune diseases which means the body as a whole is diseased. We need to have this understanding that such patients need to be recognized early and given an early and comprehensive treatment with the principle of treat to target as there had been a paradigm change in the understanding of path physiology of these diseases and their management.
In general the musculoskeletal and rheumatic diseases can be inflammatory and non- inflammatory or mechanical in cause
When the patient comes with pain in joint area, one has to make out is it joint involvement or not. Joint affection is made out by swelling of joint with effusion, accompanied by warmth and redness. There is tenderness in joint all through the joint movement. All these signs and symptoms lead us to diagnose arthritis.
The next step is to make out whether it is inflammatory or non inflammatory. Inflammatory joint diseases present as pain joints worst in early mornings accompanied by prolonged stiffness (> 30 minutes). The pain improves after moving or exercising the joint but after rest the pain worsens. It responds well to NSAIDs and has a fluctuating course.
Another common myth is regarding the presence of Rheumatoid factor in patients with non specific body pains but no arthritis.
If there’s no arthritis clinically or even radiological as with musculoskeletal ultrasonography then presence of auto antibodies does not dictate diagnosis or treatment. Rheumatoid factor is an autoantibody (IgG, IgM or IgA) directed against our own IgG. Five percent of our population has it normally. If a patient has nonspecific body aches then Rheumatoid factor positivity does not make it as Rheumatoid arthritis. There are many metabolic causes which can present as nonspecific myalgia or arthralgia for example thyroid diseases, vitamin D3 deficiency. Fibromyalgia is a common cause of such symptoms. If no cause can be found out then refer the patient to a rheumatologist for further evaluation.
Hyperuricemia does not mean presence of gout.
Hyperuricemia is reflection of our calorie intake and associated with metabolic syndrome and is a risk factor for coronary artery disease. Literature says Hyperuricemia without any presence inflammatory joint involvement is not to be treated unless we are bothered about cardiovascular health. When there is inflammatory involvement of joint, tendons or bursae, or there is presence of tophi, needs treatment.
Yet another myth is that monoarthrit is tubercular arthritis.
The commonest cause of monoarthrit is autoimmune. We need to look for present or past features like enthesitis, inflammatory back pain, uveitis, psoriasis etc. Infectious cause is ruled out by synovial fluid examination or synovial biopsy examination.
Even one sided sacroiliitis does not always mean tuberculosis. Spondyloarthritis should not be forgotten as this is a common cause and quite frequently missed diagnosis
Methotrexate is two drugs: Low dose (LD) Methotrexate and High dose (HD) Methotrexate Drugs used in Rheumatology are taken as too toxic drugs especially Methotrexate. High dose Methotrexate is a cancer drug and causes bone marrow suppression. LD (low dose) Methotrexate is used for autoimmune diseases which has a different mechanism of action and is an anti-inflammatory and immune-modulating drug. It is one of the safest drugs used in medicine.
Retinopathy with Hydoxychloroquin is rare; therefore the drug should not be blamed for any eye problem in a patient taking it.
No increase in perisurgical infections in patients taking DMARDs
In the latest studies it has been found that there is no infection found after doing DMARDs. Rather in a well controlled inflammatory state there would be better healing!
While many in the treatment community once tended to use NSAIDs early in the course of the disease and only add other drugs, such as DMARDs, as RA progressed, it is now standard practice, in early RA with a certain level of disease activity, to start DMARDs soon after diagnosis to prevent or minimize joint and other tissue damage.
To conclude Medical science has really evolved in understanding and safe management of rheumatologic diseases.