Winning Over Rheumatoid Arthritis: A Success Story
The following case study is a narration by Dr. Vineeta Shobha, Senior Rheumatologist in Bangalore. It talks about a 67-year-old woman suffering from rheumatoid arthritis, how the disease progressed and the medications she is using as part of its treatment.
RA is a long-term or chronic condition which affects joints and multiple internal organs
- Seropositive RA is the most common form of RA
- Timely treatment is the key to controlling RA progression
- RA can result in bone deformities
It all began with joint pain, swelling and stiffness of joints and fatigue in winters of 1997. The first symptoms of rheumatoid arthritis (RA) in Mrs.Madhu Malhotra (name changed), 47-year-old lady were not taken seriously by both herself as well as her family. Symptoms were attributed to overwork, aging and menopause. She began treatment of symptoms with alternate medicines. Symptoms began to show in 1997, but it was not until 2002, that she was diagnosed positive for rheumatoid factor. Thereafter, she visited rheumatologists and was initiated on effective combination Disease-modifying anti-rheumatic drugs (DMARDs) at St. John's Hospital. Most people do not understand that this disease process, even though named as arthritis, can affect many internal organs too, such as lungs, eyes, skin, nerves etc. Early initiation of DMARDs is most effective method of reducing inflammatory burden and halting or reducing progression of RA.
What is Rheumatoid Arthritis?
RA is a long-term or chronic condition which affects joints and multiple internal organs. Seropositive RA is the most common form of RA i.e. when rheumatoid factor is demonstrated to be positive. A person suffering from seropositive RA has antibodies in blood that can help in identifying with the condition. These antibodies can either be anti-cyclic citrullinated peptide (anti-CCPs) or rheumatoid factors (RF).
These antibodies are not present in case of seronegative RA. However, the symptoms are still similar to RA. Usually, symptom severity and deformities are more in case of seropositive compared with seronegative RA.
How rheumatoid arthritis progressed in Mrs. Madhu Malhotra
For initial few years, she responded well to medications. Afterwards, she began experiencing recurrent flares. Typically such patients are treated with combination immunomodulator drugs (DMARDs) in escalating doses till complete relief is experienced. The disease process inherently has ups and downs, which is called flares, in medical terms. This requires changes in medications as well as escalation of dosing based on symptomatology. The alternate medicines taken during the initial stages were ineffective in controlling progression of RA. This resulted in deformities in hands and feet (began in 2004).
These complications were primarily developed because of delayed treatment. Receiving timely treatment is the key to controlling progression of RA. During the early illness period, the immune system has the capability to get back to normal. But this does not occur during the later phases of illness.
Madhu neglected her health while her children were growing up. She used to frequently miss her medications. It was only after she developed deformities that she realised the value of timely treatment and compliance in case of RA."
Dr. Vineeta ShobhaProfessor and Head, Department of Clinical Immunology and Rheumatology, St John's Medical College Hospital
Due to ongoing inflammation, she was initiated on biologics for one year in 2008-09. Biologics are immunomodulators that are targeted to a few specific cytokines. These cytokines are responsible for the aforementioned disease process. A person with moderate to severe RA, who fails to respond to traditional DMARDs, is prescribed biologics by the doctor. These biologics can either be taken alone or along with other RA medications. However, these medications are priced high and are beyond reach of most of RA patients in India. Additionally most of existing insurance schemes do not include arthritic diseases and do not cover for biologics medicines.
During the one year use of biologics by Madhu, she reported complete relief from pain, fatigue and swelling of joints. However, deformities of her hands did not regress simply because of permanent structural changes in her joints.She has undergone two plastic surgeries in her hands for tendon repair, which had ruptured because of ongoing arthritis.
Over the years, the deformities have gradually worsened. Madhu is now using hand and finger splints in order to maintain mobility of hands. Finger splints are specially designed rings that are made for stabilising finger deformities.
Madhu neglected her health while her children were growing up. She used to frequently miss her medications. She took painkillers to get relief from pain, especially in morning when she experienced extreme morning stiffness. It was only after she developed deformities that she realised the value of timely treatment and compliance in case of rheumatoid arthritis.
Madhu is currently 67. Her children are settled abroad, while she resides in Bangalore with her spouse. She can cook meals and is also able to look after household chores. 3 months ago, she has been prescribed new RA medications in tablet form (JAK inhibitor). This has helped reduced her symptoms to a great extent. Her RA is stable on treatment.
RA treatment and medications are going to continue endlessly for Madhu. In case she had received timely treatment, her hand functions would have been good and she could have possibly been able to go off medications.
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