Rheumatoid arthritis (RA) is an autoimmune systemic inflammatory disease which affects up to 0.8% of the population which translates into 2.4 million Americans. It’s cause is due to genetic susceptibility and environmental factors which research is beginning to identify. It causes joint pain, stiffness, patterned symmetrical joint swelling of the fingers and wrists (being most common), deformities, X-ray damage, decreased function, poor quality of life and disability. RA contributes to other disease states such as heart attacks and strokes. The diagnosis is made on the symptoms, examination, blood tests known as rheumatoid factor and anti-CCP antibody, X-rays, ultrasound, and MRI.

Cortisone (e.g. prednisone) and NSAIDs e.g. ibuprofen, naproxen can help symptoms but do not have the ability to modify the joint destruction and functional decline. They may cause stomach bleeding, poor kidney function, high blood pressure and cardiovascular side effects among other side effects.

Disease modifying anti-rheumatic drugs (DMARDs) have the capacity to drive the disease to a low activity state. The gold standard methotrexate at 15-25 mg per week, Arava, sulfasalazine, and the less potent Plaquenil are examples. But they often fail to induce remission. Newer biologic agents especially when used with methotrexate can affect good clinical outcomes. They include Enbrel, Remicade, Humira, Orencia, Rituxan, Cimzia, Simponi, and Actemra (listed in the order of approval by the FDA). However, even on these agents most RA patients do not achieve remission and they also may cause mild and serious side effect which limit their use. More research is needed to refine treatments with these agents and to identify new more effective, safe and less expensive drugs to help patients with RA. Only when RA patients volunteer for clinical research trials are better therapies discovered.

The physicians in practice at Arizona Arthritis & Rheumatology Associates and their research division Arizona Arthritis & Rheumatology Research are dedicated to the care of patients with RA. They helped develop the available RA therapies and are investigating new drugs on the horizon. We encourage patients with RA to contact us to participate in our growing research efforts and to become patients of our cutting edge rheumatology center.

By Dr. John Tesser, MD, Rheumatologist

A patient presented to my office as a new patient, sent because of elbow pain. After careful history taking and an examination of the elbow, it was determined that she had what is better known as “Tennis elbow”, or lateral epicondylitis. Further examination, revealed what we call dactylitis (sausage digit, because it looks like a sausage), pitting of a couple of finger nails and some psoriasis in the Umbilicus (belly button). The diagnosis then went from a localized/isolated tennis elbow to a diagnosis of Psoriatic arthritis.
Psoriatic arthritis comes in many forms and varieties. It can look just like rheumatoid arthritis (RA), involve the spine in a way similar to ankylosing spondylitis (inflammation of the spine), and can be associated with non-musculoskeletal issues such as sores in the mouth and inflammation in the eye. Of course, it is also possible to have Rheumatoid Arthritis in combination with, but unrelated to psoriasis. It is an excellent example of how the pattern of joint involvement can be a clue to the correct diagnosis, and of how the precise diagnosis can be elusive, but is usually more straight forward in the hands of an experienced physician who knows what questions to ask and takes the time to do a thorough exam. Psoriatic skin/nail changes, may predate the joint symptoms, or even follow the joint symptoms by years.
X-rays and labs can assist in the diagnosis, but can be as confusing to the “uninitiated/inexperienced” observer as they can be helpful. Psoriatic arthritis is, as are most illnesses, diagnosed primarily with a good history, good physical exam, and experience helps. The lab and x-rays are only ancillary. Just because a patient has a positive Rheumatoid factor, does not mean that they have RA and not psoriatic arthritis.
Patients have chronic illness, characterized by periods of relative improvement and then periods of flare-ups i.e., worsening. Our aim is to control the numbers of flares, the severity of the baseline level of inflammation, discomfort and disability, and to lessen the severity and the duration of flares. Ultimately, we aim to place the problem into prolonged remission
with drugs such as Methotrexate, and other DMARD (Disease Modifying Anti-rheumatic Drugs) and/or the Biologic modifiers, such as Remicade, Humira, Enbrel, just to mention a few. Because of potential side-effects, we tend to use less often, the class of drugs known as Non-steroidal anti-inflammatory drugs (NSAIDs). Since I had started in practice, the treatment has improved by leaps and bounds.
From time to time, we, at AARA PC might have a research protocol or two aimed at psoriatic arthritis, and it wouldn’t hurt to periodically call us and check up on this if one has been diagnosed as having Psoriatic Arthritis. We also have ongoing research studies for RA, and OA and other varieties of Rheumatic disease.

By Dr. John Starr MD, Rheumatologist

Osteoarthritis, not surprisingly, is referred to as the “wear and tear” type of arthritis since it will likely occur in all of us who tread long enough on this planet with gravity or who have had repeated injury or stress on our joints. This idea also helps conceptually to distinguish osteoarthritis from inflammatory types of arthritis such as rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis and lupus arthritis, to mention a few. Cartilage is a substance (you’ve seen that pearly smooth material on the ends of chicken bones) that protects our bones where they connect with each other to make a movable joint. As the structure of cartilage fails, stresses are transferred directly to bone. The silky smooth joint interface is then lost. The bone responds to more direct stress by thickening and at some point the joint begins to hurt.

Although the concept is useful, it is a bit of an oversimplification, since there is a strong genetic component to osteoarthritis that is revealed in the big differences among individuals and families in the rate of degeneration of protective cartilage in our joints over the years. While there is no question that obesity is a risk factor for advancing osteoarthritis particularly in the hips, knees and lower back, we sometimes see lightweight, dainty ladies who have probably never broken a real sweat come in with end-stage osteoarthritis requiring joint replacement to maintain the ability to walk. There is a familial type of osteoarthritis that occurs commonly in the small joints of the fingers that is genetically programmed to progress regardless of hand activity.

Medical science understands a lot about the mechanism of cartilage metabolism and degeneration, but hasn’t yet discovered a way to stop the degenerative process or to make us re-grow new “original equipment” cartilage. Despite the genetic observations, management of osteoarthritis begins with prevention, or as we call it, joint protection. Wearing proper supportive foot wear as well as all the available protective gear for sports and work, using proper body mechanics with lifting, maintaining normal body weight and avoiding carelessness that results in joint injury all make a difference.

Many modalities are in medical use to help people deal with the symptoms of osteoarthritis and to remain active. These include exercise and strength maintenance, pain medications, joint injections of corticosteroids or biological lubricants, supportive devices for joints and walking aids. Arizona Arthritis and Rheumatology Associates participate regularly in clinical trials of new medications or devices for osteoarthritis and people are encouraged to consider these studies among the available options. Surgical interventions by orthopedists including arthroscopy or joint replacement are appropriate for some folks with osteoarthritis.

By Dr. Paul Caldron, MD, Rheumatologist

Physicians diagnose gout when they see someone who has the classic presentation of intermittent flares of their joints in the setting of high blood uric acid. Although the blood uric acid is not always elevated during an acute flare it is almost always elevated between flares. A definitive diagnosis can be made when fluid is aspirated from the joint and it shows the colorful needle-shaped crystals of uric acid.

Treatment of gout involves two different approaches:

1.Treating the inflammation

2.Preventing flares by lowering the uric acid.

Treating flares of gout can be done with nonsteroidal anti-inflammatory agents, colchicine, and corticosteroids. Treatment of flares usually works best if started as soon as possible after an attack begins. Gout can be prevented with medications like allopurinol, febuxostat, and probenecid. These medications lower uric acid quickly but it will usually take months to completely prevent flares. Restricting foods high in purine is also important in controlling blood levels of uric acid. These include foods like seafood, organ meat and beer.

Although gout can be an extremely painful disease it also is one of the most treatable diseases. With careful attention to diet and strict compliance to medications most patients can lead normal active lives.

At Arizona Arthritis and Rheumatology Associates we help patients control their gout with dietary and medical management. Our research arm of the practice Arizona Arthritis and Rheumatology Research (AARR) helps develop new medications to advance the treatment and prevention of gout.

By Dr. Eric Peters, MD, Rheumatologist

Ankylosing spondylitis (AS) is a chronic inflammatory disease that causes pain and inflammation of the joints of the spine and the joints between the spine and pelvis (sacroiliac joints). However, AS may also involve other parts of the body as well. AS and its related diseases affect as many as 2.4 million people in the United States. AS commonly occurs in people between the ages of 17-35, but it can affect children and older adults. AS is more common in men, but occurs in women as well. Although the exact cause of AS is unknown, we do know that genetics, along with some environmental factors, play a key role in AS.

The first symptoms of AS are frequent pain and stiffness in the lower back and buttocks, which comes on gradually over a period of a few weeks or months. This pain and stiffness is usually worse in the mornings and during the night, and improves with light exercise. Some patients with AS can also have inflammation in their tendons and other joints of the body. In patients with advanced disease, inflammation can cause the spine to fuse in a fixed, immobile position, sometimes creating a forward-stooped posture.

The goal of treatment is to relieve pain and stiffness, and prevent or delay complications and spinal deformity. Nonsteroidal anti-inflammatory drugs (NSAIDs) are initially used to reduce inflammation and pain. Other drugs used are sulfasalazine or methotrexate . These drugs, however, are not as effective in controlling inflammation in the spine. Newer drugs, called TNF-inhibitors have been shown to improve the symptoms of AS. These include medications such as Humira, Enbrel, Simponi and Remicade. Recently, it has been shown that these drugs control symptoms but there is still some residual inflammation seen on MRI of the SI joints in patients with AS. Symptoms reoccur on stopping these medications. There are ongoing trials to find more effective and longer lasting medications for these patients.

The physicians at Arizona Arthritis and Rheumatology Associates see a lot of patients with Ankylosing Spondylitis. We also have a research arm, AARR, which is dedicated in helping to develop newer drugs which can be more effective and less expensive for our patients. We would like to encourage patients with AS to call our office if they are interested in treatment and in participating in one of our clinical trials for AS.

By Dr. Areena Swarup, MD, Rheumatologist

Systemic Lupus Erythematosus (SLE) is a disease that is a good example of an “autoimmune disease”. It is a chronic inflammatory disease where the immune system attacks the tissues of different organ systems throughout the body and can result in many problems. It occurs worldwide, and is more common in some populations than others. Overall, this disease occurs to a frequency of about one in 1000. It is most common in women, particularly in the fertile years. In these years this disease has a ratio of about 9 women to 1 man, while in other years the ratio is much closer.

There are many manifestations of systemic lupus, from mild to life threatening. The most common symptoms include: rash (with a “butterfly rash” occurring on the face being common); sun sensitivity; arthritis; mouth and other mucous membranes sores; pericarditis (inflammation around the lining of the heart); pleurisy (inflammation around the lining of the lungs); a tendency to form blood clots; a tendency for blood vessels to get inflamed; seizures; renal disease which can lead to kidney failure and dialysis; blood abnormalities, etc. As can be imagined, because of the many different manifestations this can be a very difficult disease to diagnose. Blood tests are helpful. Rheumatologists are often consulted to help confirm the diagnosis. Because of the difficulty in treating some of these problems they are also needed to take part in the management of this disease.

The cause for SLE is not known. There is a genetic predisposition to it, and it may be triggered by environmental exposures. Because of these genetic influences, it is more common in some parts of the world than in others. Many patients are also very sensitive to the sun, and sunlight can trigger diverse elements of the disease, such as renal disease.

SLE has no cure, but there are medications that help manage its varied manifestations. Medications used for the treatment of SLE include: relatively mild medications such as Plaquenil, medications for pain, varying doses of glucocorticoids (such as prednisone) which often results in many adverse effects, and immunosuppressives (such as chemotherapeutic agents) which need careful monitoring.

It is hard to believe, but there has been no new approved drug for the treatment of systemic lupus for several decades! This is in part because of the many problems of the disease. It is difficult to find patients with similar manifestations who have a similar activity to their disease. This is needed to prove that a medication is effective. This is why it is so important to continue to look for new treatments in SLE. A new medication may be approved for use in SLE soon, but much needs to be done. Arizona Arthritis and Rheumatology Associates is proud to take part in many of these trials which look for new treatments for this potentially life-threatening disease.

By Dr. Ralph Bennett, MD, Rheumatologist