Ankylosing spondylitis (pronounced ank-kih-low-sing spon-dill-eye-tiss), or AS, is a form of arthritis that primarily affects the spine, although other joints can become involved. It causes inflammation of the spinal joints (vertebrae) that can lead to severe, chronic pain and discomfort.
Back pain is a common reason for absence from work and doctor visits. Although back pain may be painful and uncomfortable, it is not usually serious.
- Intensely painful, swelling joints (most often in the big toe or other part of the foot) and/or bouts of arthritis that come and go may indicate gout.
- Finding the characteristic crystals in the fluid of joints allows health care providers to correctly diagnose gout.
- Gout treatments exist, but therapy should be tailored for each person. Treatment choices depend on kidney function, other health problems, personal preferences and other factors.
- Patients may need medications to lower their elevated blood uric acid levels that predispose to gout. The goal is a uric acid level less than 6 milligrams per deciliter (mg/dL).
- There are two types of medicine for gout. For control of acute attacks of joint pain, there are NSAIDs, colchicine and corticosteroids. After gout flares have resolved, there are medications that can lower the level of uric acid over time in order to prevent or lessen attacks.
- Lifestyle changes such as controlling weight, limiting alcohol intake and limiting meals with meats and fish rich in purines also can help control gout.
Gout is a painful and potentially disabling form of arthritis that has been around since ancient times. It is sometimes referred to as the “disease of kings,” because people long have incorrectly linked it to the kind of overindulgence in food and wine only the rich and powerful could afford. In fact, gout can affect anyone, and its risk factors vary.
The first symptoms usually are intense episodes of painful swelling in single joints, most often in the feet, especially the big toe. The swollen site may be red and warm. Fifty percent of first episodes occur in the big toe, but any joint can be involved. Fortunately, it is possible to treat gout and reduce its very painful attacks by avoiding food and medication triggers and by taking medicines that can help. However, diagnosing gout can be hard, and treatment plans often must be tailored for each person.
What causes gout?
Gout occurs when excess uric acid (a normal waste product) collects in the body, and needle‐like urate crystals deposit in the joints. This may happen because either uric acid production increases or, more often, the kidneys cannot remove uric acid from the body well enough. Certain foods and drugs may raise uric acid levels and lead to gout attacks. These include:
- Shellfish and red meats
- Alcohol in excess
- Sugary drinks and foods that are high in fructose
- Some medications, such as:
- low-dose aspirin (but because it can help protect against heart attacks and strokes, we do not recommend that people with gout stop taking low-dose aspirin)
- certain diuretics (“water pills”) such as hydrochlorothiazide (Esidrix, Hydro‐D) and Lasix
- immunosuppressants used in organ transplants such as cyclosporine (Neoral, Sandimmune) and tacrolimus (Prograf)
Over time, increased uric acid levels in the blood may lead to deposits of urate crystals in and around the joints. These crystals can attract white blood cells, leading to severe, painful gout attacks and chronic arthritis. Uric acid also can deposit in the urinary tract, causing kidney stones.
Who gets gout?
Gout affects more than three million Americans. This condition and its complications occur more often in men, women after menopause, and people with kidney disease. Gout is strongly linked to obesity, hypertension (high blood pressure), hyperlipidemia (high cholesterol and triglycerides) and diabetes. Because of genetic factors, gout tends to run in some families. Gout rarely affects children.
How is gout diagnosed?
Some other kinds of arthritis can mimic gout, so proper diagnosis (detection) is key. Health care providers suspect gout when a patient has joint swelling and intense pain in one or two joints at first, followed by pain‐free times between attacks. Early gout attacks often start at night.
Diagnosis depends on finding the distinguishing crystals. The physician may use a needle to extract fluid from an affected joint and will study that fluid under a microscope to find whether urate crystals are present. Crystals also can be found in deposits (called tophi) that can appear under the skin. These tophi occur in advanced gout.
Uric acid levels in the blood are important to measure but can sometimes be misleading, especially if measured at the time of an acute attack. Levels may be normal for a short time or even low during attacks. Even people who do not have gout can have increased uric acid levels.
X-rays may show joint damage in gout of long duration. Ultrasound and dual energy computed tomography (commonly called dual energy CT) can show early features of gouty joint involvement. These imaging techniques also can help suggest the diagnosis.
How is gout treated?
Treatment of acute attacks
One treatment for active gout flares is colchicine. This medicine can be effective if given early in the attack. However, colchicine can cause nausea, vomiting, diarrhea and other side effects. Side effects may be less frequent with low doses. Patients with kidney or liver disease, or who take drugs that interact (interfere) with colchicine, must take lower doses or use other medicines. Colchicine also has an important role in preventing gout attacks (see below).
Nonsteroidal anti‐inflammatory drugs– commonly called NSAIDs – are aspirin‐like medications that can decrease inflammation and pain in joints and other tissues. NSAIDs, such as indomethacin (Indocin) and naproxen (Naprosyn), have become the treatment choice for most acute attacks of gout. There is no proof that any one NSAID is better than others. High doses of short‐acting NSAIDs give the fastest relief of symptoms. These medicines may cause stomach upset, ulcers or diarrhea, but they are well tolerated by most people when used for the short term. Some people cannot take NSAIDs because of health conditions such as ulcer disease or impaired kidney function or the use of blood thinners. The fact sheet on NSAIDs lists the types of patients who cannot take NSAIDs.
In patients with chronic undertreated gout crystals can be found in uric acid deposits (called tophi) that can damage joints & can appear under the skin. Corticosteroids such as prednisone and triamcinolone are useful options for patients who cannot take NSAIDs. Given orally (by mouth) or by injection (shot) into the muscle, these medicines can be very effective in treating gout attacks. If only one or two joints are involved, your doctor can inject a corticosteroid directly into your joint.
Health care providers may prescribe anakinra (Kineret) , an “interleukin 1 beta antagonist,” for very severe attacks of gout. Though this rheumatoid arthritis drug is not approved by the Food and Drug Administration (FDA), for gout treatment, it can quickly relieve gout symptoms for some patients. Some home remedies may help ease gout pain. Rest the affected joint and apply ice packs or cold compresses (cloths soaked in ice water and wrung out) to that spot.
Treatment to remove excess uric acid
Patients who have repeated gout flares, abnormally high levels of blood uric acid, or tophi or kidney stones should strongly consider medicines to lower blood uric acid levels. These medications do not help the painful flares of acute gout, so most patients should start taking them after acute attacks subside. The drug most often used to return blood levels of uric acid to normal is allopurinol (Lopurin, Zyloprim). It blocks production of uric acid. Another option, febuxostat (Uloric), also acts by blocking uric acid production.
Probenecid (Benemid) helps the kidneys remove uric acid. Only patients with good kidney function who do not overproduce uric acid should take probenecid.
Pegloticase (Krystexxa) is given by injection and breaks down uric acid. This drug is for patients who do not respond to other treatments or cannot tolerate them. New drugs to lower uric acid levels and to treat gout inflammation are under development.
Gout flares often can occur when you first start to use medications that lower blood uric acid levels. Patients can help prevent flares when starting these medications by also using low‐dose colchicine or NSAIDs. Often, doctors advise patients to keep taking colchicine in a low, preventive dose together with the uric acid-lowering medicine for at least six months.
If you are taking a uric acid-lowering drug, your doctor should slowly raise the dose and keep checking your blood uric acid levels. Once your uric acid levels drop below 6 mg/dL (normal), crystals tend to dissolve and new deposits of crystals can be prevented. You probably will have to stay on this medicine long term to prevent gout attacks.
What works well for one person may not work as well for another. Therefore, decisions about when to start treatment and what drugs to use should be tailored for each patient. Treatment choices depend on kidney function, other health problems, personal preferences and other factors.
What you eat can increase uric acid levels. Limit the amount of high-fructose drinks, such as non-diet soda. Also, do not drink alcohol, especially beer. Restrict eating foods that are rich in purines, compounds that break down into uric acid. These compounds are high in meat and certain types of seafood. New research has found purines in vegetables appear to be safe. Low‐fat dairy products may help lower uric acid levels.
In almost all cases, it is possible to successfully treat gout and bring a gradual end to attacks. Treatment also can decrease the number and size of tophi (deposits of uric acid crystals).
Broader health impacts of gout
Gout often is associated with high blood pressure, heart and kidney disease, or the use of medications that increase uric acid levels. Therefore, health care providers should test for these related health problems. Researchers are studying whether lowering blood uric acid levels can help heart disease and kidney disease.
Living with gout
Gout affects quality of life by both the intermittent attacks and the potential for chronic (lasting) arthritis. Compliance with your treatment plan is critical. Lifestyle changes may make it easier to manage this lifelong disease. Suggestions include gradual weight loss, avoidance of alcohol and reduced consumption of fructose‐containing drinks and foods high in purines.
The rheumatologist's role in the treatment of gout
Treatment of gout can be difficult because of coexisting illnesses and other medications. As experts in the treatment of arthritis,rheumatologists examine patients to learn whether gout is the cause of their arthritis and to educate them about the role and proper use of medications and other treatments for gout. They also act as a resource to primary care doctors.
- Lupus occurs 10 times more often in women than in men.
- Treatment depends on the symptoms and how serious they are.
- Because it is a complex disease, lupus requires treatment by or consultation with a rheumatologist , a doctor who is an expert in treating lupus and other rheumatic diseases.
- People can live well with lupus if they actively work toward good health.
Systemic lupus erythematosus, referred to as SLE or lupus, is a chronic (long-term) disease that causes inflammation — pain and swelling. It is sometimes called the “great imitator,” because of people often confuse lupus with other health problems due to its wide range of symptoms.
In addition to affecting the skin and joints, it can affect other organs in the body such as the kidneys, the tissue lining the lungs (pleura) and heart (pericardium), and the brain. Most patients feel fatigue and have rashes, arthritis (painful and swollen joints) and fever.
Lupus flares vary from mild to serious. Most patients have times when the disease is active, followed by times when the disease is mostly quiet — referred to as a remission. Yet, there is much reason for hope. Improvements in treatment have greatly improved these patients’ quality of life and increased their lifespan.
What causes lupus?
The immune system is the body’s defense system. When healthy, it protects the body by making antibodies (blood proteins) that attack foreign germs and cancers. With lupus, the immune system misfires. Instead of producing protective antibodies, an autoimmune disease begins and makes “autoantibodies,” which attack the patient’s own tissues. Doctors sometimes refer to this as a “loss of self-tolerance.”
As the attack goes on, other immune cells join the fight. This leads to inflammation and abnormal blood vessels ( vasculitis ). These antibodies then end up in cells in organs, where they damage those tissues. Why this inflammatory response begins is not clear. It most likely results from a mix of inherited tendencies and things in your environment. These include viruses, sunlight and drug allergies. People with lupus may also have an impaired process for clearing old and damaged cells from the body, which causes an abnormal immune response.
Most often, lupus starts in people in their 20s and 30s. The disease is more common in some ethnic groups, mainly blacks and Asians, and tends to be worse in these groups.
How is lupus diagnosed?
Lupus can be hard to detect because it is a complex disease that has many symptoms, and they can come on slowly. As experts in diagnosing and treating autoimmune diseases such as lupus, rheumatologists can best determine whether a patient has lupus and advise them about treatment options.
People with lupus often have symptoms that are not specific to lupus. These include fever, fatigue, weight loss, blood clots and hair loss in spots or around the hairline. They may also have heartburn, stomach pain, and poor circulation to the fingers and toes. Pregnant women can have miscarriages.
The American College of Rheumatology has a list of symptoms and other measures that doctors can use as a guide to decide if a patient with symptoms has lupus. If your doctor finds that you have at least four of these problems, and finds no other reason for them, you may have lupus:
- butterfly-shaped rash over the cheeks — referred to as malar rash
- red rash with raised round or oval patches — known as discoid rash
- rash on skin exposed to the sun
- Mouth sores: sores in the mouth or nose lasting from a few days to more than a month
- Arthritis: tenderness and swelling lasting for a few weeks in two or more joints
- Lung or heart inflammation: swelling of the tissue lining the lungs (referred to as pleurisy or pleuritis) or the heart (pericarditis), which can cause chest pain when breathing deeply
- Kidney problem: blood or protein in the urine, or tests that suggest poor kidney function
- Neurologic problem: seizures, strokes or psychosis (a mental health problem)
Abnormal blood tests such as:]
- low blood cell counts: anemia, low white blood cells or low platelets
- positive antinuclear antibodies (ANA) result: antibodies that can cause the body to begin attacking itself that are present in nearly all lupus patients
- certain antibodies that show an immune system problem: anti-double-strand DNA (called anti-dsDNA), anti-Smith (referred to as anti-Sm) or antiphospholipid antibodies, or a false-positive blood test for syphilis (meaning you do not really have this infection)
If your doctor suspects you have lupus from your symptoms, you will need a series of blood tests to confirm that you do have the disease. The most important blood screening test measures ANA, but you can have ANA and not have lupus. Therefore, if you have positive ANA, you may need more specific tests to prove the diagnosis. These blood tests include antibodies to anti-dsDNA and anti-Sm.
The presence of antiphospholipid antibodies can help doctors detect lupus. These antibodies signal a raised risk of certain complications such as miscarriage, difficulties with memory, or blood clots that may lead to stroke or lung injury. Doctors also may measure levels of certain complement proteins (a part of the immune system) in the blood, to help detect the disease and follow its progress.
How is lupus treated?
There is no cure for lupus, and treating lupus can be a challenge. However, treatment for lupus has improved a great deal. Treatment depends on the type of symptoms you have and how serious they are. Patients with muscle or joint pain, fatigue, rashes and other problems that are not dangerous can receive “conservative” treatment.
Common treatment options include:
- Nonsteroidal anti-inflammatory drugs (NSAIDs): NSAIDs decrease swelling, pain and fever. These drugs include ibuprofen (brand names Motrin, Advil) and naproxen (Naprosyn, Aleve). Some of these NSAIDs can cause serious side effects like stomach bleeding or kidney damage. Always check with your doctor before taking any medications that are over the counter (without a prescription) for your lupus.
- Antimalarial drugs: Patients with lupus also may receive an antimalarial medication such as hydroxychloroquine (Plaquenil). Though these drugs prevent and treat malaria, they also help relieve some lupus symptoms, such as fatigue, rashes, joint pain or mouth sores. They also may help prevent abnormal blood clotting.
- Corticosteroids and immune suppressants: Patients with serious or life-threatening problems such as kidney inflammation, lung or heart involvement, and central nervous system symptoms need more “aggressive” (stronger) treatment. This may include high-dose corticosteroids such as prednisone (Deltasone and others) and drugs that suppress the immune system. Immune suppressants include azathioprine (Imuran), cyclophosphamide (Cytoxan) and cyclosporine (Neoral, Sandimmune). Recently mycophenolate mofetil has been used to treat severe kidney disease in lupus – referred to as lupus nephritis.
- Biologics: Newer treatment options include drugs called biologics that are already approved for treatment of other rheumatic diseases such as rheumatoid arthritis. Examples are rituximab (Rituxan) and abatacept (Orencia). These two drugs are not approved for treatment of lupus. In 2011, though, the FDA approved a biologic, belimumab (Benlysta), for treatment of active SLE in adult patients, but not for those with severe disease. It is the first new drug approved for lupus since 1955.
This exciting treatment advance occurred thanks to research studies in patients—called clinical trials . It provides hope that some of the other drugs that researchers are testing in patients will help lupus. It also underscores the need for patients with lupus to take part in studies.
- Combination treatment: Health care providers may combine a few medications to control lupus and prevent tissue damage. Each treatment has risks and benefits. Most immune-suppressing medications, for instance, may cause major side effects. Side effects of these drugs may include a raised risk of infections as well as nausea, vomiting, hair loss, diarrhea, high blood pressure and osteoporosis (weak bones). Rheumatologists may lower the dose of a drug or stop a medicine because of side effects or when the disease goes into remission. As a result, it is important to receive careful and frequent health exams and lab tests to track your symptoms and change your treatment as needed.
Broader health impact of lupus
Even when it is not active, lupus may cause problems later. Some of these problems can be fatal. One of these problems is atherosclerosis (clogging of the arteries) that may develop in younger women or may be more severe than usual. This problem raises the risk of heart attacks, heart failure and strokes. Thus, it is vital that patients with lupus lower their other risk factors for heart disease, such as smoking, high blood pressure and high cholesterol. It is also important to have as active a lifestyle as possible.
Lupus may also cause kidney disease, which can advance to kidney failure and need dialysis. You can help prevent these serious problems by seeking treatment at the first signs of kidney disease. These signs include:
- High blood pressure
- Swollen feet and hands
- Puffiness around your eyes
- Changes in urination (blood or foam in the urine, going to the bathroom more often at night, or pain or trouble urinating)
Living with lupus
Most people with lupus can live normal lives. Treatment of lupus has improved, and people with the disease are living longer. But, it is still a chronic disease that can limit activities. Quality of life can suffer because of symptoms like fatigue and joint pain. Furthermore, some people do not respond to some treatments. Also, you may not be able to predict when lupus will flare. Such problems can lead to depression, anger, loss of hope or loss of the will to keep fighting.
Here are a couple of tips that may help you when living with lupus:
- Form a support system. A good doctor-patient relationship and support from family and friends can help you cope with this chronic and often unpredictable illness.
- Get involved in your care. Learn as much as you can about lupus, your medications, and what kind of progress to expect. Take all your medications as your doctor prescribes, and visit your rheumatologist often to prevent serious problems. This lets your doctor keep track of your disease and change your treatment as needed. If you do not live near a rheumatologist, you may need to have your primary care doctor manage your lupus with the help of a rheumatologist.
- Stay active. Exercise helps keep joints flexible and may prevent heart disease and strokes. This does not mean overdoing it. Switch off doing light to moderate exercise with times of rest.
- Avoid excess sun exposure. Sunlight can cause a lupus rash to flare and may even trigger a serious flare of the disease itself. When outdoors on a sunny day, wear protective clothing (long sleeves, a big-brimmed hat) and use lots of sunscreen.
If you are a young woman with lupus and wish to have a baby, carefully plan your pregnancy. With your doctor’s guidance, time your pregnancy for when your lupus activity is low. While pregnant, avoid medications that can harm your baby. These include cyclophosphamide, cyclosporine, and mycophenolate mofetil. If you must take any of these medicines, or your disease is very active, use birth control. For more information, see “Pregnancy and Rheumatic Disease.”
Rheumatologists have long been concerned that the female hormone estrogen or treatment with estrogen may cause or worsen lupus. Recent research showed that estrogen therapy can trigger some mild or moderate flares of lupus, but does not cause symptoms to get much worse. Yet, estrogen can raise the risk of blood clots. Thus, you should not take estrogen if your blood tests show antiphospholipid antibodies (meaning you already have a high risk of blood clots).
- Though some of the joint changes are irreversible, most patients will not need joint replacement surgery.
- OA symptoms (what you feel) can vary greatly among patients.
- Exercise is an important part of OA treatment, because it can decrease joint pain and improve function.
- At present, there is no treatment that can reverse the damage of OA in the joints. Researchers are trying to find ways to slow or reverse this joint damage.
Osteoarthritis (also known as OA) is a common joint disease that most often affects middle-age to elderly people. It is commonly referred to as "wear and tear" of the joints, but we now know that OA is a disease of the entire joint, involving the cartilage, joint lining, ligaments, and bone. Although it is more common in older people, it is not really accurate to say that the joints are just “wearing out.” It is characterized by breakdown of the cartilage (the tissue that cushions the ends of the bones between joints), bony changes of the joints, deterioration of tendons and ligaments, and various degrees of inflammation of the joint lining (called the synovium).
This arthritis tends to occur in the hand joints, spine, hips, knees, and great toes. The lifetime risk of developing OA of the knee is about 46 percent, and the lifetime risk of developing OA of the hip is 25 percent, according to the Johnston County Osteoarthritis Project, a long-term study from the University of North Carolina and sponsored by the Centers for Disease Control and Prevention (often called the CDC) and the National Institutes of Health.
OA is a top cause of disability in older people. The goal of osteoarthritis treatment is to reduce pain and improve function. There is no cure for the disease, but some treatments attempt to slow disease progression.
What is osteoarthritis?
OA is a frequently slowly progressive joint disease typically seen in middle-aged to elderly people. In osteoarthritis, the cartilage between the bones in the joint breaks down. This causes the affected bones to slowly get bigger. The joint cartilage often breaks down because of mechanical stress or biochemical changes within the body, causing the bone underneath to fail. OA can occur together with other types of arthritis, such as gout or rheumatoid arthritis.
OA tends to affect commonly used joints such as the hands and spine, and the weight-bearing joints such as the hips and knees. Symptoms include:
- Joint pain and stiffness
- Knobby swelling at the joint
- Cracking or grinding noise with joint movement
- Decreased function of the joint
Who gets osteoarthritis?
OA affects people of all races and both sexes. Most often, it occurs in patients age 40 and above. However, it can occur sooner if you have other risk factors (things that raise the risk of getting OA). Risk factors include:
- Older age
- Having family members with OA
- Previous traumatic Joint injury or repetitive use (overuse) of joints
- Joint deformity such as unequal leg length, bowlegs or knocked knees
How is osteoarthritis diagnosed
Rheumatologists are doctors who are experts in diagnosing and treating arthritis and other diseases of the joints, muscles and bones. You may also need to see other health care providers, for instance, physical or occupational therapists and orthopedic doctors. Most often doctors detect OA based on the typical symptoms (described earlier) and on results of the physical exam. In some cases, X-rays or other imaging tests may be useful to tell the extent of disease or to help rule out other joint problems.
How do you treat osteoarthritis?
There is no proven treatment yet that can reverse joint damage from OA. The goal of osteoarthritis treatment is to reduce pain and improve function of the affected joints. Most often, this is possible with a mixture of physical measures and drug therapy and, sometimes, surgery.
Physical measures:Weight loss and exercise are useful in OA. Excess weight puts stress on your knee joints and hips and low back. For every 10 pounds of weight you lose over 10 years, you can reduce the chance of developing knee OA by up to 50 percent. Exercise can improve your muscle strength, decrease joint pain and stiffness, and lower the chance of disability due to OA. Also helpful are support (“assistive”) devices, such as orthotics or a walking cane, that help you do daily activities. Heat or cold therapy can help relieve OA symptoms for a short time.
Certain alternative treatments such as spa (hot tub), massage, and chiropractic manipulation can help relieve pain for a short time. They can be costly, though, and require repeated treatments. Also, the long-term benefits of these alternative (sometimes called complementary or integrative) medicine treatments are unproven but are under study.
Drug therapy:Forms of drug therapy include topical, oral (by mouth) and injections (shots). You apply topical drugs directly on the skin over the affected joints. These medicines include capsaicin cream, lidocaine and diclofenac gel. Oral pain relievers such as acetaminophen are common first treatments. So are nonsteroidal anti-inflammatory drugs (often called NSAIDs), which decrease swelling and pain.
In 2010, the government (FDA) approved the use of duloxetine (Cymbalta) for chronic (long-term) musculoskeletal pain including from OA. This oral drug is not new. It also is in use for other health concerns, such as mood disorders, nerve pain and fibromyalgia.
Patients with more serious pain may need stronger medications, such as prescription narcotics.
Joint injections with corticosteroids (sometimes called cortisone shots) or with a form of lubricant called hyaluronic acid can give months of pain relief from OA. This lubricant is given in the knee, and these shots may help delay the need for a knee replacement by a few years in some patients.
Surgery:Surgical treatment becomes an option for severe cases. This includes when the joint has serious damage, or when medical treatment fails to relieve pain and you have major loss of function. Surgery may involve arthroscopy, repair of the joint done through small incisions (cuts). If the joint damage cannot be repaired, you may need a joint replacement.
Supplements:Many over-the-counter nutrition supplements have been used for osteoarthritis treatment. Most lack good research data to support their effectiveness and safety. Among the most widely used are calcium, vitamin D and omega-3 fatty acids. To ensure safety and avoid drug interactions, consult your doctor or pharmacist before using any of these supplements. This is especially true when you are combining these supplements with prescribed drugs.
Living with osteoarthritis
There is no cure for OA, but you can manage how it affects your lifestyle. Some tips include:
- Properly position and support your neck and back while sitting or sleeping.
- Adjust furniture, such as raising a chair or toilet seat.
- Avoid repeated motions of the joint, especially frequent bending.
- Lose weight if you are overweight or obese, which can reduce pain and slow progression of OA.
- Exercise each day.
- Use adaptive devices that will help you do daily activities.
You might want to work with a physical therapist or occupational therapist to learn the best exercises and to choose arthritis assistive devices.
- Osteoporosis results from a loss of bone mass (measured as bone density) and from a change in bone structure. Many factors will raise your risk of developing osteoporosis and breaking a bone. You can change some of these risk factors, but not others. Recognizing your risk factors is important so you can take steps to prevent this condition or treat it before it becomes worse.
- Age is not the only risk factor for osteoporosis. Lifestyle choices, certain diseases and even medications can lead to this condition.
- A simple test known as a bone density scan can give important information about your bone health.
- Newer medications can slow and even stop the progression of bones getting weaker, and can help decrease fracture risk.
Osteoporosis is a common condition where bones become weak that affects both men and women, mainly as they grow older. Bone is living tissue that is in a constant state of regeneration. That is, the body removes old bone (called bone resorption) and replaces it with new bone (bone formation). By their mid-30s, most people begin to slowly lose more bone than can be replaced. As a result, bones become thinner and weaker in structure.
Osteoporosis is silent because there are no symptoms (what you feel). It may come to your attention only after you break a bone. When you have this condition, a fracture can occur even after a minor injury, such as a fall. The most common fractures occur at the spine, wrist and hip. Spine and hip fractures, in particular, may lead to chronic (long-term) pain and disability, and even death. The main goal of treating osteoporosis is to prevent such fractures in the first place.
Fortunately, you can take steps to reduce your risk of osteoporosis. By doing so, you can avoid the often-disabling broken bones (fractures) that can result from this condition. If you already have osteoporosis, new medications are available to slow or even stop the bones from getting weaker. These medicines also can decrease the chance of having a fracture.
What causes osteoporosis?
Osteoporosis results from a loss of bone mass (measured as bone density) and from a change in bone structure. Many factors will raise your risk of developing osteoporosis and breaking a bone. You can change some of these risk factors, but not others. Recognizing your risk factors is important so you can take steps to prevent this condition or treat it before it becomes worse.
Major risk factors that you cannot change include:
- Older age (starting in the mid-30s but more likely with advancing age)
- Non-Hispanic white or Asian ethnic background
- Small bone structure
- Family history of osteoporosis or an osteoporosis-related fracture in a parent or sibling
- Prior fracture due to a low-level injury, particularly after age 50
Risk factors that you may be able to change include:
- Low levels of sex hormone, mainly estrogen in women (e.g., menopause)
- The eating disorders anorexia nervosa and bulimia
- Cigarette smoking
- Alcohol abuse
- Low calcium and vitamin D, from low intake in your diet or inadequate absorption in your gut
- Sedentary (inactive) lifestyle or immobility
- Certain medications, including the following:
- glucocorticoid medications (also called corticosteroids), such as prednisone (brand names: Deltasone, Orasone, etc.) or prednisolone (Prelone); see fact sheet on glucocorticoid-induced osteoporosis
- excess thyroid hormone replacement in those taking medications for low thyroid or hypothyroidism
- heparin, a commonly-used blood thinner
- some treatments that deplete sex hormones, such as anastrozole (Arimidex) and letrozole (Femara) to treat breast cancer or leuprorelin (Lupron) to treat prostate cancer and other health problems
- Diseases that can affect bones
- endocrine (hormone) diseases (hyperthyroidism, hyperparathyroidism, Cushing's disease, etc.)
- inflammatory arthritis (rheumatoid arthritis, ankylosing spondylitis, etc.)
Who gets osteoporosis?
Osteoporosis is more common in older women, mainly non-Hispanic white and Asian women. Yet it can occur at any age, in men as well as women, and in all ethnic groups. People over age 50 are at greatest risk of developing osteoporosis and having related fractures. Over age 50, one in two women and one in six men will suffer an osteoporosis-related fracture at some point in their lives. In the U.S., about 4.5 million women and 0.8 million men over the age of 50 have osteoporosis, according to 2005–06 data. These figures are lower than older estimates, suggesting that osteoporosis is decreasing in the population. This is consistent with recent trends seen in decreasing rates of hip fracture.
However, another 22.7 million women and 11.8 million men over age 50 have low bone mass (known as osteopenia). People with low bone mass are also at higher risk of fractures, but it is not as high as for people with osteoporosis. If bone loss continues, people with osteopenia can become osteoporotic.
How is osteoporosis diagnosed?
You can learn if you have osteoporosis by having a simple test that measures bone mineral density—sometimes called BMD. BMD —the amount of bone you have in a given area—is measured at different parts of your body. Often the measurements are at your spine and your hip, including a part of the hip called the femoral neck, at the top of the thighbone (femur). Dual energy X-ray absorptiometry (referred to as DXA or DEXA and pronounced “dex-uh”) is the best current test to measure BMD.
The test is quick and painless. It is similar to an X-ray, but uses much less radiation. Even so, pregnant women should not have this test, to avoid any risk of harming the fetus. DXA test results are scored compared with the BMD of young, healthy people. This results in a measure called a T-score. The scoring is as follows:
DXA T-score Bone mineral density (BMD)
Not lower than –1.0 Normal
Between –1.0 and –2.5 Osteopenia (mild BMD loss)
-2.5 or lower Osteoporosis
The risk of fracture most often is lower in people with osteopenia than those with osteoporosis. But, if bone loss continues, the risk of fracture increases.
How is osteoporosis diagnosed?
If you have osteoporosis, your health care provider will advise the following:
- Calcium. Make sure you are getting enough calcium in your diet or you might need to consider taking supplements. The National Osteoporosis Foundation recommends 1,000 milligrams (shortened as mg) per day for most adults and 1,200 mg per day for women over age 50 or men over age 70.
- Vitamin D. Get adequate amounts of vitamin D, which is important to help your body absorb calcium from foods you eat. The recommended daily dose is 400–800 International Units (called IU) for adults younger than age 50, and 800–1,000 IU for those age 50 and older. (These are the current guidelines from the National Osteoporosis Foundation.) You may need a different dose depending on your blood level of vitamin D.
- Physical activity. Get exercise most days, especially weight-bearing exercise, such as walking.
Some people also will need medication. A number of medications are available for the prevention and/or treatment (“management”) of osteoporosis.
Bisphosphonates. The US Food and Drug Administration (better known as the FDA) has approved certain drugs called bisphosphonates to prevent and treat osteoporosis. This class of drugs (often called “anti-resorptive” drugs) helps slow bone loss, and studies show they can decrease the risk of fractures. The Table shows the drug names and dosing (how often you receive the drug) of bisphosphonates approved in the US for management of osteoporosis.
Bisphosphonate Medications for Osteoporosis (OP)
Generic drug name
FDA approved uses for OP
Dosing and form
Prevention and treatment of postmenopausal OP in women
Treatment of OP in men
Treatment of OP due to use of glucocorticoid medicines in women and men
Once-daily or once-weekly pills
Prevention and treatment of postmenopausal OP in women
Treatment of OP in men
Prevention and treatment of OP due to use of glucocorticoid medicines in women and men
Once-daily, once-weekly or once-monthly pills
Prevention and treatment of postmenopausal OP in women
Once-monthly pills, or every three months by intravenous infusion (often called IV) given through a vein
Same as for risedronate
Once a year by IV
With all of these medications, you should make sure you are taking enough calcium and vitamin D, and that the vitamin D levels in your body are not low. (Your doctor can measure your vitamin D level with a blood test.) Alendronate, risedronate and ibandronate are pills that you must take on an empty stomach with water only, or else you will not properly absorb the medicine. These drugs sometimes can irritate the esophagus (the tube that goes from the throat to the stomach). Therefore, you should remain upright for at least an hour after taking these medications.
Other bisphosphonates include clodronate (Bonefos), etidronate (Didronel), pamidronate (Aredia) and tiludronate (Skelid). They are used to treat other bone diseases but are not FDA approved for osteoporosis treatment. In some other countries, clodronate is approved for osteoporosis treatment. The bisphosphonates are also used to treat cancer that has spread to the bones. The dose used is most often higher than for osteoporosis. Zoledronic acid used in cancer treatment is marketed under another name (Zometa).
There have been reports of rare side effects that may be linked to use of bisphosphonates. These include osteonecrosis of the jaw (also called jaw osteonecrosis or ONJ) and atypical femoral fractures :
- Osteonecrosis of the jaw. There have been reports of ONJ (permanent damage of the bones of the jaw) resulting after use of bisphosphonates, mostly in people who recently had a dental procedure or had dental disease. Most cases were in people who received high-dose IV bisphosphonates for cancer treatment. The risk of this problem in people taking these medications at doses recommended for osteoporosis management seems to be very low. Still, doctors recommend that anyone taking a bisphosphonate have good oral hygiene and regular dental care.
- Atypical femoral fractures. Uncommon types of thighbone fractures have occurred in a small percent of people using bisphosphonates long term for their osteoporosis. Again, this risk appears to be very low, especially compared with the number of fractures that bisphosphonates prevent.
Calcitonin (Calcimar, Miacalcin). This medication, a hormone made from the thyroid gland, is given most often as a nasal spray or as an injection (shot) under the skin. It is FDA- approved for the management of postmenopausal osteoporosis and helps prevent vertebral (spine) fractures. It also is helpful in controlling pain after an osteoporotic vertebral fracture.
Estrogen or hormone replacement therapy. Estrogen treatment alone or combined with another hormone, progestin, has been shown to decrease the risk of osteoporosis and osteoporotic fractures in women. However, combination estrogen and progestin can increase the risk of breast cancer, strokes, heart attacks and blood clots. Estrogens alone may raise the risk of strokes. Consult with your doctor about whether hormone replacement therapy is right for you.
Selective estrogen receptor modulators. These medications, often referred to as SERMs, mimic estrogen’s good effects on bones without some of the serious side effects such as breast cancer. However, there is still a risk of blood clots and stroke with use of SERMs. The SERM raloxifene (Evista) decreases the risk of spine fractures in women. It is approved for use only in postmenopausal women.
Teriparatide (Forteo). Teriparatide is a form of parathyroid hormone that helps stimulate bone formation. It is approved for use in postmenopausal women and men at high risk of osteoporotic fracture. It also is approved for treatment of glucocorticoid-induced osteoporosis. It is given as a daily injection under the skin and can be used for up to two years. If you have ever had radiation treatment or your parathyroid hormone levels are already too high, you may not be able to take this drug.
Strontium ranelate. This medicine is approved for managing postmenopausal osteoporosis in several countries around the world, but not the U.S. (Brand names include Protelos, Protos, Osseor, Bivalos, Protaxos and Ossum.) Studies show it lowers the fracture risk in postmenopausal women. The drug comes as a powder, which women dissolve in water and take daily. Because of an increased risk of blood clots, it should be used with caution in women who have a history of or risk of blood clots such as deep venous thrombosis or pulmonary embolism.
Denosumab (Prolia). This new class of “antiresorptive” drug is a fully human monoclonal antibody, a type of immune therapy. It works against a protein that interferes with the survival of bone-resorbing cells. This treatment is approved for use in postmenopausal women who have osteoporosis and are at high risk of fracture. Another approved use is for women and men at high risk of bone loss and fractures from hormone-depleting medications used to treat breast and prostate cancer. Patients receive this medicine as an injection under the skin every six months.
This medication can make your calcium levels go very low, so your calcium and vitamin D levels should not be low when you start to take this medicine. There may be an increased risk of infections when using this drug. There have also been rare reports of ONJ linked to use of denosumab. This drug is also approved for the treatment of cancer involving the bones, and is marketed under another name (XGEVA).
Pregnancy and osteoporosis
Young women who have risk factors for osteoporosis and fractures need to carefully consider their medication options if they are planning a pregnancy. None of the drugs for managing osteoporosis has enough safety data available to recommend using them in women who are pregnant or breastfeeding.
Bisphosphonates, even after you stop taking them, can stay in your body a long time. Animal studies show that bisphosphonates cross the mother’s placenta and enter the fetus. The risk of harm to the fetus in humans is not known. Thus, women who want to become pregnant later should weigh the expected benefits of bisphosphonates against the possible risks. If a woman who has taken a bisphosphonate becomes pregnant, she should have her blood calcium levels checked, because they could become low.Preventing osteoporosis
Lifestyle changes may be the best way of preventing osteoporosis. Here are some tips:
- Make sure you get enough calcium in your diet or through supplements (roughly 1,000–1,200 mg/day, but will depend on your age).
- Get enough vitamin D (400–1,000 IU/day, depending on your age and your blood level of vitamin D measured by your doctor).
- Stop smoking.
- Avoid excess alcohol intake: no more than two or three drinks a day.
- Be physically active and do weight-bearing exercises, like walking, most days each week. Aim for at least 2½ hours a week (30 minutes a day five times a week or 50 minutes a day three times a week), or as much as you can. Exercises that can improve balance, such as Tai Chi or yoga, may help prevent falls.
- Change lifestyle choices that raise your risk of osteoporosis.
- Implement strategies to help decrease your risk of falling.
You also should get treatment of any underlying medical problem that can cause osteoporosis. If you are on a medication that can cause osteoporosis, ask your doctor if you can lower the dose or take another type of medicine. Never change the dose or stop taking any medicine without speaking to your doctor first.
If you have low bone density and a high risk of breaking a bone, your doctor may suggest medicine to prevent your bones from getting weaker. (See the section “How is glucocorticoid-osteoporosis treated?”) Health care providers now have a tool for estimating the risk of a patient’s having an osteoporotic fracture in the next 10 years - it is called the fracture risk assessment tool ( FRAX). It was developed by the World Health Organization, and the score can help guide treatment decisions.
Living with osteoporosis
As doctors who are experts in diagnosing and treating diseases of the joints, muscles and bones, rheumatologists can help find the cause of osteoporosis. They can provide and monitor the best treatments for this condition.
The most serious health consequence of osteoporosis is a fracture. Spine and hip fractures especially may lead to chronic pain, long-term disability and even death. The main goal of treating osteoporosis is to prevent fractures. If you have osteoporosis, it is important to help prevent not just further bone loss but also a fracture. Here are some ways to decrease your chance of falls:
- Use a walking aid. If you are unsteady, use a cane or walker.
- Remove hazards in the home. Remove throw rugs. Also, remove or secure loose wires or cables that may make you trip. Add nightlights in the hallways leading to the bathroom. Install grab bars in the bathroom and nonskid mats near sinks and the tub.
- Get help carrying or lifting heavy items. If you are not careful, you could fall, or even suffer a spine fracture without falling.
- Wear sturdy shoes with soles that grip. This is above all true in winter or when it rains.
- Psoriatic arthritis is a chronic arthritis. In some people, it is mild, with just occasional flare ups. In other people, it is continuous and can cause joint damage if it is not treated. Early diagnosis is important to avoid damage to joints.
- Psoriatic arthritis typically occurs in people with skin psoriasis, but it can occur in people without skin psoriasis, particularly in those who have relatives with psoriasis.
- Psoriatic arthritis typically affects the large joints, especially those of the lower extremities, distal joints of the fingers and toes, and also can affect the back and sacroiliac joints of the pelvis.
- For most people, appropriate treatments will relieve pain, protect the joints, and maintain mobility. Physical activity helps maintain joint movement.
- Psoriatic arthritis is sometimes misdiagnosed as gout , rheumatoid arthritis or osteoarthritis.
Psoriatic arthritis is an inflammatory arthritis that is seen in association with skin psoriasis. It causes joint pain and swelling that can lead to damage of the joint if the inflammation is not controlled. Joint damage can be prevented with the appropriate medications. Skin psoriasis is a scaly red skin lesion that occurs on the extensor aspects of the body (elbows, knees, scalp). Usually psoriatic arthritis is blood test negative. The diagnosis is typically made by a rheumatologist after reviewing a clinical history and performing a physical exam. X-ray studies can show changes specific to psoriatic arthritis but these are rarely present at the onset of symptoms. It is estimated about 15 – 30 percent of patients with skin psoriasis will develop an associated arthritis. At times, the arthritis can appear before the skin disorder.
Psoriatic arthritis usually appears in people between the ages of 30 to 50, but can begin as early as childhood. Men and women are equally at risk. Children with psoriatic arthritis are also at risk to develop uveitis (inflammation of the middle layer of the eye). Approximately 15 percent of people with psoriasis develop psoriatic arthritis. At times, the arthritis can appear before the skin disorder.
What is psoriatic arthritis?
Psoriasis and psoriatic arthritis are autoimmune conditions. An autoimmune condition occurs when the body's immune system mistakenly sends inflammation to normal tissue/structures. In skin psoriasis, the inflammation is mistakenly directed toward the skin. In psoriatic arthritis, the inflammation is directed toward the joints, similar to rheumatoid arthritis, causing inflammation (swelling, redness, pain and stiffness) and damage. Like any autoimmune condition, psoriasis and psoriatic arthritis can present across a broad spectrum from mild to severe disease. There is a weak relationship between the severity of skin disease and arthritic involvement. Some patients may have severe skin disease and no arthritis and some arthritis patients may have only minimal skin disease.
Psoriatic arthritis can affect any joint in the body, and it may affect just one joint, several joints or multiple joints. For example, it may affect one or both knees. Affected fingers and toes can resemble swollen sausages, a condition often referred to as dactylitis. Finger and toe nails also may be affected with thickening or nail pitting. Psoriatic arthritis in the spine, called spondylitis , causes pain in the back or neck, and difficulty bending. Psoriatic arthritis also can cause tender spots where tendons and ligaments join onto bones. This condition, called enthesitis, can result in pain at the back of the heel, the sole of the foot, around the elbows or in other areas. Enthesitis is one of the characteristic features of psoriatic arthritis.
Recent research suggests that persistent inflammation from psoriatic arthritis causes joint damage later, so early accurate diagnosis is essential. Fortunately, treatments are available and effective for most people.
What causes psoriatic arthritis?
What causes psoriatic arthritis is not known exactly. About 40 percent of patients with psoriasis or psoritaic arthritis have a family member with psoriasis or arthritis, suggesting heredity may play a role. Psoriatic arthritis can also result from an infection that activates the immune system. There are theories that an infection could trigger an autoimmune condition in a person with the right genetic background, but this has not been definitively proven.
How is psoriatic arthritis diagnosed?
To diagnose psoriatic arthritis, rheumatologists look for swollen and painful joints, certain patterns of arthritis, and skin and nail changes typical of psoriasis. X-rays often are taken to look for joint damage. MRI, ultrasound or CT scans can be used to look at the joints in more detail.
Typically blood tests are negative in psoriatic arthritis. Blood tests may be done to rule out other types of arthritis that have similar signs and symptoms, including gout, osteoarthritis and rheumatoid arthritis. Inflammation markers can be elevated in psoriatic arthritis but are commonly normal. The presence of an HLA-B27 genetic marker is associated with psoriatic arthritis but it is not diagnostic. Occasionally skin biopsies (small samples of skin removed for analysis) are needed to confirm the psoriasis.
How is psoriatic arthritis treated?
Medications are used to reduce inflammation caused by arthritis reducing pain, swelling and stiffness. Many of the medications suppress the immune system and lead to a potential increase risk of infections. The majority of the medications treat both the skin and joint disease, but some medications may work better for one compared to the other. Non-steroidal anti-inflammatory drugs such as ibuprofen (Motrin or Advil) or naproxen (Aleve) are the initial treatment for very mild arthritis. These do not help skin psoriasis. Non-steroidal anti-inflammatory medications have not been proven to stop damage caused by more aggressive/severe psoriatic arthritis.
If the arthritis does not respond, disease modifying anti-rheumatic drugs may be prescribed. These include sulfasalazine (Azulfidine), methotrexate (Rheumatrex, Trexall, Otrexup, Rasuvo), cyclosporine (Neoral, Sandimmune, Gengraf) and leflunomide (Arava). Although these medications can be very helpful with improving both skin and joint disease, they have not been proven to stop the progression of joint damage radiographically. If joint damage is present at time of diagnosis, consider increasing therapy to include biologic therapy.
Older DMARD therapies that are less commonly used today due to the development of biologic therapies are sulfasalazine (Azulfidine), Azathioprine (Imuran), and the anti-malarial drug hydroxychloroquine (Plaquenil). It was once thought Hydroxychloraquine would flare skin psoriasis but this has not been proven.
Newer biologic therapy has been developed to block molecules and/or their receptors leading to decreased inflammation. Many of these medications are given by injections at home or by an infusion at the doctor’s office. These medications suppress the immune system to a great degree compared to the DMARDs. They have been proven to stop joint damage as well as pain and swelling in moderate to severe psoriatic arthritis. They are very good at clearing skin psoriasis. The biologic therapies include anti-tumor necrosis factor (anti-TNF) drugs such as adalimumab (Humira), etanercept (Enbrel), golimumab (Simponi), certolizumab (Cimzia) and infliximab (Remicade) are also available and can help the arthritis as well as the skin psoriasis. Other biologic therapies include ustekinumab (Stelara) which blocks two proteins IL-12 and IL-23. This is given as a subcutaneous injection every 3 months. The newest biologic to be FDA approved (in January of 2016) is secukinumab (Cosentyx) which blocks IL-17 to reduce inflammation. It is given by a subcutaneous injection and has been approved for treatment of both skin psoriasis and psoriatic arthritis.
Apremilast (Otezla) is a phosphodiesterase 4 inhibitor that helps stop inflammation. It is an oral pill taken twice daily. Unlike the other treatments, it is not thought to suppress the immune system causing increased risk on infections. Stomach upset, headache, weight loss and worsening depression are potential side effects.
For swollen joints, corticosteroid injections can be useful. Surgery can be helpful to repair or replace badly damaged joints.
Broader health impact of psoriatic arthritis
The impact of psoriatic arthritis depends on the joints involved and the severity of symptoms. Ocular inflammation, including uveitis and conjunctivitis, occurs in some patients with psoriatic arthritis. Some psoriatic arthritis patients also experience mood changes. Treating the arthritis and reducing the levels of inflammation helps with these problems. People with psoriasis are slightly more likely to develop high blood pressure, high cholesterol, obesity or diabetes. Maintaining a healthy weight and treating high blood pressure and cholesterol are also important aspects of treatment.
Living with psoriatic arthritis
Many people with arthritis develop stiff joints and muscle weakness due to lack of use. Proper exercise is very important to improve overall health and keep joints flexible. This can be quite simple. Walking is an excellent way to get exercise. A walking aid or shoe inserts will help to avoid undue stress on feet, ankles, or knees affected by arthritis. An exercise bike provides another good option, as well as yoga and stretching exercises to help with relaxation.
Some people with arthritis find it easier to move in water. If this is the case, swimming or walking laps in the pool offers activity without stressing joints. Many people with psoriatic arthritis also benefit from physical and occupational therapy to strengthen muscles, protect joints from further damage, and increase flexibility.
The rheumatologist's role in the treating psoriatic arthritis
Psoriatic arthritis is easy to confuse with other diseases. As specialists in musculoskeletal disorders, rheumatologists are more likely to make a proper diagnosis. They also can advise patients about the best treatment options.
- Rheumatoid arthritis (RA) is the most common type of autoimmune arthritis. It is triggered by a faulty immune system (the body’s defense system) and affects the wrist and small joints of the hand, including the knuckles and the middle joints of the fingers.
- Treatments have improved greatly and help many of those affected. For most people with RA, early treatment can control joint pain and swelling, and lessen joint damage.
- Perform low-impact aerobic exercises, such as walking, and exercises to boost muscle strength. This will improve your overall health and reduce pressure on your joints.
- Studies show that people who receive early treatment for RA feel better sooner and more often, and are more likely to lead an active life. They also are less likely to have the type of joint damage that leads to joint replacement.
- Seek an expert in arthritis: a rheumatologist. Expertise is vital to make an early diagnosis of RA and to rule out diseases that mimic RA, thus avoiding unneeded tests and treatments. Rheumatologists are experts in RA and can design a customized treatment plan that is best suited for you.
People have long feared rheumatoid arthritis (commonly called RA) as one of the most disabling types of arthritis. The good news is that the outlook has greatly improved for many people with newly diagnosed (detected) RA. Of course, RA remains a serious disease, and one that can vary widely in symptoms (what you feel) and outcomes. Even so, treatment advances have made it possible to stop or at least slow the progression (worsening) of joint damage. Rheumatologists now have many new treatments that target the inflammation that RA causes. They also understand better when and how to use treatments to get the best effects.
What is rheumatoid arthritis?
RA is the most common form of autoimmune arthritis, affecting more than 1.3 million Americans. Of these, about 75 percent are women. In fact, 1–3 percent of women may get rheumatoid arthritis in their lifetime. The disease most often begins between the fourth and sixth decades of life. However, RA can start at any age.
RA is a chronic (long-term) disease that causes pain, stiffness, swelling and limited motion and function of many joints. While RA can affect any joint, the small joints in the hands and feet tend to be involved most often. Inflammation sometimes can affect organs as well, for instance, the eyes or lungs.
The stiffness seen in active RA is most often worst in the morning. It may last one to two hours (or even the whole day). Stiffness for a long time in the morning is a clue that you may have RA, since few other arthritic diseases behave this way.
For instance,osteoarthritis most often does not cause prolonged morning stiffness. Other signs and symptoms that can occur in RA include:
- Loss of energy
- Low fevers
- Loss of appetite
- Dry eyes and mouth from a related health problem,Sjogren's syndrome
- Firm lumps, called rheumatoid nodules, which grow beneath the skin in places such as the elbow and hands
What causes rheumatoid arthritis?
RA is an autoimmune disease. This means that certain cells of the immune system do not work properly and start attacking healthy tissues — the joints in RA. The cause of RA is not known. Yet, new research is giving us a better idea of what makes the immune system attack the body and create inflammation. In RA, the focus of the inflammation is in the synovium, the tissue that lines the joint. Immune cells release inflammation-causing chemicals. These chemicals can damage cartilage (the tissue that cushions between joints) and bone. Other things likely play a role in RA as well. For instance, genes that affect the immune system may make some people more prone to getting RA.
How is rheumatoid arthritis diagnosed?
RA can be hard to detect because it may begin with subtle symptoms, such as achy joints or a little stiffness in the morning. Also, many diseases behave like RA early on. For this reason, if you or your primary care physician thinks you have RA, you should see a rheumatologist. A rheumatologist is a physician with the skill and knowledge to reach a correct diagnosis of RA and to make the most suitable treatment plan.
Diagnosis of RA depends on the symptoms and results of a physical exam, such as warmth, swelling and pain in the joints. Some blood tests also can help confirm RA. Telltale signs include:
- Anemia (a low red blood cell count)
- Rheumatoid factor (an antibody, or blood protein, found in about 80 percent of patients with RA in time, but in as few as 30 percent at the start of arthritis)
- Antibodies to cyclic citrullinated peptides (pieces of proteins), or anti-CCP for short (found in 60–70 percent of patients with RA)
- Elevated erythrocyte sedimentation rate (a blood test that, in most patients with RA, confirms the amount of inflammation in the joints)
X-rays can help in detecting RA, but may not show anything abnormal in early arthritis. Even so, these first X-rays may be useful later to show if the disease is progressing. Often, MRI and ultrasound scanning are done to help judge the severity of RA.
There is no single test that confirms an RA diagnosis for most patients with this disease. (This is above all true for patients who have had symptoms fewer than six months.) Rather, a doctor makes the diagnosis by looking at the symptoms and results from the physical exam, lab tests and X-rays.
How is rheumatoid arthritis treated?
Therapy for RA has improved greatly in the past 30 years. Current treatments give most patients good or excellent relief of symptoms and let them keep functioning at, or near, normal levels. With the right medications, many patients can achieve “remission” — that is, have no signs of active disease.
There is no cure for RA. The goal of treatment is to lessen your symptoms and poor function. Doctors do this by starting proper medical therapy as soon as possible, before your joints have lasting damage. No single treatment works for all patients. Many people with RA must change their treatment at least once during their lifetime.
Good control of RA requires early diagnosis and, at times, aggressive treatment. Thus, patients with a diagnosis of RA should begin their treatment with disease-modifying antirheumatic drugs — referred to as DMARDs. These drugs not only relieve symptoms but also slow progression of the disease. Often, doctors prescribe DMARDs along with nonsteroidal anti-inflammatory drugs or NSAIDs and/or low-dose corticosteroids, to lower swelling, pain and fever. DMARDs have greatly improved the symptoms, function and quality of life for nearly all patients with RA. Ask your rheumatologist about the need for DMARD therapy and the risks and benefits of these drugs.
Common DMARDs include methotrexate (Rheumatrex, Trexall, Otrexup, Rasuvo), leflunomide (Arava), hydroxychloroquine (Plaquenil) and sulfasalazine (Azulfidine).
Gold is an older DMARD that is often given as an injection into a muscle (such as Myochrysine), but can also be given as a pill — auranofin (Ridaura). The antibiotic minocycline (Minocin) also is a DMARD, as well as the immune suppressants azathioprine (Imuran) and cyclosporine (Neoral, Sandimmune, Gengraf). These three drugs and gold are rarely prescribed for RA these days, because other drugs work better or have fewer side effects.
Patients with more serious disease may need medications called biologic response modifiers or “biologic agents.” They can target the parts of the immune system and the signals that lead to inflammation and joint and tissue damage. FDA-approved drugs of this type include abatacept (Orencia), adalimumab (Humira), anakinra (Kineret), certolizumab (Cimzia), etanercept (Enbrel), golimumab (Simponi) infliximab (Remicade), rituximab (Rituxan, MabThera) and tocilizumab (Actemra). Most often, patients take these drugs with methotrexate, as the mix of medicines is more helpful.
Janus kinase (JAK) inhibitors are another type of DMARD. People who cannot be treated with methotrexate alone may be prescribed a JAK inhibitor such as tofacitinib (Xeljanz).
The best treatment of RA needs more than medicines alone. Patient education, such as how to cope with RA, also is important. Proper care requires the expertise of a team of providers, including rheumatologists, primary care physicians, and physical and occupational therapists. You will need frequent visits through the year with your rheumatologist. These checkups let your doctor track the course of your disease and check for any side effects of your medications. You likely also will need to repeat blood tests and X-rays or ultrasounds from time to time.
Living with rheumatoid arthritis
Research shows that people with RA, mainly those whose disease is not well controlled, have a higher risk for heart disease and stroke. Talk with your doctor about these risks and ways to lower them.
It is important to be physically active most of the time, but to sometimes scale back activities when the disease flares. In general, rest is helpful when a joint is inflamed, or when you feel tired. At these times, do gentle range-of-motion exercises, such as stretching. This will keep the joint flexible.
When you feel better, do low-impact aerobic exercises, such as walking, and exercises to boost muscle strength. This will improve your overall health and reduce pressure on your joints. A physical or occupational therapist can help you find which types of activities are best for you, and at what level or pace you should do them.
Finding that you have a chronic illness is a life-changing event. It can cause worry and sometimes feelings of isolation or depression. Thanks to greatly improved treatments, these feelings tend to decrease with time as energy improves, and pain and stiffness decrease. Discuss these normal feelings with your health care providers. They can provide helpful information and resources.
The rheumatologist's role in the treatment of rheumatoid arthritis
RA is a complex disease, but many advances in treatment have occurred recently. Rheumatologists are doctors who are experts in diagnosing and treating arthritis and other diseases of the joints, muscles and bones. Thus, they are best qualified to make a proper diagnosis of RA. They can also advise patients about the best treatment options.
- Scleroderma differs from person to person but can be very serious.
- There are medications, as well as steps individuals can take, to ease the symptoms of Raynaud's phenomenon , skin problems and heartburn.
- Effective treatments are available for those with severe disease, including acute kidney disease, pulmonary hypertension, lung inflammation and gastrointestinal problems.
- It is important to recognize and treat organ involvement early on to prevent irreversible damage.
- Patients should see physicians with specialized expertise in the care of this complex disease.
Scleroderma is an autoimmune rheumatic disease affecting the skin and other organs of the body, meaning that the body’s immune system is acting abnormally. The main finding in scleroderma is thickening and tightening of the skin and inflammation and scarring of many body parts, leading to problems in the lungs, kidneys, heart, intestinal system and other areas. There is still no cure for scleroderma but effective treatments for some forms of the disease are available.
Scleroderma is relatively rare. About 75,000 to 100,000 people in the U.S. have this disease; most are women between the ages of 30 and 50. Twins and family members of those with scleroderma or other autoimmune connective tissue diseases, such as lupus, may have a slightly higher risk of getting scleroderma. Children can also develop scleroderma, but the disease is different in children than in adults.
Although the underlying cause is unknown, promising research is shedding light on the relationship between the immune system and scleroderma. A great deal of research is also underway to find better treatments for scleroderma and, hopefully, someday a cure.
What is scleroderma?
Scleroderma (also known as systemic sclerosis) is a chronic disease that causes the skin to become thick and hard, a buildup of scar tissue, and damage to internal organs such as the heart and blood vessels, lungs, stomach and kidneys. The effects of scleroderma vary widely and range from minor to life-threatening, depending on how widespread the disease is and which parts of the body are affected.
The two main types of scleroderma are:
- Localized scleroderma , which usually affects only the skin, although it can spread to the muscles, joints and bones. It does not affect other organs. Symptoms include discolored patches on the skin (a condition called morphea); or streaks or bands of thick, hard skin on the arms and legs (called linear scleroderma). When linear scleroderma occurs on the face and forehead, it is called en coup de sabre.
- Systemic scleroderma , which is the most serious form of the disease, affects the skin, muscles, joints, blood vessels, lungs, kidneys, heart and other organs.
The cause of scleroderma is not known. Genetic factors (different genes) appear be important in the disease. Although exposure to certain chemicals may play a role in some people having scleroderma, the vast majority of patients with scleroderma do not have a history of exposure to any suspicious toxins. The cause of scleroderma is likely quite complicated.
How is scleroderma diagnosed?
Diagnosis can be tricky because symptoms may be similar to those of other diseases. There is no one blood test or X-ray that can say for sure that you have scleroderma. To make a diagnosis, a doctor will ask about the patient’s medical history, do a physical exam and possibly order lab tests and X-rays. Careful clinical evaluation is the primary method for monitoring scleroderma. X-rays and computerized tomography (CT) scans are used to look at bone abnormalities. Thermography can detect differences in skin temperature between the lesion and normal tissue. Ultrasound and magnetic resonance imaging (MRI) can aid soft tissue assessment. Some symptoms he or she will look for include:
- Raynaud’s phenomenon: This term refers to color changes (blue, white and red) that occur in fingers (and sometimes toes), often after exposure to cold temperatures. It occurs when blood flow to the hands and fingers is temporarily reduced. This is one of the earliest signs of the disease; more than 90 percent of patients with scleroderma have Raynaud’s. Raynaud’s can lead to finger swelling, color changes, numbness, pain, skin ulcers and gangrene on the fingers and toes. People with other diseases can also have Raynaud’s and some people with Raynaud’s do not have any other disease.
- Skin thickening, swelling and tightening: This is the problem that leads to the name “scleroderma” (“Sclera” means hard and “derma” means skin). The skin may also become glossy or unusually dark or light in places. The disease can sometimes result in changes is personal appearance, especially in the face. When the skin becomes extremely tight, the function of the area affected can be reduced (for example, fingers).
- Enlarged red blood vessels on the hands, face and around nail beds (called “telangiectasias”)
- Calcium deposits in the skin or other areas
- High blood pressure from kidney problems
- Heartburn; this is an extremely common problem in scleroderma
- Other problems of the digestive tract such as difficulty swallowing food, bloating and constipation, or problems absorbing food leading to weight loss
- Shortness of breath
- Joint pain
How is scleroderma treated?
While some treatments are effective in treating some aspects of this disease, there is no drug that has been clearly proven to stop, or reverse, the key symptom of skin thickening and hardening. Medications that have proven helpful in treating other autoimmune diseases, such as rheumatoid arthritis and lupus , usually don’t work for people with scleroderma. Doctors aim to curb individual symptoms and prevent further complications with a combination of drugs and self-care. For example:
- Raynaud's phenomenon can be treated with drugs such as calcium channel blockers or drugs called PDE-5 inhibitors ⎼sildenafil (Viagra®), tadalafil (Cialis®) ⎼, which open up narrowed blood vessels and improve circulation. To prevent further damage, it’s important to keep the whole body warm, especially fingers and toes. It’s also important to protect fingertips and other skin areas from injury, which can happen even during normal daily activities.
- Heartburn (acid reflux) can be treated with antacid drugs, especially proton-pump inhibitors (omeprazole and others). These medications ease gastro-esophageal reflux disease (known as GERD).
- Scleroderma kidney disease can be treated with blood pressure medications called “angiotensin converting enzyme inhibitors” (ACE inhibitors). These can often effectively control kidney damage if started early and use of these drugs has been a major advance for treating scleroderma.
- Muscle pain and weakness can be treated with anti-inflammatory drugs such as glucocorticoids (prednisone), intravenous immunoglobin (IVIg), and/or immunosuppressive medications. Physical and occupational therapy may be useful to maintain joint and skin flexibility. Early referral to therapy should be considered to help prevent the loss of joint motion and function.
There are two types of lung disease that patients with scleroderma may develop. The first type is called interstitial lung disease (scarring). There is evidence that cyclophosphamide is somewhat effective in treating the interstitial lung disease in scleroderma. Clinical trials are underway assessing the effectiveness of several other drugs for this problem.
The second type of lung disease seen in scleroderma is pulmonary arterial hypertension (high blood pressure in the arteries in the lungs). In the last 10 years, a number of drugs have become available to treat this condition, including prostacyclin-like drugs (epoprostenol, treprostinol, iloprost), the endothelin receptor antagonists (bosentan, ambrisentan), and PDE-5 inhibitors (sildenafil, vardenafil, tadalafil).
Much research is ongoing into new treatments for scleroderma. Patients and their families should know that experts remain optimistic and take comfort in the fact that work towards a cure will continue.
Broader health impact of scleroderma
Scleroderma can involve almost every organ system in the body. Although symptoms vary greatly from patient to patient, it can dramatically impact someone’s life. Patients should consult a rheumatologist—or a team of specialists---who are experienced in dealing with this complicated disease. Several other diseases that affect the skin are sometimes confused with scleroderma.
Living with scleroderma
Living with scleroderma is quite challenging. Everyday activities can sometimes be difficult due to physical limitations and pain. Problems with digestion may require changes in diet; patients often have to eat several small meals rather than fewer large meals. Patients must also keep the skin well-moisturized to lessen stiffness and be careful during activities such as gardening, cooking—even opening envelopes---to avoid finger injuries. To keep the body warm, patients should dress in layers; wear socks, boots and gloves; and avoid very cold rooms. Unfortunately, moving to a warmer climate does not necessarily lead to dramatic improvement. Exercise and/or physical therapy may ease stiffness in the joints.
Patients must also deal with the psychological setbacks that come from living with a disease that is chronic, uncommon and currently incurable. Because scleroderma can cause significant changes in appearance, a patient’s self-esteem and self-image are almost always affected. The support of family and friends is vital in helping to maintain a good quality of life.
- Tendinitis and bursitis are inflammation or degeneration (breakdown) of the soft tissue around muscles and bones.
- Immediate treatment includes RICE: Rest, Ice, Compression and Elevation.
- Danger signs include rapid worsening of pain, redness and swelling, or sudden inability to move a joint.
Tendons are cord-like structures located where a muscle narrows down to attach to a bone. The tendon is more fibrous and dense than the elastic, fleshy muscle. A tendon transmits the pull of the muscle to the bone to cause movement. Tendinitis is often very tender to the touch.
Tendinitis or bursitis often involves the shoulder, elbow, wrist, hip, knee and ankle. The pain it causes may be quite severe and often occurs suddenly. As in arthritis, the pain is worse during movement. Unlike arthritis, the pain is often in parts of the body far from a joint. Tendinitis often results from repetitive use (overuse). Though the problem can recur or be chronic (long term) in some people, it is most often short term, mainly if treated early.
Bursitis is inflammation of a bursa. This small sac acts as a cushion between moving structures (bones, muscles, tendons or skin). If a muscle or tendon is pulling around a corner of a bone, or over a bone, a healthy bursa protects it from fraying and stress. When a bursa is inflamed, it becomes very painful, even during rest.
What causes tendinitis and bursitis?
Tendinitis can occur from a sudden intense injury. Most often, though, it results from a repeated, minor injury of that tendon. Doctors call this repetitive stress or overuse. For example:
- Painting a ceiling for four hours or more, typing long hours, improper body position while using a keyboard, chopping, cutting or sawing may result in tendinitis or bursitis hours or days later.
- Tight clenching while using hand tools or while driving a long time.
- Using a backhand, mainly single handed, in an early-season game of tennis (“tenniselbow”).
- Wearing improper running shoes or not getting the proper training before sports.
To prevent these overuse injuries, follow the tips in the Joint Protection Table.
Persons with gout, pseudogout, or blood or kidney diseases often develop bursitis as part of that disease. Older persons are more prone to get tendinitis and bursitis. Rarely, some drugs can cause tendinitis and tendon rupture (spontaneous tear). These include fluoroquinolone antibiotics and statins drugs that lower cholesterol).
How are tendinitis and bursitis diagnosed?
To determine the cause of these problems, a health care provider asks about your medical history and does a careful physical exam. Tenderness along the tendon or its sheath (outer covering), or at one specific point in the tendon, suggests tendinitis. Pain occurs when the muscle to which the tendon is attached is worked against resistance as part of the exam.
Most patients at first do not need imaging tests like X-rays, magnetic resonance imaging (often referred to as MRI) or ultrasound scans. Imaging and blood tests are done only if the problem recurs or does not go away. A blood test also can help detect an infection. Signs of an infection include redness, warmth and swelling. If bursitis is the result of infection, fluid must be drained from the bursa at once and promptly studied.
How are tendinitis and bursitis treated?
Treatment depends on the cause. In overuse or injury, you must reduce the causing force or stress. If tendinitis is job related, the doctor or physical therapist should review proper ergonomics, so you can work safely. Some patients may need joint protection advice and support of the involved region. There is little proof that therapeutic ultrasound helps these problems, and most doctors do not recommend it. Treatment can consist of any of the following:
- Rest. You should rest the injured limb or joint, at least for a short time. Failure to rest it will most likely continue your symptoms. If the problem is in a hip, leg or foot, you may need to stop stressful weightbearing activities for a short time. This lets the inflammation lessen.
- Ice. Ice may help reduce inflammation and pain. Ice the area for 10–15 minutes once or twice a day.
- Medicine. If your pain persists, you may need nonsteroidal anti-inflammatory drugs—often referred to as NSAIDs – such as aspirin, ibuprofen or naproxen. Topical (applied to the skin) forms of NSAIDs are now available and may reduce pain and inflammation without stomach upset. Acetaminophen (Tylenol) also can help relieve pain.
Corticosteroid injections may provide short-term benefit in certain forms of tendinitis, and may be considered if you are unable to take NSAIDs. If an infection is present, you most often will need a proper antibiotic. (Daily drainage of fluid with a needle also may be needed.) If crystals of gout are found in joint fluid, there is medicine that controls the disease.
- Supports. Use of a cane in the opposite hand can help a painful hip. Splints or braces for the affected body part help rest and reduce stress on the body. Off-the-shelf supports may be enough. If not, you may need custom-made braces and referral to an occupational therapist.
For ankle tendinitis, you may need orthotics to reduce the stress at the ankle or in the foot. An orthotic is a device that goes inside the shoe, which changes the support and the angle of the foot. This improves foot mechanics and relieves pain or pressure. They can be custom made or off the shelf.
- Physical therapy. Some tendon problems do not go away despite standard treatment. If tendinitis lasts beyond a few weeks, you may need a referral to a physical therapist or a rheumatologist. The doctor or therapist can give you exercises to do that will maintain strength and function. If the tendinitis or bursitis has begun to limit joint movement, or already restricts movement, seeing a physical therapist is wise. For instance, if pain in a shoulder has gone away, but you can no longer raise your arm as high as your healthy arm, a "frozen shoulder" or other rotator cuff problems are developing. You can prevent this problem with early treatment.
- Surgery. If, after a few months of treatment, tendinitis still limits an essential activity, you may want to consider surgery. Ask your doctor to refer you to an experienced orthopaedic surgeon. Some patients with an infection or adhesions of the tendon or bursa may need a cortisone injection or an operation.
A possibly serious complication of tendinitis is rupture of a tendon. The most common rupture is a tear of the Achilles tendon in the lower calf. It most often needs surgery.
Preventing Tendinitis and Bursitis
There are ways you can prevent these problems from occurring. These tips apply to all joints:
- Before strenuous exercise, warm up and stretch.
- Properly train for a new activity. Slowly increase the intensity of your workout.
- Engage in exercise and sports daily or near daily rather than just on weekends.
- Learn and maintain proper posture and body mechanics.
- Make sure sports equipment is the right size and fit for you, and designed for the sport you are doing.
- Avoid staying in one position for too long. Take rest breaks or change positions every 20–40 minutes.
- Stop any activity that causes pain.
- Avoid compulsive behavior, like “I’m going to finish this job even if it kills me!”
The Table shows how to protect certain joints.
- Face an object you are reaching for, rather than reaching sideways or backward.
- Rise from a chair by pushing off with your thigh muscles, not your shoulders or hands.
- Do pushups from the wall, not the floor.
- When reaching for a heavy object overhead, keep the load centered in front of you and use both hands.
- Face an object you are reaching for, rather than reaching sideways or backward.
- Rise from a chair by pushing off with your thigh muscles, not your shoulders or hands.
- Do pushups from the wall, not the floor.
- When reaching for a heavy object overhead, keep the load centered in front of you and use both hands.
Elbow and wrist
- Recognize and avoid hand clenching or gripping tools or other objects too hard. Use power tools. In the kitchen, use aids such as jar openers. Pad your car steering wheel.
- Use your stomach muscles to help roll over when getting out of bed.
- Avoid carrying heavy items in one hand or at the side of your body.
Knee and ankle
- Avoid sitting with a leg folded under.
- Wear shoes that give support and comfort, with room for the toes to extend fully during weightbearing.
- Check shoes often for signs of wear, and replace them when worn.
- If you walk or stand on concrete, cushion the inside bottom of your shoes with pads or wear walking or running shoes with cushioned soles.
- Keep leg muscles strong. Do leg lifts with ankle weights (5–20 pounds) while seated.
- Face an object you are reaching for, rather than reaching sideways or backward.
- Rise from a chair by pushing off with your thigh muscles, not your shoulders or hands.
- Do pushups from the wall, not the floor.
- When reaching for a heavy object overhead, keep the load centered in front of you and use both hands.
Living with tendinitis or bursitis
Tendinitis or bursitis in the shoulder can become a greater problem if the shoulder becomes stiff. It is important to do range of motion exercises, such as stretching, each day. This preserves movement in the shoulder joint.
Tendinitis or bursitis can be painful. Seek medical attention early to prevent joint stiffness and chronic problems that may follow. It also is important to rest the limb or the joint, at least until movement is free of pain. Failure to rest it most often delays full healing.
Tips for living with tendinitis or bursitis include:
- Rest the painful tendon. Avoid heavy activity or any activity that causes pain.
- Ice the area for 10 – 15 minutes once or twice a day.
- Seek medical help at once if pain worsens, if redness and swelling appear or if the problem does not improve in 3 – 6 weeks.
- Avoid overuse of any part of the body, such as doing the same motion over and over.
- Warm up by exercising at a relaxed pace before doing more strenuous activity.
- Vasculitis can range from mild to life-threatening.
- Early detection and treatment of severe vasculitis can prevent permanent damage. Detection of vasculitis most often requires biopsy of affected tissue or angiography.
- Vasculitic diseases are inflammatory health problems that often need treatment with immunosuppressive drugs. The most common medication used is glucocorticoids.
- Patients also may be prescribed other medicines that suppress the immune system. These can help severe disease or let patients take lower doses of glucocorticoids.
Vasculitis is a term for a group of rare diseases that have in common inflammation of blood vessels. These vessels include arteries and veins. There are many types of vasculitis, and they may vary greatly in symptoms, severity and duration. Most types of vasculitis are rare, and the causes are generally not known. Vasculitis affects persons of both sexes and all ages. A few forms of vasculitis affect certain groups of people. For instance, Kawasaki disease occurs only in children. IgA Vasculitis (Henoch-Schönlein) is much more common in children than adults. On the other hand, giant cell arteritis occurs only in adults over 50 years old.
Vasculitis can result in poor blood flow to tissues throughout the body, such as the lungs, nerves and skin. Thus, vasculitis has a wide range of signs and symptoms (what you see and feel), such as:
- Shortness of breath and cough
- Numbness or weakness in a hand or foot
- Red spots on the skin (“purpura”), lumps (“nodules”) or sores (“ulcers”)
On the other hand, vasculitis of the kidneys may produce no symptoms at first but is still a serious problem. Vasculitis can be mild or disabling, or even lead to death. Patients can have one episode of vasculitis or have repeated episodes over several years. Most types of vasculitis are rare.
What causes vasculitis?
We do not know what causes most types of vasculitis. Genetic factors (different genes) appear be somewhat important in the disease. Vasculitis is thought to be an autoimmune disease, which means the body comes under attack by its own immune system. In vasculitis, the immune system attacks blood vessels. Some cases of vasculitis are caused by reactions to medicines. Also, some chronic (long-term) infections, including with hepatitis C or hepatitis B virus, can cause vasculitis.
Vasculitis can be a part of other rheumatic diseases, mainly including systemic lupus erythematosus , rheumatoid arthritis and Sjögren’s syndrome . Most patients with vasculitis have none of these diseases.
How is vasculitis diagnosed?
Physicians suspect vasculitis when a patient has symptoms and abnormal results of the physical exam, lab tests or both, and there is no other clear cause. The most common tests are:
- Biopsy—surgical removal of a small piece of tissue for inspection under a microscope
- Angiography—a type of X-ray to look for abnormalities of blood vessels
- Blood tests
For most patients, doctors can detect the type of vasculitis based on the size of the affected blood vessels (see Table) and the organs involved. To find small-vessel vasculitis, doctors most often do a biopsy, such as of the skin or a kidney. Detection of medium-vessel vasculitis happens by either biopsy (for instance, of skin, nerve or brain) or angiography. Angiography also is the test that often finds large-vessel vasculitis. Detecting giant cell arteritis often involves a biopsy of an artery in the scalp.
A few forms of vasculitis, such as Behçet’s disease and Kawasaki disease, are usually detected on the basis of a collection of clinical findings rather than biopsy or angiography.
Some blood tests are so suggestive of a certain type of vasculitis that a positive (abnormal) test can be enough evidence to help doctors make the diagnosis. The most useful of these tests is for “antineutrophil cytoplasmic antibodies”—often referred to as ANCA. A positive ANCA test can help detect these types of vasculitis: granulomatosis with polyangiitis (Wegener’s) , microscopic polyangiitis or eosinophilic granulomatosis with polyangiitis (Churg-Strauss). Other lab tests can show damage to organs, but the tests are not enough to prove vasculitis.
Types of Vasculitis
|Largest arteries: aorta and major branches||
Giant cell arteritis
Aortitis in Cogan’s syndrome
Aortitis in spondylarthropathies
|small and medium-sized arteries||
Granulomatosis with polyangiitis (former name: Wegener’s granulomatosis) Microscopic polyangiitis
Eosinophilic granulomatosis with polyangiitis (Churg-Strauss )
Primary angiitis of the central nervous system
IgA Vasculitis (Henoch-Schönlein)
Vasculitis related to rheumatoid arthritis, systemic lupus erythematosus and Sjögren’s syndrome
Anti-GBM disease (Goodpasture’s)
|Arteries and veins of various sizes||
Abbreviations: ANCA, antineutrophil cytoplasmic antibodies; GBM, glomerlular basement membrane. This list is not complete. It does not include some forms of vasculitis related to infection or diseases such as cancer.
How is vasculitis treated?
Glucocorticoids: Glucocorticoids (prednisone, prednisolone or others), often referred to as “steroids,” are an important part of treating most forms of vasculitis. The dose and length of treatment depend on how bad the disease is and how long the patient has had it. These drugs help reduce inflammation but can have long-term side effects.
Other drugs: Doctors sometimes prescribe immune-suppressing drugs because their side effects may be less serious than those of glucocorticoids. This is called “steroid-sparing” treatment. Cyclophosphamide is the strongest of these drugs, and doctors may prescribe it when severe disease endangers vital organs.
For less serious vasculitis, patients may receive methotrexate , azathioprine or other immune-suppressing drugs. Doctors often prescribe these drugs to treat other rheumatic diseases, but they are useful for vasculitis, too.
Newer drugs designed to treat other autoimmune and inflammatory diseases may also help vasculitis. Researchers found that one of these drugs, rituximab effectively treats severe cases of certain forms of vasculitis. These include granulomatosis with polyangiitis, microscopic polyangiitis and cryoglobulinemic vasculitis. Some patients with the most severe cases of these diseases may receive plasma exchange (“plasmapheresis”) or intravenous immunoglobulin (often called “IVIg”).
Surgery: Damage from severe vasculitis sometimes requires surgery. This may involve vascular bypass grafting (a surgery to redirect blood flow around a blockage in a blood vessel). Depending on where the damage is, other possible operations are sinus surgery or a kidney transplant.
Living with vasculitis
Vasculitis can be short term or lifelong. Doctors often focus, with good reason, on preventing permanent damage to vital organs (such as the lungs, kidneys and brain) and the nerves. It is crucial, of course, to prevent death and long-term disability from vasculitis. Yet, other issues often trouble patients. These include fatigue (feeling very tired), pain, arthritis, nose and sinus problems, and many other problems.
Side effects from medications, especially glucocorticoids, also can be troubling. Patients taking immunosuppressants are at risk of infections. Follow your doctor’s advice on how to reduce your infection risk.
Fortunately, with current treatments, the outcome for patients with vasculitis is often good.
The rheumatologist’s role in treating vasculitis
Rheumatologists are usually the specialists with the most overall knowledge about vasculitis. Thus, they direct the care of patients, particularly those with chronic or severe disease. Patients with vasculitis often benefit from seeing experts in the organ systems that are or might become affected. Doctors that patients may need to see include a dermatologist (skin doctor), neurologist (expert in nervous system diseases), ophthalmologist (eye doctor), otorhinolaryngologist (ear, nose and throat doctor), nephrologist (kidney doctor) or pulmonologist (lung doctor).