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Be a member of the Rheumatoid Arthritis Society (Singapore) Click here to apply Laughter, the Best Form of Medicine Biological Agents and Future Therapies for the Treatment of Rheumatoid Arthritis Disease modifying anti-rheumatic drugs- What the family doctor should know The appropriate use of anti-inflammatory drugs (nsaids) and Corticosteroids in Rheumatoid Arthritis (RA) Extra-articular Complications of Rheumatoid Arthritis Letter written to the Press Relaxation and Rheumatoid Arthritis Cholesterol drug may be helpful in treatment of Rheumatoid Arthritis Surgery For The Rheumatoid Knee Rheumatoid Arthritis: Exercise & Physiotherapy for the knee Diet And Rheumatoid Arthritis Rheumatoid Arthritis Society of Singapore's Annual Oration How do I know if my rheumatoid arthritis is active? Biological Agents and Future Therapies for the Treatment of Rheumatoid Arthritis Many cytokines (protein-like molecules) have been shown to play a role in the inflammatory cascade in the rheumatoid joint. Of these, tumour necrosis factor - alpha (TNF alpha) has been identified to be a dominant proinflammatory mediator. Biological agents that target TNF alpha and inhibit its action have demonstrated dramatic effect in ameliorating the rheumatoid arthritis (RA) disease and improve patient outcome. Three anti-TNF alpha agents that are currently approved for the treatment of RA and are available in Singapore, are Etanercept (Enbrel), Infliximab (Remicade) and Adalimumab (Humira). Who should be treated with anti-TNF agents? Current guidelines proposed that anti-TNF agents may be indicated in patients with moderate to severely active RA despite treatment with disease modifying anti-rheumatic drug (DMARD), of which methotrexate is an common example. The high cost of the anti-TNF therapy is also another reason why these agents are often considered only if the patient fails to response to conventional DMARDs. However, the cost of the treatment should be weighed against its potential benefit in a disease that may lead to irreparable joint damage and impairment. Up to two thirds of patients treated with anti-TNF drugs respond well despite having failed other DMARDs previously. The respond may be dramatic with some patients showing marked improvement within one to two weeks. How are anti-TNF agents given and are there differences between the three drugs currently in used? Ant-TNF agents cannot be given orally. Infliximab is given by infusion over a few hours, Etanercept is given by subcutaneous injections 25mg twice a week and Adalimumab is administered by subcutaneous injection 40mg once in two weeks. The efficacy of the three drugs appears to be similar but there are no studies comparing them head to head. Infliximab should be given together with methotrexate whereas Etanercept and Adalimumab can be used as monotherapy. Patients may respond to another anti-TNF agent even though they have failed to respond to one earlier. What are the potential side effects of anti-TNF agents? A key concern on the use of anti-TNF agents is the risk of infection especially the increased susceptibility to tuberculosis or reactivation of latent tuberculosis. All patients should undergo screening for tuberculosis, which includes a chest Xray and Mantoux (skin) test, prior to the start of treatment. Another concern is the risk of lymphoma that is complicated by the fact that severe RA itself is associated with a higher incidence of lymphoma. Patients with active infections, demyelinating disorders, congestive heart failure or who are pregnant should not be treated with anti-TNF agents. Other Biological agents and Future therapies Interleukin (IL)-1 is another key cytokine in pathogenesis of RA. The anti-IL-1 agent (Anakinra) that is approved for the treatment of RA is presently not available in Singapore. The indications for the used of anti-IL-1 agents and its precautions are similar to that of anti-TNF agents although an increased incidence of tuberculosis has not been report. Abatacept (T cell costimulation blocker), Rituximab (anti-CD20 monoclonal antibody) and IL-6 receptor monoclonal antibody are other biological agents that have shown promising results in clinical trials. Autologous stem cell transplantation used for severe refractory RA has shown good results in some cases. Key Points Anti-TNF agents are recommended for the treatment of active RA after the use of another DMARD has failed. Anti-TNF agents have to be given by infusion or subcutaneous injections Up to two thirds of patients may have a good response to anti-TNF agents even though they have failed to respond to other DMARDs. Patients should be screened for tuberculosis before starting anti-TNF agents. Dr Koh Wei Howe Consultant Rheumatologist Mount Elizabeth Medical Centre Back to top Disease modifying anti-rheumatic drugs- What the family doctor should know What is a DMARD ? A disease modifying anti-rheumatic drug( DMARD ) can be briefly defined as a drug that modifies disease outcome and retards joint destruction. When should a DMARD be used? A DMARD should be used as soon as the diagnosis of rheumatoid arthritis is made, because clinical inflammation is maximal in first 1-3 years as pannus formation and erosions is most rapid in year 1( 70% by year 3) and early aggressive treatment of RA with DMARDs improves outcome as response is less in patients longer disease duration. What are the commonly used DMARDs ? Currently, Methotrexate, Sulfasalazine, anti-malarials(incombination) and occasionally Leflunomide are commonly used as first line DMARDs. Combinations of methotrexate + sulfasalazine + hydroxychloroquine or methotrexate + leflunomide are the most frequently used in current practice. Occasionally combinations of methotrexate + cyclosporin or methotrexate + gold compounds are used. Older DMARDs such as Gold compounds, Cyclosporine, D - penicillamine, Azathioprine and Cyclophosphamide are used only infrequently now, because of lack of response or adverse effects. Are DMARDs safe to use? DMARDs are safe to use if proper monitoring of side effects is carried out. A guide to monitoring of DMARDs is obtainable from the website of the American College of Rheumatology http://www.rheumatology.org under publications, in the article Guidelines for the Management of Rheumatoid Arthritis 2002 Update - http://www.rheumatology.org/publications/guidelines/raguidelines02 Why use DMARDs early and consistently? Immediate treatment with DMARDs improves symptoms at 1 year compared to NSAIDs alone Continued treatment with DMARDs in patients in remission decreases relapse rate by 50% Consistent treatment with DMARDs improves outcome at 10 years compared to NSAIDs and steroids Dr Howe Hwee Siew Senior Consultant Rheumatologist, Tan Tock Seng Hospital Back to top The appropriate use of anti-inflammatory drugs (nsaids) and Corticosteroids in Rheumatoid Arthritis (RA) There has been a paradigm shift in the management of RA since the 1990's and currently there is ample evidence that therapeutic intervention early in the course of RA leads to earlier disease control and less joint damage. Recently, there has also been rapid expansion in the understanding of the pathogenesis of RA and exciting development of powerful and expensive therapeutic agents for RA. Although the emphasis is in initiating DMARDS early in the disease, NSAIDS and corticosteroids play a critical role in the management of RA. NSAIDS These drugs provide symptomatic relief but do not modify the course of disease and are usually used in conjunction with DMARDS. The individual response to different NSAIDS vary somewhat and several NSAIDS may be tried before a suitable one is identified. NSAIDS work by inhibiting the synthesis of cyclooxygenase enzymes(COX) and two main isoforms exist: COX I and COX II. COX I is mainly expressed constitutively and is involved in homeostasis whereas COX 2 is mainly induced during pathophysiologic processes. It is the inhibition of COX2 which accounts for the therapeutic benefits of NSAIDS and the inhibition of COX1 which results in the adverse effects. All NSAIDS are associated with adverse events and although COX2 inhibitors have been been shown to have a much better GI tolerability, there is new evidence of cardiovascular risk with these group of drugs. CORTICOSTEROIDS This can be used in 3 main ways: to settle a flare as an adjunct to DMARDS as a regular treatment There are a few modes of treatment including intra-articular injections using long acting depot for eg triamcinolone, regular daily oral corticosteroids or intramuscular/intravenous steroids. The intravenous route is more often used in managing the systemic complications of RA. For the oral route, doses >7.5mg daily should be avoided in the absence of systemic complications as continual steroid therapy exacerbates the local and systemic osteopaenia that accompanies active and chronic RA on top of other adverse effects of steroids. Although controversy persists, low doses corticosteroids in combination with DMARDS have been shown to reduce rate of progression of joint damage. Key Points Low dose oral corticosteroids and NSAIDS are often used in combination with DMARDS and not on its own. NSAIDS and corticosteroids are associated with multiple adverse effects. Intra-articular steroids are helpful in settling flare ups. Dr Lian Tsui Yee Consultant Rheumatologist Tan Tock Seng Hospital Back to top Extra-articular Complications of Rheumatoid Arthritis 1) Osteoporosis (T score <-2.5) of the hip or lumbar spine is common (22%) in RA. All patients with RA lose bone mineral. There is a high incidence of stress fracture of long bones in patients with RA, particularly in those treated with steroids. Vertebral compression deformities are also more common among those with RA. Dual energy X-ray absorptiometry is a precise and popular method for measuring bone density. In view of generalized and periarticular osteopenia there should be a low threshold for therapy to prevent bone loss. All patients should be given supplemental calcium (1000 to 1500 mg/day) and vitamin D3 (400 to 800 IU) while high-risk patients should be given bisphosphonate. 2) Patients with RA develop accelerated atherosclerosis and have increased risk of sudden death and myocardial infarction. Strict control of inflammation in RA by use of aggressive therapy could reduce the development and progression of atherosclerotic cardiovascular disease. 3) Most patients with RA have a mild (=10 g/dL) normocytic hypochromic anemia of chronic disease which correlates with the erythrocyte sedimentation rate and general disease activity. Reactive thrombocytosis and eosinophilia generally parallel disease activity and do not require treatment. Patients with Felty's syndrome, need to be differentiated from LGL syndrome, have positive rheumatoid factor and neutropenia and may be associated with anemia or thrombocytopenia, an enlarged spleen, and (rarely), leg ulcers. Patients with Large granular lymphocyte (LGL) syndrome have many circulating LGLs, neutropenia, splenomegaly, and frequent infections. In a minority, it will progress to LGL leukemia. The risk of lymphoma is increased. 4) Muscle weakness is a common symptom in RA. Most patients have generalized atrophy of type II fibers due to disuse. Synovial inflammation, associated with diminished motion of joints, rapidly produces reflex atrophy in muscle bundles surrounding the joints. Physical therapy should be instituted in all patients with RA soon after the diagnosis is made, not when weakness is clinically apparent and associated with disability. For stable patients, isokinetic exercises under close supervision are appropriate. Variable resistance, isotonic exercise is contraindicated in patients with acutely inflamed joints and isometric exercises are recommended. 5) Steroid myopathy is very unusual in patients without Cushingoid features treated with <10 mg/day of prednisone. There is a dose response relationship. Large daily doses (> 40 - 60 mg/day) for > 1 month almost always result in weakness. This is a diagnosis of exclusion with normal serum muscle enzyme levels, and weakness develops at a time when the RA is quiescent. Improved strength is demonstrated within 3 - 4 weeks after dose reduction. 6) Other complications include lung diseases, rheumatoid nodules and skin diseases scleritis and episcleritis, keratoconjunctivitis sicca, Sjögren's syndrome, pericarditis and myocarditis, mononeuritis multiplex, cervical myelopathy, vasculitis, and lymphedema. Key points: RA is a systemic disease with possible involvement of many systems. Osteoporosis and accelerated atherosclerosis are common in RA. Risk of lymphoma is increased in RA. Dr Kong Kok Ooi Consultant Rheumatologist Tan Tock Seng Hospital Back to top The Proper Use of Drugs Helps Arthritis Patients I refer to the article, "Why drug scares can actually be reassuring" (ST,Nov 6) and I would like to comment on some of the points raised by the writer. Rheumatoid arthritis is chronic immune disease that affects the joints and it can lead to severe deformities and disability. Studies have shown that patients with severe rheumatoid arthritis have increased mortality. The aim of treatment is not only to alleviate the pain but also to try to slow disease progression and prevent joint damage. It is thought that there is a "window of opportunity" in the first two years of the disease whereby proper treatment is necessary before irreparable joint damage occurs. Treatment with pain-killers or non-steroidal anti-inflammatory drugs alone is clearly inadequate and most patients would require an anti-rheumatic agent such as methotrexate. The article mentions methotrexate, a cancer drug, as a "highly toxic drug" but this should be put in the right perspective. Methotrexate has been used for the treatment of rheumatoid arthritis for more than twenty five years and the dosage used in the treatment of arthritis is a relatively low weekly dose. Although there are potential serious side effects with the use of methotrexate, it is generally well tolerated and effective. Furthermore, there are guidelines for the monitoring of adverse effects to minimize their occurrences. At present, methotrexate is probably the most commonly prescribed anti-rheumatic agent. The biological agents such as Remicade, Enbrel and Humira that antagonise tumour necrosis factor (TNF) have been used for the treatment for rheumatoid arthritis in recent years. All of them have shown good results even in patients who have done badly with conventional anti-rheumatic agents. However, there have been concerns about the risks of serious side effects such as infection and lymphoproliferative disorder. The relation between the anti-TNF agents and the development of lymphoma is presently unclear. This uncertainty is compounded by the fact that rheumatoid arthritis is associated with an increased incidence of lymphoma especially in those with more severe arthritis (1), the very patients who are more likely to use anti-TNF drugs. As would be expected, the long-term safety profile of any new drug is usually lacking. This is one of the reason why current consensus guidelines recommend that anti-TNF agents be used only after an adequate trial of another effective anti-rheumatic drug, of which methotrexate is a commonly used example (2). I believe that analogous to the use of steroid, a drug that plays an important role in the treatment of rheumatoid arthritis but is sometimes abused and misunderstood, the proper use of anti-TNF agents will have a positive impact on the patient's disease. A good drug used indiscriminately will lead to adverse outcomes and may affect patients' confidence in their arthritis treatment in general. There is no doubt that continued post-marketing surveillance is necessary but it would be a shame if patients who will greatly benefit from treatment, shy away from it because of adverse publicity. Yours Sincerely, Dr Koh Wei Howe President, Rheumatoid Arthritis Society (Singapore) References Ekstrom K, Hjalgrim H, Brandt L, et al. Risk of malignant lymphomas in patients with rheumatoid arthritis and in their first-degree relatives. Arthritis Rheum 2003;48:963-70. Furst DE, Breedveld FC, Kalden JR et al. Updated consensus statement on biological agents for the treatment of rheumatoid arthritis and other rheumatic diseases. Ann Rheum Dis 2002;61(Suppl II):ii2-ii7 Back to top Relaxation and Rheumatoid Arthritis In life, been arthritic or not does not change the fact that we, all, are subject to a variety of stress. The work environment and the family structure have changed with the modernization of the society. We have to adapt ourselves; we have to adjust ourselves to the new situation. When we suffer from chronic diseases, we know that stress does not only affect our body and mind, but it has also an impact on our chronic diseases. Stress can increase the intensity or start a flare. Controlling our stress is becoming an important factor in our life. In general, if we are overwhelmed by the stress, we feel tired, without much energy and with more difficulties to cope with daily activities as well as with work. That kind of situation does not allow us to keep an upper hand on our chronic disease. Therefore, the control of our stress enables us to free ourselves from physical and mental tensions. When we control our stress, we keep a positive approach toward our problems and our disease; we are more open to the others; we have better relation within our family. It exists various techniques to de-stress on the market. I choose sophrology because it has been taught in all Europe and in Japan. It has been of great help to many of my patients. My aunty -95 years old- with chronic back problems, uses her sophrology daily to cope better with her pains; she still lives by herself. The principle of the sophrology is to work with our body and our mind. To have good impact, we work in a level of consciousness that is neither awake nor asleep; it means we are not awake and we are not asleep, but between. To achieve that, we need to relax all our muscles. It exists different possibilities to work in sophrology, but for this article and the presentation given earlier this year, we give you the basic that you can apply at home on your own path. That simple work will already help you to cut the stress and feel better The technique goes as follow: Lying down, comfortably, we first start by releasing the tension of the muscles of our head (jaws, mouth, noze, cheeks, ears, eyes, skull), than we continue with our arms, shoulders and neck, thereafter we continue with the muscles between our shoulder blades, those of the chest, of the abdomen and of the spine; we continue by releasing the muscle tension of our lower abdomen, buttocks, thighs, legs, calves and feet. The muscles tension been reduced to the minimum, we glide from awake to between awake and asleep and we feel what happens in our body. When we have finished with feeling what happens in our body we restore our muscle tonus starting from the feet and going up. Philippe Steiner Senior Physiotherapist Private Practice Back to top Cholesterol drug may be helpful in treatment of Rheumatoid Arthritis Clinical observations have suggested that statins, a family of drugs approved for reducing cholesterol, may also be beneficial in the treatment of inflammatory diseases for which rheumatoid arthritis (RA) is one. The mechanisms involved in this however are unclear. A recent article published in the British medical journal Lancet, showed that atorvastatin improved both the arthritis and inflammation on blood tests. What was done In this study which involved 116 patients with RA, half of them were given atorvastatin and the other half were given a placebo (ie a sugar pill) on top of their usual RA medications. They were then assessed over 6 months for the severity of their arthritis both by the doctor and patients and also by blood investigations. What was found The patients were mainly women with an average age of 56. They had RA for a median duration of 11.5 years and at 6 months, 31% of patients allocated to atorvastatin improved significantly in the severity of arthritis compared with 10% in the placebo group. Some blood tests of inflammation also showed improvement in the patients on atorvastatin. On analysis of these findings, Iain B McInnes and colleagues from the Centre for Rheumatic Diseases, Glasgow Royal Infirmary, United Kingdom, felt that "although the magnitude of change (ie improvement) was modest", this study showed that statins as a whole offered treatment opportunity in inflammatory disease. Comment On statistical analyses, the improvement in the severity of arthritis was considered only modest and this study was for a short period of 6 months. However, this study does suggest that statins may be beneficial as an additional medication in RA on top of their usual medications. Further studies are now needed to establish what long term benefits are conferred by including statins in the treatment of RA. Back to top Surgery For The Rheumatoid Knee Rheumatoid arthritis is on of the commonest inflammatory joint disease that affects the knee. Apart from the pain and swelling suffered during an acute flare up, the inflammatory process will destroy the meniscus and denude the soft cartilage that covers the surface of the knee joint. Unfortunately, once the joints are damaged by the disease, the cartilage rarely returns to normal even if the arthritis settles down. Therefore treatment must be instituted early. The main line of treatment is anti-inflammatory medication. There are many new and highly effective drugs available to the rheumatologist to help induce remission of the disease. However, in some instances, the rheumatoid arthritis is so florid that the patient is in constant and recurrent pain that can lead to destruction of the knee joint. Intra-articular injections with steroids can help but overuse of this drug can itself be harmful to the joint. Physiotherapy and splinting in the acute flare-up can often bring some relief. When conservative measures fail to alleviate the symptoms, surgery will be required. The type of surgery will depend on the state of destruction of the knee joint. The established surgical procedures available to treat rheumatoid arthritis of the knee include synovectomy, realignment procedures and knee replacement. New surgical approaches that include tissue engineering and cartilage resurfacing may be a viable option in suitable patients. Synovectomy involves removing the excessive tissues that line the knee joint. This can be done using the arthroscope through two or three small key-holes around the knee. Early rehabilitation of the knee is possible with this minimally invasive procedure. Realignment procedures involve correcting the curve of the knee joint. It is common to find a valgus or 'knock knees' deformity in a rheumatoid patient. Like an unbalanced tyre, the outer side the knee is under increased pressure and will wear out prematurely. Realigning the knee by cutting a wedge of the bone, usually in the femur or thigh bone, and stabilizing it in with a metal plate will help redistribute and even out the stress on the knee joint. Joint replacement will be required when the knee is badly destroyed by the disease process. Replacing the whole knee with metal and a piece of intervening plastic will relieve the patient of the pain of arthritis. However, these implants have a finite life-span of ten to fifteen years before revision surgery will be necessary. In certain patients, the knee is only partially destroyed by the disease only. It is thus possible to replace only part of the knee. This procedure involves cutting less bone that will result in faster and better recovery of knee function. Dr Tho Kam San Consultant Orthopaedic Surgeon Island Orthopaedic Consultants Back to top Rheumatoid Arthritis: Exercise & Physiotherapy for the knee The clinical features of the rheumatoid arthritic knee may include joint pain, swelling, ligamentous laxity, synovial hyperthrophy, joint stiffness, limitation of movements, muscle atrophy and swollen calf. The role of physiotherapy is to relieve pain, reduce swelling, maintain joint mobility and muscle function. In the acute phase of inflammation, when the knee is hot, red, swollen and painful, the function of the lower limb may be impaired. Icing is found to be useful in the acute phase. It may help to reduce the swelling by reducing the blood flow to the knee as well as decrease the release of pain-inducing chemicals. In the subacute and chronic phase of inflammation, shortwave and ultrasound are the two modalities commonly used in the physiotherapy clinics for pain relief. Shortwave diathermy generates deep heat and it may help to alleviate joint pain by improving blood circulation and removing metabolic waste. Some people may ask: What is the difference between deep heat treatment and the hot pack which we purchase in the pharmacy? The distinct difference is that the heat produced by shortwave diathermy passes through our subcutaneous tissue (the fat layer below our skin) and reaches our muscle. However, the heat of hot pack stays at the skin level and does not penetrate to the deeper tissue. Therefore in some clinical circumstances, deep heat treatment is more effective for tissue healing. Ultrasound is a type of high frequency sound wave generating vibration and oscillation of molecules in the soft tissue. Research has shown that it may help to facilitate tissue repair via improving collagen synthesis and removing metabolic waste by increasing permeability of blood vessels. The knee is one of the weight-bearing joints of the lower limb. The lower limb is a stack of bones connected to each other by ligaments and muscles. The proper function of the lower limb is highly dependent on the integrity of the soft tissue (i.e. the ligaments and the muscles) surrounding it. The ligaments are like strong ropes that connect the bones. They are the "static stabilizers" of the joint. The ligaments can be torn under vigorous, abrupt twisting force. Surgery may be necessary when major ligament is injured. The muscles around the knee act as the "dynamic stabilizer" of the knee. The stability of the joint is highly affected when the muscles are not working properly. It becomes wobbly in standing, walking and running. Due to the process of rheumatoid arthritis, the ligaments of the knee may become lax; therefore, enhancing the performance of the muscles is important. A well-balanced muscle group with good strength and coordination may help to compensate the disadvantages of having lax ligaments. Tips to protect your knee: Recondition the muscles around the knee as they help to dissipate the impact and stress through the joint. Swimming is a good choice as it is non-weight bearing. You can consult your physiotherapist regarding suitable exercises for yourself. Control your body weight within normal range as extra poundage increases the stress of the weight-bearing joint. Avoid frequent and sustained deep squatting or kneeling, avoid excessive running and stairs climbing; all these will increase the pressure and impact in the knee and thus may increase the chances of wear and tear of the joint. Chong Kar Huey Physiotherapist Gleneagles Hospital Diagrams illustrated below are some clinical exercises for the knee: Back to top Diet and Rheutmatoid Arthritis Patients with rheumatoid arthritis frequently ask their doctors for diet recommendations. Routine dietary interventions and over-the-counter preparations, including dietary supplements, vitamin and mineral therapies, comprise a significant proportion of alternative use. Although much has been written on this subject, the results of different diets on the arthritis itself are often inconclusive. The studies that have been conducted have included fasting, vegan diet, Mediterranean diet (with a low content of red meat and high content of olive oil), Dong diet and other elimination diets, supplementation of polyunsaturated fatty acids and antioxidants including vitamins A, E and C, beta-carotene, bioflavanoids, zinc and selenium. In general, elimination diets or fasting is believed to eliminate food ingredients that can aggravate arthritis, while supplementation of antioxidants is directed at antioxidative and anti-inflammatory effect of these food compounds. To date, both approaches have not shown any significant objective benefit. Patients with active rheumatoid arthritis have a slightly increased risk for cardiovascular events and a cholesterol-lowering diet may be recommended. In general, patients with rheumatoid arthritis should consume as varied a diet as possible, based on current Department of Health (UK, 1991) guidelines. Dr Lian Tsui Yee Back to top Rheumatoid Arthritis Society of Singapore's Annual Oration To address the RASS annual oration held on 2nd July 2001 at the York Hotel, we had the privilege of having Professor Roy Fleischmann, Rheumatology Professor of Medicine at the University of Texas. He spoke on the topic "Treatment of Rheumatoid Arthritis: What the Patient Should Know." He began his talk by emphasising the importance of early and aggressive treatment of rheumatoid arthritis (RA). Since disease progression is rapid in the early stages, with continued inflammation of joints leading to cumulative damage, he presented the rationale for early treatment with disease modifying anti-rheumatic drugs (DMARDs). Such drugs include gold, sulphasalazine, hydroxychloroquine, prednisolone and methotrexate. Hence, the traditional model of treating RA first with anti-inflammatory drugs and then stepping up to stronger DMARDs has been reversed in recent years to one of a "step down" treatment model. Professor Fleischmann stressed the importance of preventing and slowing down synovial hyperplasia with the appropriate DMARDs and consequently preventing joint destruction "before it is too late". An early referral to a rheumatologist would ensure that both a correct diagnosis and a treatment plan would be made without unnecessary delay. He then went on to discuss the various types of drugs used for RA. He also touched on their contraindications, side-effects and efficacy. He added that RA patients, in addition to focal bone erosions, also face the risk of osteoporosis. This means that other medications such as calcium supplements and drugs to improve bone mass such as alendronate would also prove beneficial. Finally, he discussed the newer DMARDs such as etanercept, infliximab and leflunomide. Leflunomide (Arava) has recently been made available in Singapore. He highlighted studies showing the advantage of leflunomide in improving joint function. The treatment of RA has come a long way. Current drugs to suppress the disease has meant a lower mortality and morbidity rate as compared to the past. Ongoing research on RA will help improve future understanding in the basic disease pathogenesis, as well as enable newer, more effective but safer therapies to be discovered. To RA sufferers, this is indeed encouraging news. Back to top How do I know if my rheumatoid arthritis is active? Thinking of doing something to make your arthritis better? Let's get started. There are many things that you can do to help yourself manage your rheumatoid arthritis better. First, let's talk about how you would know if your arthritis is active. Knowing that your arthritis is active early means that you can see your doctor earlier for treatment to control the disease before it gets worse. So, what does active arthritis look like? If you still remember the symptoms you had and the condition you were when you were first developed rheumatoid arthritis, that is what active arthritis feels like. Basically, you feel that you have more joint pain, especially in the morning when you wake up or in the middle of the night whilst sleeping. The stiffness of the joints lasts longer and you start to notice new joint swelling or the swelling in the joint increases gradually. Some patients may notice that the active joints are warm and have some reddish discoloration. There may be fluid accumulating in the joint. You may feel more easily tired as well. Of course, not all patients will have all the abovementioned features when their arthritis is active. If you have pain, stiffness or swelling in or around a joint for more than two weeks, it's time to see your doctor. These symptoms can develop suddenly or slowly. Only a doctor can confirm if it is due to active arthritis. The doctor will examine you and he/she may find swollen and tender joints with limited range of motion. Sometimes, joint effusion (increased amount of joint fluid) may be detected as well. The doctor may then do some investigations which may show the presence of anaemia (low blood count), raised platelet count (blood cells that prevent bleeding), high ESR or CRP (tests which reflects the degree of inflammation). But "you have arthritis" is not a diagnosis. Ask for a specific diagnosis of the type of arthritis you have. Even though you have rheumatoid arthritis, you can still have osteoarthritis (a degenerative form of arthritis) that is the cause of all the joint symptoms. Getting the right treatment requires getting the right diagnosis. The earlier an accurate diagnosis is made and treatment given, the better. Early treatment can often mean less joint damage and less pain. So, see your doctor for an early diagnosis and immediate treatment plan, if you have active arthritis. Dr Kong Kok Ooi Department of Rheumatology, Allergy and Immunology Tan Tock Seng Hospital Back to top Laughter, the Best Form of Medicine It seems that when your joint hurts, it is better to laugh than cry. A group of Japanese researchers have found that a good laugh may have beneficial effects on the immune response of patients with severe rheumatoid arthritis (RA). Their study was recently reported in the journal called Rheumatology. The effect of laughter on cytokines, protein-like substances produced by the immune system, was studied in 41 patients with rheumatoid arthritis and 23 healthy people. The patients were divided into two groups, those whose arthritis was difficult to control and those with easily controlled disease. The study subjects were asked to listen to a very funny traditional Japanese story called Rakugo. The levels of cytokines that promote ("pro") inflammation and those that inhibit ("anti") inflammation, were measured before and after the story was played. The researchers noted that the baseline levels of "pro" inflammatory cytokines were much higher in patients with RA compared to the control subjects. Interestingly, the levels of "pro" inflammatory cytokines such as interleukin-6 and interleukin-4 were significantly reduced in patients with RA but not in healthy subjects after they have laughed at the funny story. On the other hand, the levels of "anti" inflammatory cytokines in patients with RA increased after laughing. The results of the study suggested that laughter may have a positive effect on the immune processes in RA and the psychological condition of the patient may have an impact on the disease activity. Furthermore, it has been suggested that the interaction between stress and the immune system could lead to the progression of RA disease. It is thus important that patients with RA receive psychological support from their family and friends, and patients who are depressed should seek treatment. The lyrics of a popular song ("Don't Worry, Be Happy") may actually provide a useful tip for patients with RA on how to cope with their daily concerns and make their arthritis better. Back to top Home | About Society | About RA | RA Grapevine | Patients' Perspective | Arthritis News | Upcoming Events | Financial Information Designed by Strategic Thinking Business P/L. All Rights Reserved.