The Many Faces of Rheumatoid Arthritis

Rheumatoid arthritis: debilitating, painful, challenging. This destructive inflammatory disease affects over 300,000 Canadians and in as many different ways. When it strikes, how it responds or doesn’t respond to treatment, and whether it is remissive or relentless, varies from patient to patient.

There are more than 100 forms of arthritis, but rheumatoid arthritis is a destructive form, which chews away at bone and causes permanent damage. It strikes women three times as often as men and generally between the ages of 30 and 60.

“Rheumatoid arthritis is a systematic inflammatory disease characterized by skin and joint involvement,” says Dr. Shikha Mittoo, a rheumatologist at the Arthritis Centre. “The joints become inflamed, red, and swollen. It can also be associated with skin nodules.”

Mittoo says it is not only present in the joints, but in the blood. Patients typically experience fatigue and other symptoms contributing to a general malaise.

It is important to diagnose rheumatoid arthritis early, preferably within the first six months. Mittoo says treating it early and aggressively leads to better outcomes such as less joint disability and less damage.

She stresses the importance of regular evaluations by a rheumatologist. “There are what we call extra auricular manifestations of the disease,” says Mittoo. “Rheumatoid arthritis can sometimes affect the lungs, heart and eyes.”

TREATMENT
There are two categories of treatment for rheumatoid arthritis. One manages the pain. Analgesics such as acetaminophen (Tylenol) are used for pain control while anti-inflammatory drugs such as Advil and Celebrex treat both pain and inflammation. The other treatment category is DMARDs (disease modifying anti-rheumatic drugs), which are used to modify the course of the disease and limit the destruction over time.

“People can do well with the DMARDs but it’s a variable course,” says Mittoo. “Some progress along a severe course, some maintain and others improve and may go into remission.”

Patients in the later stages, or those who are not responding to DMARDs move on to biologic therapies, genetically engineered drugs, which are infused or injected.

Joan Kennedy is a 47-year-old self-employed management consultant. Kennedy became symptomatic at the tender age of 17 while on a summer French immersion course in Montreal. At first she thought her aching feet, weight loss and morning stiffness were due to the rainy Quebec weather. By November, her doctor suspected arthritis but her blood test was negative. She worsened over Christmas and in January sought out a diagnosis by the university medical center. Kennedy was advised to take Aspirin. In her case, 18 tablets a day.

“By the time I was diagnosed I did have some permanent joint damage,” says Kennedy. “Eventually I was prescribed anti-inflammatory drugs, then cortisone. They keep adding on different things to attack the disease to hope it will be better managed.”

Kennedy has had virtually all of her joints affected including her wrists, feet, knees and hips. She has had half a dozen surgeries. She has been on cortisone since her early twenties and numerous combinations of other drugs. She has tried three different biologics along the way.

When Kennedy was first diagnosed, the advice was, ‘"if it hurts, don’t move". Today the advice has changed to "get moving." Kennedy does just that. She’s a self-described gym rat and pursues golf and cycling. She hired a personal trainer and they work together to adapt exercises to meet her capabilities day-to-day.

“It’s not what you can’t do, it’s about finding a way to do it,” says Kennedy. “I haven’t had the benefit of remission but I don’t think about gloom and doom scenarios. It’s never enough to keep me from getting up in the morning.”

Tannis Charles was diagnosed over 12 years ago, originally with reactive arthritis and definitively with rheumatoid arthritis about four years ago. Charles is 44 years old and works for a large Winnipeg insurance company. While she has a primarily sedentary lifestyle, rheumatoid arthritis affected the core of her daily life.

“The symptoms started after I had a baby boy,” says Charles. “I had difficulty picking him up. I was not able to change his diaper. Once he kicked my wrist and I cried for 10 minutes. It was excruciating.”

Charles’s rheumatoid arthritis was in her wrists and the balls of her feet. She found the most mundane household tasks to be tremendous chores.

In 1997, her knee swelled up and she was hospitalized and referred to a rheumatologist. He prescribed DMARDs, including sulfasalazine, and Charles improved. By 2002, she was taking celebrex and started on methotrexate. In 2005, she was deteriorating again. The following year, her rheumatologist asked her about participating in one of three biologic drug trials. She chose rituxamab (brand name Rituxin), which was the only trial drug already being used for other conditions. It changed her life.

“When I started this trial, they did a joint count,” says Charles. “I had 26 tender joints and 36 swollen joints. All my blood work showed that things were bad. Six months later, everything had improved by 50 per cent. Within a year, by 75 per cent. Now my blood work is normal and my last joint count was four swollen joints and no tender joints.”

In June 2006, she was able to applaud as her children crossed the finish line at the Manitoba Marathon Super Run. In December 2007, she and her husband visited England and she hiked up and down a 1,250-metre mountain.

“I can stir up a triple batch of cookies,” says Charles. “I can ride a bicycle and drive my standard vehicle.”

Charles urges other rheumatoid arthritis patients to talk to their doctor. “There are multiple treatment options,” says Charles. “Perhaps they just haven’t tried the right one yet.”

While treatments developed over the past five to 10 years have been revolutionary, Dr. Hani El-Gabalawy is attacking rheumatoid arthritis at the source. El-Gabalawy is a Professor of Medicine and Head of the Division of Rheumatology at the University of Manitoba. El-Gabalawy’s major research project, Early Detection of Rheumatoid Arthritis in First Nations, has the ultimate aim of a vaccine for high-risk individuals.

“We know that First Nations people get rheumatoid arthritis twice as much as anyone in the world,” says El-Gabalawy. “They get severe disease that is rapidly progressing and crippling. While rheumatoid arthritis in most populations is about 10 per cent familial, in Aboriginal people it occurs anywhere from 30 per cent to 50 per cent. The onset is at least 10 years younger than in most Caucasian populations, which makes the burden of disease much longer.”

There is also a gene-environment interaction with smoking and a certain genetic background found in Aboriginal people that further increases the risk. Also, a certain bacteria causing gum disease appears to be associated with early rheumatoid arthritis.

El-Gabalawy’s project has recruited 500 family members of rheumatoid arthritis patients, 320 rheumatoid arthritis patients, and 500 controls. He recently presented findings at a meeting at the American College of Rheumatology in Philadelphia.

El-Gabalawy’s research discovered that the main genetic risk is immune-regulating genes called HMA genes. These are the genes involved in transplantations and rejection of foreign tissue. Certain types of those genes are found in three-quarters of the Aboriginal population. There are several other genes associated with rheumatoid arthritis in populations around the world and El-Gabalawy’s research has found that one particular gene combined with the HMA gene predisposes to rheumatoid arthritis.

“The second gene is only relevant in context of the first gene,” says El-Gabalawy. “If you have a population without the first gene, the second gene is totally irrelevant. The two together is what makes the difference.”

There may be more than one gene that interacts in this way with the primary genetic risk, but discovering the interactive relationship is a major scientific breakthrough.  There is still a lot of work ahead as El-Gabalawy’s team continue to figure out exactly which genes are predisposing.

El-Gabalawy is particularly proud of the partnership between his project and the leadership from the First Nations community.

“For us that’s every bit as important as the scientific discovery,” says El-Gabalawy.

As for the possibility of a vaccine?

As El-Gabalawy says, “It’s within our reach.”

For more information about rheumatoid arthritis, go to the Arthritis Society’s website, www.arthritis.ca. You can also contact the AS at 1-800-321-1433 or 942-4892.