Early Inflammatory Arthritis
Dealing with early inflammatory arthritis
The principles and types of treatment for all forms of early inflammatory arthritis are the same and involve early use of medicines to reduce and control inflammation. Commonly used medicines for short-term, early control of joint inflammation include steroids as joint injections, intra-muscular injections or less commonly as tablets. Disease-modifying anti-rheumatic medicines (DMARDS) are also started promptly (and often in combination) to achieve long-term control of joint inflammation.
See here for information on commonly used anti-rheumatic medicines.
Once a diagnosis of early inflammatory arthritis is made it may be possible to classify it as a particular form of inflammatory arthritis at the first clinic visit, although it may take a few weeks or months for a formal diagnosis to be made.
Types of inflammatory arthritis
- Kidney impairment
- Medicines such as diuretics and long term aspirin
- High alcohol consumption (particularly beer)
- Family history of gout
- Excessive fructose consumption (for example in fruit juice)
Gout is more common in men than women (gout is extremely rare in pre-menopausal women).
Gout can cause acutely painful attacks that resolve within 1-2 weeks. The commonest joints involved (in order of frequency) are the big toe, other joints within the feet, ankles, knees, elbows, wrists and hands, Treatment of these acute attacks is with anti-inflammatory medicines.
Gout can be a longer term problem causing joint damage, uric acid collection in soft tissues (tophi) and kidney damage.
Treatment is aimed at controlling inflammation and reducing blood uric acid levels.
Ankylosing Spondylitis (AS) or Axial Spondyloarthritis is an inflammatory arthritis of the back and spine which can occur with or without inflammation in other joints. In AS, symptoms typically first occur in the early twenties, although average diagnosis lags 10 years behind the onset of symptoms. Men and women are equally effected. Back pain is common in the general population but back pain of more than 3 months duration may be inflammatory if it fulfils 4 or more of the following criteria:
- Age at onset less than 40 years
- Onset starts gradually
- Improvement with exercise
- Improvement with anti-inflammatory drugs
- No improvement with rest
- Pain at night (with improvement on getting up)
- Buttock pain
- Family history of AS in first degree relative
- History of psoriasis and/or enthesitis
AS is related to some other types of arthritis such as psoriatic arthritis, and other conditions such as crohns disease and ulcerative colitis. It is strongly associated with a type of eye inflammation called iritis or uveitis.
AS responds well to physiotherapy, hydrotherapy, daily stretching exercises and medicines including non-steroidal anti-inflammatory drugs and newer biologic therapies. This will form part of the treatment following diagnosis in the rheumatology clinic.
Symptoms of psoriatic arthritis include:
- Joint pain, swelling and stiffness lasting more than 30 minutes in the morning which improves with activity
- Swollen fingers or toes (dactylitis), caused by inflammation in both joints and tendons
- Buttock or back pain, caused by inflammation in the spine (spondylitis)
- Pain and swelling in the heels (Achilles tendonitis/plantar fasciitis) or other areas where tendons attach to bones, eg knee, hip and chest, tennis elbow
- Pitting, discoloration and thickening of your nails
As with other types of inflammatory arthritis, treatment is with disease modifying anti-rheumatic medicines (DMARDS).
Lupus is an autoimmune disease, which means that the immune system, the body’s defence system, produces antibodies that attack the body’s own tissues, causing inflammation.
There are two main types of lupus:
- Discoid lupus where only skin is affected and usually looked after by dermatologists
- Systemic lupus erythematosus (SLE)
SLE affects 1 in 1000 people and is much more common in women. The most common symptoms of SLE are:
- Joint pains
- Raynauds phenomenon
- Skin rashes
- Extreme tiredness (fatigue)
Other symptoms which can be quite common are:
- Fever
- Weight loss
- Swelling of the lymph glands
Lupus can affect many different parts of the body, and when internal organs such as the heart, lungs, brain or kidneys are involved it can be much more serious. But most people will only have one or a few of the possible symptoms, and many people will find that the symptoms come and go. Diagnosis and treatment require specialist rheumatological care.
Inflammatory arthritis affects around 1 in every 1000 children and is called juvenile idiopathic arthritis (JIA). The diagnosis of JIA is made when a child under 16 presents with joint inflammation persisting for at least 6 weeks where other known conditions have been excluded. There is no specific diagnostic test for JIA.
Delayed diagnosis is common, not least because young children rarely complain of pain and seek medical attention with non-specific complaints such as limps or being reluctant to walk or play sport.
Children and young people with joint swelling, joint pain lasting more than 6 weeks or unexplained problems with normal movements should be examined for evidence of joint problems and referred to a paediatric rheumatologist for further assessment.
JIA is significantly associated with chronic anterior uveitis (an inflammatory condition of the eye). Children and young people often don’t complain of a change in vision and all children with JIA are regularly screened for this problem. Delaying a diagnosis of JIA may mean missing a potentially reversible cause of blindness.
JIA commonly continues to be active and cause severe problems in adults even when it may have gone into remission and caused no problems for months and even years. Adults with a previous history of JIA and new joint symptoms should be referred for a rheumatological assessment.
Symptoms are severe and painful stiffness, often worse in the morning, especially in shoulders and thighs and usually affecting both sides. PMR often strikes suddenly, appearing over a week or two and sometimes just after a flu-like illness. Other symptoms include feeling generally unwell, fever, weight loss and overwhelming tiredness.
The symptoms are quite different from the ache felt after exercise. The pain and stiffness is often widespread, is worse when resting and improves with activity or as the day goes on and may be severe enough to interrupt sleep.
PMR is sometimes associated with painful inflammation of the arteries of the skull. This is called giant cell arteritis (GCA) or temporal arteritis and needs prompt treatment as there’s a risk of damage to the arteries of the eyes. About 20% of people with PMR also develop GCA, while 40–60% of people with GCA also have symptoms of PMR. The symptoms of GCA are: severe headache, tenderness at temple or jaw pain when chewing, scalp pain and blurred or double vision. Anyone with these symptoms in addition to PMR need urgent referral to rheumatology.