There was a time when Ritu Malhotra, a 30-something consulting editor with Oxford University Press, could not drive her car, lift her baby or carry a shopping bag. The agony began in 2004, when she woke up one morning with a severe pain in her elbow. Over the next few days, it got progressively worse until she couldn’t bend her elbow. She kept visiting orthopaedic specialists until her father-in-law, a doctor himself, suggested she see a rheumatologist. Tests confirmed an autoimmune disorder.
Arthritis at work: Rheumatism can strike the young.
Malhotra is one of the estimated 10 million Indians suffering from rheumatoid arthritis, a debilitating condition caused by an overactive immune system. Among the several types of arthritis, rheumatoid arthritis is one of the most dangerous, cutting short lifespan by 10 years. Unlike osteoarthritis, which affects the old, rheumatoid arthritis mostly strikes people in their prime, especially smokers and women. Approximately 60% of sufferers are under the age of 65, which puts most of the afflicted in the working age group.
Not just a pain in the bone
A.N. Malaviya, consultant, rheumatology, Indian Spinal Injuries Centre, New Delhi, warns that this is a killer disease: “Left untreated, it poses increased risk of heart attack, brain stroke, increased chances of infections and cancer.”
Although genetic in nature, “incidence of rheumatoid arthritis is two-three times higher in smokers than in non-smokers,” says Josef Smolen, head, Center of Rheumatic Diseases, Hietzing Hospital, Vienna.
Early referral and early recognition is key
Malhotra is one of the luckier ones, as her condition was diagnosed early, but for a majority of sufferers in India, it takes several years—largely due to lack of awareness in both the lay and medical community. Says Dr Malaviya, “Very often such long delays lead to deformity of limbs.”
R. Handa, consultant rheumatologist, Indraprastha Apollo Hospital, New Delhi, points out that when joint pain strikes, most people tend to self-medicate—apply some balm, get a massage, or seek alternative remedies such as Ayurveda. He cites a 2008 survey of rheumatoid arthritis patients at the All India Institute of Medical Sciences (AIIMS): 82% admitted to exploring alternatives before coming to see a doctor.
Early signs include stiffness in the joints for more than half an hour in the morning, with pain that comes and goes in cycles. Some people also get flu-like symptoms, and feel tired, irritable or depressed.
Rheumatologists say there is nothing with a proven ability to prevent rheumatoid arthritis. But nutritionists suggest fish and sunflower oil may help. And strangely enough, in a study published in BMJ (5 June 2008), Scandinavian researchers suggested drinking alcohol cuts the risk of developing rheumatoid arthritis in half.
To get treated
The good news is that remission can be achieved in a majority of patients, though medication has to be taken throughout life.
However, Dr Malaviya points out that treatment depends on accurate evaluation of the severity of disease. This is easier said than done. Malhotra is a case in point. For the first couple of years, with conservative treatment, she was progressing pretty well and her doctor told her that she appeared to have only a mild form of the disease. “In 2007 March, things flared up,” says Malhotra. “I started getting pain in my ankles and wrist. By June...I couldn’t even put on buttons, or open the bolt of a door.”
This is the classical pattern of the disease—the pain tends to be cyclical: Just when you think you have conquered it, along comes a serious bout. Finally, Malhotra was put on biologicals, a new class of drugs, albeit a very expensive treatment, and life got back on an even keel.
The cost factor
While methotrexate is the anchor drug and corticosteroids are also used, ever since the London-based rheumatologist-immunologist R.N. Maini’s work on biologicals—particularly a 1994 paper titled New Directions for Biological Therapy in Rheumatoid
Arthritis—doctors feel they may be at last be besting the disease. Unfortunately, these drugs are expensive. Malhotra, for instance, needs eight shots each year—each shot costs Rs60,000. Rheumatologists in India are now exploring if patients treated with biologics for a few years can then go on to more affordable agents. Clinical trials are on in this area.
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