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| Rheumatology – Past, present and future |
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What does Rheumatology mean?
Rheumatology represents a subspeciality in internal medicine and pediatrics that is devoted to the appropriate diagnosis and therapy of rheumatic diseases. The word rheumatology has its origin in the word "rheuma" which means flowing, and is mentioned in Hippocratic corpus. Rheumatic disorders were attributed to humors (rheuma). It was postulated that a substance i.e. humor, flows, settles in joints, and causes arthritis.
Rheumatology developed as a well-recognized specialty of medicine way back in the 20 th century. American Physicians, Bernard Comroe and Joseph Lee Hollander, coined the term rheumatologist in 1940. Since then, rheumatology has come a long way. Today, there is virtually no branch of internal medicine that does not interact with rheumatology. Rheumatology has changed significantly over the last twenty years from a largely inpatient-based speciality to a primarily outpatient-based speciality with targeted and science-based therapies. The adequate understanding of pathophysiological processes underlying rheumatic diseases prompted the development of new drugs. In addition, rheumatology offers diverse prospects for both clinical and scientific research. This field is undoubtedly set to develop even further in the future, as better assessment of diseases, improved science, the development of new biomarkers, as well as the optimization of drug usage will help address many challenges ahead.
What are the diseases dealt in Rheumatology?
Rheumatology deals primarily with autoimmune diseases (body’s defense mechanism attacking its own organs), the rest being metabolic diseases involving joints and degenerative joint diseases. Rheumatology has rapidly advanced during the last 50 years due to improved diagnosis as a result of progress in immunology, molecular biology, genetics and imaging. There is always ongoing research into knowing the genetic and immunological basis of several henceforth unknown etiology of many diseases. Even conditions like hyperuricemia related joint inflammation commonly called as gout is being dealt with anti-cytokine agents like Anti IL 1 receptor blockers. This is because of the understanding of the immune basis of the inflammation triggered by hyperuricemia. Likewise lot of studies with regard to the immune phenomenon are being done in the so called degenerative diseases as well.
Broadly rheumatology can be looked at dealing with two set of autoimmune diseases 1) Systemic autoimmune diseases and 2) single organ autoimmune diseases. Systemic autoimmune diseases like Systemic lupus erythematosus, Rheumatoid arthritis, Systemic sclerosis, Sjogren’s syndrome, Vasculitis etc. are dealt by rheumatologist. The single organ autoimmune disease can be involving any organ and some are still evolving and are being dealt by experts in that speciality on their own or in some cases in liason with rheumatologist. Examples include autoimmune encephalitis, thyroiditis, pancreatitis, hepatitis, inflammatory bowel disease etc.
What should one expect when meeting a Rheumatologist?
The core of Rheumatology is internal medicine. Hence a rheumatologist first listens to the symptoms of a patient and then plans for investigations. Depending on the possibility of the diseases considered, the investigations would be either basic tests including complete blood count, inflammatory markers, muscle enzymes, creatinine, liver enzymes, uric acid and urine routine.
Autoimmune workup is carefully done since nonspecific positivity and low titre antibody positivity (weak positive) may create unnecessary confusion for the treating physician and anxiety for the patients. The pretest probability of an auto antibody test is the key determinant of how effective the result of that test would be in confirming the diagnosis. The diagnosis is most often based on the clinical findings and is supported by a carefully chosen battery of immunological investigations.
These autoantibody tests are sometimes costly but it is done mostly only once to make a diagnosis of these immune mediated illnesses. Rarely in certain conditions like SLE, certain factors are retested to monitor the disease activity. In certain situations, imaging would be utilized along with blood test to facilitate diagnosis.
What is the current role of NSAIDS (pain killers) and steroids in Rheumatology?
NSAIDS are used for a short period (if at all) and mostly stopped once the disease is under good control. It is very rarely used once the definitive treatment agents are initiated. Steroids have a key role in early control of disease, but with the use of newer targeted agents and early use of second line immunosuppressants, it is very much possible to stop steroids completely in most of the patients. Hence the management of rheumatic diseases in this decade and in the future would be mostly by agents that are not painkillers and steroids. The myth that steroids and pain relievers are often only used is not applicable to current practice in rheumatology.
What are the agents used in treatment of Rheumatic diseases?
Advances in molecular biology have helped in better understanding of the disease process as well as finding new therapeutic targets such as inflammatory mediators.
Starting from anti-inflammatory molecules like aspirin, steroids and agents like gold used in rheumatoid arthritis, there has been a steady progress and a giant leap towards treatment of the several rheumatic diseases. Methotrexate though used initially in oncology was found to be very good immune modulator in micro (very low) doses in rheumatology. When used judiciously it forms the sheet anchor of treatment in rheumatology. Likewise several molecules like sulfasalazine leflunomide, hydroxychloroquine and other immunosuppressants have been used with good scientific evidence in the management of rheumatic diseases.
The next major therapeutic progress was with the innovation of biologic molecules which are complex large molecules synthesized through a laborious process targeting the cytokines or receptors of cytokines or cells. The first agent was Anti TNF alpha drug which has been followed by several such molecules. The advantage of these agents have been targeted therapy leading to very fast and tremendous control of the immune mediated inflammatory process. The understanding of the role of the B lymphocyte and T lymphocytes in an abnormal fashion in several of these immune mediated autoimmune disease let to use of biologic agents like Rituximab and Abatacept.
The most recent advancement in the therapeutic armamentarium are small molecules which are agents that act at the level below the cell membrane by manipulating the messenger system from cell surface to the nucleus. Such advanced is the understanding of the immunological events that newer and newer small molecules are being introduced at a very fast pace and studied systematically in several of the autoimmune rheumatic diseases.
How long rheumatic diseases need to be treated?
Like other chronic lifestyle mediated diseases, rheumatic diseases have a genetic basis and hence need to be treated long term. As we use drugs to control blood sugar in diabetes, drugs are used to control the autoimmune self-destructive process and to maintain normal health. The number of medicines and the dose of the medicines are slowly reduced once we achieve our target and then minimum drugs are used to maintain the control of the disease.
What is the key factor for successful treatment in rheumatology?
The key element in the treatment of rheumatic disease is that if the disease is detected early, the chance for successful control is very high. Likewise any damage due to the disease could be averted completely if early intervention is initiated. Equally important is a proper and regular follow-up with the rheumatologist who would monitor the disease by physical examination and blood investigations. There are validated disease activity measures which would be utilized to monitor the disease to the full benefit of the patient.
Dr. Rajesh.S MD, DM, MRCP (UK), FRCP
Senior Consultant Rheumatologist
KIMSHEALTH, Thiruvananthapuram.
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