Subscribe
Share
Share
Embed
Welcome to the DocTalks Podcast, a conversation on what’s new and relevant in the world of Canadian medicine and hospital health care. Join us for each episode, as we interview physicians, patients and caregivers to dive deep into what it’s like to treat and live with some of today’s most common health challenges. Hosted by Ian Gillespie.
Note: The content of St. Joseph's DocTalks Podcasts is for informational purposes only. The material is not intended for and should not be used as a substitute for direct medical advice from a licensed health care practitioner.
DocTalks S3E17
Putting out the fire - Rheumatoid arthritis w/ Dr. Tom Appleton
[00:00:00] Ian: Hello, I'm in Gillespie. Welcome to the DocTalks podcast, brought to you by St. Joseph's Healthcare London. You've probably heard of an ailment that tends to be thought of as. Only affecting older people.
I'm referring to arthritis. What you may not know is that there are several types of arthritis and one known as rheumatoid arthritis that affects approximately one in a hundred Canadians of all ages. Today we're gonna learn a lot more about this condition because I'm talking to Dr. Tom Appleton, a rheumatologist in the Rheumatology Center at St.
Joseph's Healthcare. he's part of the Bone and Joint Institute at Western University, where he's also an assistant professor in the Department of Rheumatology and the Director of the Western Rheumatology Multidisciplinary Specialty Center for Osteoarthritis. Appleton, thanks for joining us today.
[00:00:51] Dr. Appleton: My pleasure to be here, Ian. Thanks for having me.
[00:00:53] Ian: So simple questions. I'm good at that. Rheumatoid arthritis. What is it?
[00:00:58] Dr. Appleton: Well, rheumatoid arthritis is probably our kingpin type of arthritis that most people think of when they think of autoimmune or inflammatory arthritis. So what do I mean by that? We usually think of swollen joints. And of course with that comes pain and inflammation is really the main driver in this disease.
So we try to think of it as a fire in the joints, but also other parts of the body. And that fire continues to burn away unless it gets treated. And that's where the good news comes in with rheumatoid arthritis.
[00:01:33] Ian: And uh, next question would be, I guess who gets it? We often associate it with older people, but is that actually the case?
[00:01:41] Dr. Appleton: Well, I'm really blessed to get to work with quite a few different colleagues in rheumatology, and some of them are actually in pediatrics. Now, we don't call it rheumatoid arthritis when arthritis onsets in children. There are other names for it, like j i a or juvenile idiopathic arthritis. But it can look very much like rheumatoid arthritis in some cases.
But really, adults are the ones who get rheumatoid arthritis. adults meaning over the age of. 18, and it can affect any age group. In fact, we tend to see it mostly in patients who are between the ages of 20 and 40, a little bit less common midlife, and then it actually increases again later in life where you can have an increased number of people who are over the age of 60 or 65 with rheumatoid arthritis, but literally any age can get it.
[00:02:32] Ian: And am I correct, saying that it's more common in women?
[00:02:36] Dr. Appleton: Absolutely. So women are certainly at a higher risk of many autoimmune diseases, and rheumatoid arthritis is probably one of our best understood autoimmune diseases. Women are disproportionately affected for sure, as unfortunately women are for other types of arthritis as well, including osteoarthritis.
There's other risk groups that are. Also experiencing increased rates of rheumatoid arthritis. And that would include people who are of indigenous background, people who are of a lower socioeconomic status. And that's because of a lot of different determinants of people's health in terms of access to care and quality of food supply and all of these sorts of things, which we know are really important for many different health ailments that we experience.
So there are some groups who are definitely more effective than others.
[00:03:23] Ian: what is the difference or what are the um, properties of seronegative and seropositive rheumatoid arthritis. Can you talk briefly about
[00:03:31] Dr. Appleton: Yeah, so we still consider both of these entities to be rheumatoid arthritis and really what, what we're referring to there is if you're seropositive. It simply means that you have an increased level of that rheumatoid factor, that antibody in the blood, and so we call that seropositive rheumatoid arthritis, and if you don't have it, Then it's seronegative now, does that actually change your long-term outcomes?
Well, it can in some ways, but overall these are still managed as rheumatoid arthritis and largely they present, especially in the beginning, with those swollen joints that we talked about before, the chronic inflammation, and they tend to respond to the same medications about the same. So we really manage both seropositive and seronegative rheumatoid arthritis with the same medications.
But there is some difference, and some of the differences really come in that longer term risk. We know if you have these antibodies, the auto antibodies if you will, so a sign of your immune system. You know, recognizing your own tissues and attacking those antibodies can increase the risk of some of the other complications of rheumatoid arthritis.
And that means some damage to joints, sometimes scarring, and lungs or other tissues that rheumatoid can also affect. So we pay especially close attention when those antibodies are present, but we largely treat and we treat to put the fire out of that inflammation and that decreases the risk for everybody
[00:05:03] Ian: Can we talk about the symptoms or the consequences? I mean, obviously it's, it's an inflammation pain, stiffness, swelling. Can you talk uh, a little bit about the symptoms and the effect of the condition?
[00:05:14] Dr. Appleton: Yeah, absolutely. I think a little bit of context helps too. So rheumatoid arthritis, we understand affects about one to 2% of the healthy adult population. So that means that. One out of 50 per se, of us walking around in society are at risk of developing rheumatoid arthritis. Now, that may not sound like very much, but that means that in say, London alone, we have thousands of patients who have rheumatoid arthritis, many of whom are receiving care lifelong through the rheumatology center at St.
Joseph's and through our community clinics throughout London and the region. So, that's obviously a large number and that also is because people live with it for a very, very long time. Yes, stiffness and pain is a major symptom and it's a major debilitating component of rheumatoid arthritis.
But the most important sign that we see is swelling in the joints. And in particular it's the small joints of the hands. So the knuckles, if you will, on the part where your fingers meet your hand. Those knuckles will swell as will wrists, and certainly other joints can be affected as well. But the hand swelling in particular is by far the most common feature that we see.
And because it's an autoimmune disease, That means that the immune system has learned how to attack your joints and attack your body. And the important thing about our immune system is that it doesn't forget, and that's a good thing when it comes to fighting off infections, fighting off cancers and those sorts of things.
But it's not a good thing when you're talking about an autoimmune disease because it doesn't go away. And that's why we usually say that if you've had swelling in your joints for at least six weeks, Then this is a chronic type of arthritis and it needs treatment.
[00:07:07] Ian: Wow. and also people afflicted with this, they might feel generally unwell. Do they? I'm just looking at some of the notes here. Low grade fever, weight loss, poor appetite, those are also symptoms.
[00:07:19] Dr. Appleton: absolutely. So the symptoms that people usually experience in the beginning are sort of a slower, gradual onset of aches and stiffness. Fatigue is a, is a prominent feature. Fatigue can be caused by many things of course. And so just because there's fatigue doesn't mean that there's rheumatoid arthritis or any autoimmune disease, but we do see lots of fatigue.
Joint pain and stiffness in the morning is pretty prominent. One of the things that people often mention to us in the clinic is that they'll wake up feeling very, very stiff, and then as they get moving through the day, it could take half an hour, an hour, sometimes many hours, but eventually start to feel a bit better as they get moving around.
And that's pretty classic for this type of inflammatory arthritis.
[00:08:05] Ian: said it is sort of a gradual onset. I mean, I think I've heard these stories where people say, oh, they suddenly one day, you know, wake up and can't really get out of bed. But you're saying it's a more gradual
[00:08:16] Dr. Appleton: Well, I'm not saying that either one is always the case. I mean, people uh, certainly have many different experiences with it. On average, it's more of a slower, gradual onset in the beginning, and oftentimes people remember back, Hey, you know what? I've actually felt kind of like this for. Maybe even a year or sometimes longer.
And that's not the best because we really want people to be referred to as fast as possible so we can intervene as quickly as possible and we can talk about that. But yeah, absolutely. There are patients who come in and have had a very sudden onset of inflammatory arthritis as though they woke up one day with it.
That I would say that would be a little bit less common. However, there are other types of arthritis that can definitely present that way, and so we're often asking further questions about that to try to differentiate whether it's rheumatoid arthritis or maybe gout or other types of inflammation that can sometimes start out looking like rheumatoid arthritis, but maybe are something else.
[00:09:10] Ian: So I assume the average person would start experiencing these symptoms, perhaps go to a family doctor, and then I assume, get referred to the rheumatology center at, at St. Joe's. Once there, how do the experts there go about diagnosing the condition?
[00:09:25] Dr. Appleton: that care pathway that you just mentioned is, probably one of the most important things to get sorted out and, and is something that we often would, would like to see expedited for people. But to answer your question, yeah, once people land in the center, then probably the most important thing that we do, Other than hearing the story and understanding what the experience has been like for people who are suffering with this chronic disease, is the physical examination.
Rheumatology is a wonderful specialty for many reasons, and that includes the incredible breadth of treatments that we have available to really help make a difference for people. But the other thing that is really enjoyable about it is being able to examine someone. And understand what's happening at an immunologic level and at their level, and really know what the diagnosis is Much of the time based on hearing the story and doing the examination, a lot of other specialty areas really have to rely on advanced testing, imaging, these sorts of things, and we definitely use those tests, but most of what we're looking for is joint swelling on the examination, and that tells us an awful lot about what's going on.
one of the things that I think would be great for everyone to hear is that in order to be worried about rheumatoid arthritis, we really want people to have a physical exam. And many, many times, especially nowadays in the post pandemic era where many people are being assessed virtually the physical exam is not possible to do.
And so patients often ask us, Hey, can we do our visits? Virtually, and sometimes that's possible, but other times really need to do the physical exam and especially for those referrals when they're coming in, if we want to know whether it's urgent for you to be seen or not. Cuz oftentimes it's a really, really long wait for rheumatology.
If we know that your family doctor has assessed you and examined and found swollen joints, You're definitely gonna be seen much faster. And if we haven't had that, it's hard for us to know what to do. So that's an issue that we come across every single day
[00:11:25] Ian: would you also do obviously, I guess some medical history, is it something that runs in families perhaps?
[00:11:32] Dr. Appleton: there is a genetic link to it. You're absolutely right, Ian. people will often have another family member that they know. It's usually a first degree family member. And what I mean by that is a brother or sister, a child, or often a parent who had rheumatoid arthritis. Or they might have had another autoimmune disease because the risk or the genetic risk, if you will, that risk that's passed down between family members is often for multiple autoimmune disease.
Say, for example, if you've had someone in your family with type one diabetes, you are certainly at a higher risk of developing type one diabetes, but also rheumatoid arthritis. And so there's some kind of linkage between these autoimmune conditions that kind of spreads across. So we often ask questions about that as well.
[00:12:17] Ian: So again I would be examined. Medical history discussed physical examination. Are there also some kind of blood tests that are performed?
[00:12:25] Dr. Appleton: Yeah, and this is maybe a good opportunity for me to help dispel a few myths as well as talk about some pearls about blood tests. Blood tests are definitely important for us to understand what's happening for somebody who's suffering with chronic inflammation, and part of that is looking at.
The markers of inflammation in the blood. That can tell us a bit about how much inflammation there is. But the other thing that we're also looking at with blood tests is looking at how many other organs might be affected. So our kidneys are affected, you know, as liver affected, And we're thinking about that in particular because we often use medications to control this type of inflammation.
So it's important to look at those. Probably the most common question I get though about blood tests is about an antibody test called a rheumatoid factor, and rheumatoid factor probably isn't named very well. Because rheumatoid factor can be increased in many different conditions, including infections, some types of medication reactions.
And so just because somebody has a rheumatoid factor antibody on a blood test doesn't mean that they have rheumatoid arthritis. In fact, a lot of times they don't. We will see it increased in people who have rheumatoid arthritis, but not everyone. And so even if you don't have a positive rheumatoid factor on your blood test, it doesn't mean you don't have rheumatoid arthritis.
So you can sort of see how we are interested in the blood test and it can be helpful in the right setting, but it isn't the most important thing that we're looking at.
[00:13:53] Ian: What about misdiagnosis? I mean, does that happen and when it does, what are some of the other conditions or diseases that are confused perhaps with rheumatoid arthritis?
[00:14:02] Dr. Appleton: Yeah, so the concept of misdiagnosis is a tricky one because, you know, sometimes these conditions evolve over time, and what we see in the beginning might actually change and new information comes to light. six months a year down the road. This actually happened throughout history in rheumatology.
And this is how we actually came to understand what psoriatic arthritis is because some patients who were initially diagnosed as having rheumatoid or even rheumatism is what it was called in those days would develop skin psoriasis. And initially it was thought that these were the same condition, but now we understand very clearly that these are different autoimmune diseases, different types of autoimmune arthritis, and they need to be treated differently in some cases.
So, you know, the notion of whether you've really arrived at a final diagnosis. Can change over time and that's okay. And that's part of the reason that we continue to follow and reassess because sometimes new information comes up. Probably the most common thing that I think people struggle with though is maybe they've had somebody test a rheumatoid factor, that blood test that I mentioned, which is just an antibody in the in the blood that happens to have been named rheumatoid factor but does not diagnose rheumatoid arthritis.
But the sort of misconception still exists. That if you have this antibody, that you must have rheumatoid arthritis. And that simply isn't true. And so there are a number of people who will meet along the way and will say, well, you know what? It doesn't matter that you had this rheumatoid factor antibody.
You don't have swollen joints, you don't have the systemic inflammation that companies rheumatoid arthritis, and therefore we think that that rheumatoid factor was due to something else or maybe isn't at all related to your health right now. So, so that can definitely happen as well
[00:15:48] Ian: So I guess the next step, then the next question might be talked about medications. What's the treatment?
[00:15:54] Dr. Appleton: Inflammation in the blood, inflammation in the tissues is really what we're trying to treat. And that can only really be achieved with medications. So there isn't really a surgery for rheumatoid arthritis.
In the sort of bad days, as we say, a lot of people would get damage in joints from rheumatoid arthritis, and that damage would sometimes result in having to have some surgeries to correct that damage. But in terms of the actual inflammation itself, that has to be treated with medication and we call those medications, antirheumatic medications.
And really, I mean, this is such a wonderful area to be in because we have so many well-studied, Well-developed, safe and effective antirheumatic medications available to be able to use. And so if somebody is starting out on one and maybe it isn't tolerated or isn't working for them, we often have many others to be able to turn to as an alternative.
And so that's really reassuring for our patients to hear that there's hope and it isn't just, you know, one chance that it's gonna work. No, there's many other options available.
[00:17:06] Ian: so, if my understanding is correct, you can't cure the condition, but you can only treat it and get the patient to cope better with it. Is that correct?
[00:17:16] Dr. Appleton: Yeah, that's a, that's a really important point. So I think the concept of cure really kind of comes in when you're thinking about, say, an infection, an acute infection. So if you have, say a urinary tract infection and that can be treated with an antibiotic. The bacteria is cleared and it's gone, and so you've kind of cured that acute infection.
Autoimmune diseases are much different than that. What we can do very effectively is we can put the fire of the inflammation out, and that's our goal. So we're trying to achieve remission, and that means the fire is out, the inflammation is gone. There's no pain. There's much improved stiffness and the swelling in particular is gone.
We know that that will unfortunately come back if we stop treating it. So if we stop the medications, in many cases, The inflammation comes back because remember, as I said, your immune system remembers how to carry out this chronic inflammatory process. So we often are using medications kind of indefinitely or lifelong, but the good news is that the earlier we treat, the more aggressively and faster we get into remission.
The less medication we end up needing in the long run.
[00:18:27] Ian: And are there any negative consequences from the antirheumatic medications?
[00:18:33] Dr. Appleton: Yeah, that's a really common question that we get and I think it's really understandable why people want to know that. And so absolutely, as with any medication that we use for any purpose, There are always potential for side effects. There's also important side effects or consequences of course, if you don't treat the illness, and those are often far greater than any of the potential side effects that we could come across.
But this is why it's so important to be working closely with your rheumatologist and why we, in rheumatology, Follow people really throughout their entire lifespan with rheumatoid arthritis and other types of autoimmune conditions. Because we need to monitor and because we need to make sure that people are safely taking medications and if there are complications that come up, or adjustments that need to be made, then we're there and able to make those along with you.
And help to make sure that things are effective and safe and you're only using the medication that you need. So yes, we do try to monitor and prevent for any potential side effects. Most of them are pretty mild. We look at things like, you know, low blood counts. You know, sometimes people have stomach upset, taking different medications, which can happen really with, with any type of medication.
[00:19:42] Ian: Well that's encouraging, right? So you, I, I love that phrase. Put the fire out so, in many cases though, do most of the symptoms then vanish? If indeed the rheumatoid arthritis is in remission?
[00:19:54] Dr. Appleton: Yeah. So I would love to be able to say that all symptoms completely go away for everyone all of the time. But of course, life is not like that. But I think the really, the big take home message or the main story here is that because of tremendous work that's been done in research, including research that's been done in our center and other centers like ours around the world, there has been a tremendous advancement in the.
Efficacy meaning how well a medication works and the safety of many medications that we have available. So what does that mean for me? If I have rheumatoid arthritis, it means that the chances of me achieving remission are very, very high. And if not remission, then at least a low activity state where that means I have a low amount of inflammation so low that it's not going to progress.
I'm not going to get joint damage. My chances of having disability from this are very low. And probably really importantly in the long run for a lot of people to hear is a lower risk of things like. heart disease or other complications that we know come from chronic inflammation. So for the vast majority of people, we can get that fire put out and we can keep it that way for the long term.
[00:21:04] Ian: And in addition to the medications, are there certain lifestyle changes that you recommend for, patients?
[00:21:10] Dr. Appleton: this is one that comes up very often and I think, you know, we often want to try to control chronic conditions like this as much as possible with things that we know are good for us in other ways. So dietary interventions that, decrease the risk of heart disease or decrease the risk of say chronic kidney disease.
So preventing diabetes or you know, controlling weight gain and that sort of thing, those are also beneficial for chronic inflammation. So we strongly encourage people to try to make changes in their diet if they are able to, to decrease that chronic inflammation, decrease blood sugars, control, blood pressure, you know, decrease cholesterol, all of those sorts of things.
That often means decreasing simple sugars in our diet. Right. So things that would maybe come in, say in Colas or other soft drinks or adding sugar to coffee and any of those sorts of simple carbohydrates that people, we all love to eat, right? Myself included. But we, we really didn't want to try to minimize that.
And then increase things that are coming through a plant-based diet. So more complex carbohydrates, dark leafy greens, those sorts of things. You know, controlling these other risk factors through exercise is really effective for a lot of people if you're able to do it. And often, as I said, for most people, when we're able to get the, fire out, so to speak, that inflammation low.
Pain is down, stiffness is down. It makes it easier to get involved in. Even light daily activity can make a big difference for people. So we strongly encourage those lifestyle interventions and really try to promote them as much as possible once we're able to get the inflammation under control.
[00:22:48] Ian: Well that sounds very encouraging. What about the future? Are there any new treatments or discoveries uh, developments that you see on the horizon?
[00:22:57] Dr. Appleton: Yeah, I mean, I think there's sort of the future of. What are the new therapies coming along that, that are at least as good, if not a little bit better than things that we have available today? And so that's, you know, adding to our list of tools that we can use that work for people.
Let's say if another medication stops working. And that's the reality for a lot of people that, you know, rheumatoid arthritis evolves over our lifetime and sometimes medications that worked five or 10 years ago. Don't work any longer and we have to switch to other things. So we continue to see additions to the different medications that we use.
And that's a really good thing and a really important thing for us to have in rheumatology so that we can continue to adapt and adjust as rheumatoid arthritis continues to evolve in the patients that we're, we're helping to treat. The other things that we're really looking to on the sort of further away horizon are kind of fall into two categories.
Number one is how can we better use the medications that we're using? So can we find a more effective way of combining them? And some of those combinations are actually coming in the, the development of new treatments, if you will, that are targeting the same kinds of areas of the inflammation in our body, but actually putting them together.
So essentially like a combination therapy, if you will, but to two biologic medicines together, for example, that work even more effectively. In the areas that they need to. And so those kind of designer therapies are actually very close and are coming through the pipeline right now. And we're looking forward to seeing the results of the studies that are done, mostly clinical trials to help us know what to do and how to use them.
And then the other is really more along the lines of what you were talking about earlier, Ian, which is cure. And I think that cure is still very much a, you know, a far away kind of aspiration, but we are close enough now that we can actually realistically think that it might be possible. And that was a really big thing for us to try to get over in the past because it just seemed like there's no way to get rid of this.
Autoimmunity, this memory of how to attack your body once your immune system has already learned. But now we're starting to see some research emerging in this area of what we call regaining immune tolerance. Well, that means can we essentially erase the memory of your immune system?
For that particular rheumatoid arthritis immunity, and kind of start all over again. Reset the clock, if you will. And there's some really exciting new evidence that's coming out, including at the European Rheumatology Conference that I was just attending only a couple of weeks ago, showing that in other diseases like lupus or even scleroderma, That this might in fact be possible.
So there's some very exciting things that I think we'll be learning more about in the coming months and years ahead about even possibly a cure.
[00:25:55] Ian: Well, that's a, an encouraging, optimistic note I think to end on. And I think it's been very informative today and I think those who've been listening, we can help them, as you said put the fire out when it comes to rheumatoid arthritis. Dr. Appleton, this has been fascinating.
Thank you so much for joining us today on DocTalks.
[00:26:12] Dr. Appleton: Well, it's been my pleasure, Ian. Thank you so much for having me, and thanks for all the work that you're doing to help get information out to the community.