What is Systemic Lupus Erythematosus (SLE/Lupus)?

Systemic lupus erythematosus (SLE/Lupus) is an autoimmune disease. Normally, immune system helps to protect our body from many bad things like infections and cancer. In autoimmune diseases like lupus, one’s own immune system starts attacking its own body. It can occur at any age(mostly 15 to 45 years but can occur in children too). It is seenmore in women than in men.

Please note that we will use the word SLE / Lupus in this article. Both will mean same disease.

What causes SLE / lupus?

The exact cause of SLE is not known. The risk of lupus is associated with what genes are present in one’s body. It has also been found to be associated with environmental factors like sunlight exposure, certain medications, viruses, stress etc. However, in most patients, we don’t find any single gene or environment factor. Mostlikely,it is a combination of many things which causes someone to have SLE.

Who suffers from Lupus?

Lupus is about nine times as common in women as in men.

Lupus is more common in younger women. Lupus also affects children but only rarely. We don't know exactly why this happens.

What are the symptoms of Lupus?

SLE can affect any system or organ of the body. Lupus patients can develop many different types of symptoms.

The most common lupus symptoms are,

• Fatigue or tiredness
• Skin rashes, which get worse on exposure to sunlight. Many patients have a butterfly type of rash on face.
• Joint pain, stiffness more in mornings and joint swelling
• Frequent ulcers (or sores) in mouth or nose
• Hair fall / loss
• Get cold hands and feet, which change color to white or blue, especially when exposed to cold

Lupus patients can also have following symptoms or problems,

• Weight loss
• Frequent fevers without any infections detected
• Headaches and brain problems (like fits or seizures, mood swings, difficulty to think clearly, sudden psychotic or unusual behavior, stroke or paralysis)
• Swelling and puffiness of hands, feet or eyes
• Eye problems – redness, vision problems
• GMuscle weakness
• Recurrent miscarriages, blood clots etc.
• Vomiting, loose stools
• Passing less urine

It is not possible to list all symptoms of lupus here( this may be deleted). Also, having above symptomsdoesn’t itself mean one has lupus. Many of these symptoms like hair fall, fatigue, oral ulcers, swelling etc. are pretty common in people without having lupus. Lupus experts make sure that a patient is not having these symptoms due to other common causes. Most lupus patients will have a combination of many symptoms and experts will do further tests to confirm diagnosis.

Are there any long-term risks in Lupus?

Lupus is a variable and unpredictable condition and can be life threatening for a minority of patients whose vital organs like kidneys, brain, heart, blood etc. are affected. However, with modern treatments and careful monitoring of the condition the disease can be brought under in most patients.

Anything more that I should know?

Keep out of the sun: Use a sun-blocking cream, SPF 25 a greater.

Contraception: You should use contraception pills that contain only progesterone or low-dose estrogen, or consider phyiscal/barrier mehods of contraception. Your treating doctor might help.

Infections: If you have Lupus, and especially if you are on immunosuppressive drugs, then you will more prone to infection. Take sensible precautions and avoid contact with family and friends who are known to have infectious diseases like tuberculosis, chickenpox etc.

Vaccinations: Check with your doctor if you might need vaccinations.

Stress: Stress will make your illness seem worse even if it dosen't affect the course of the disease. Learn how to manage any in your life

Fatigue: Tirendness can be a significant problem. Specific causes of fatigue such as anemia or an underactive thyroid gland can be identified by a blood test and treated.

How is SLE diagnosed ?

When one thinks that a patient has lupus, it is best to get the patient evaluated by experts (Rheumatologist doctors/ other experts). They go into details of symptoms, examine, and after various investigations (blood tests, X ray, urine tests etc.), can make or reject a diagnosis of SLE.

SLE investigations can be very difficult to interpret and no single test can confirm it. Many tests ordered for SLE can come positive in normal people and some tests can be negative even if person has SLE. Hence, only an expert should make a diagnosis of SLE. Once it is confirmed that a patient has SLE, experts might have to do more investigations to find which organs are involved.

How is Lupus managed?

Lupus cannot be cured but it can be controlled. A number of different drugs may be needed depending on which symptoms you experience.

What types of medications are used in treatment of SLE?

Different types of drugs can be used to treat lupus. These are advised according to how severe the disease is and what organs are involved in the patient.The main aim of treatment is to bring lupus disease under control and prevent organ damage.

The drugs used in lupus are to control the overactive immunity which is attacking patient’s own body. They also help to decrease the inflammation in various organs.

• Non-steroidal anti-inflammatory drugs (NSAIDS) : These are drugs like ibuprofen, naproxen etc, especially given if patient has joint pains.
• Medicines like hydroxychloroquine and chloroquine :They were originally discovered to treat malaria, but can help a lot in lupus patients.
• Steroids and other medications (like methotrexate, azathioprine, mycophenolate, cyclophosphamide, rituximab etc.): These help to control or suppress the overactive immune system. Steroids are usually used only at start when disease is moderate to severe.They are very helpful to control disease to give relief and prevent organ damage. Later we use other medications and decrease steroids to maintain the control.

Experts in treating SLE use the drugs given below in best possible way to avoid or minimize the side effects.

I have SLE. Will it affect my chances of getting pregnant and having a good pregnancy outcome?

There are higher chances of problems in pregnancy in SLE females as compared to normal female pregnancies. However, if things are done properly, most lupus patients have healthy babies. Lupus is not a hereditary disease and is not passed to babies as such.

It is important to let your treating doctor know if you want to plan a pregnancy in near future. The expert can guide you and take proper measures to avoid problems in pregnancy. For example, they will advise avoiding pregnancy if your disease is active. However, once your disease is well controlled for at least 6 months, pregnancy can be safely planned under doctor’s advice.

Can one live normally with SLE? Can it be permanently cured ?

SLE can be severe disease. But, most people with SLE can live good lives, provided they showexperts and follow their advice. Continuous research in SLE has made experts learn and improve a lot with regards to SLE treatment over last 20-30 years. They are far better in treating SLE now.

There is still no permanent cure for SLE. Lupus patients will have lupus rest of their lives. It might be mild, moderate or severe. However, as mentioned, we have very good treatment available and the experts provide maximum help to let SLE patients have a good life. SLE patients are likely to live for a long time. In some patients the disease can also become silent without problems for long periods.

Should I try Homeopathy, Ayurveda or even natural therapies for my SLE / lupus ?

Lupus can be a severe disease. Allopathy treatment of SLE has improved a lot with continuous research in last 20 – 30 years and continues to improve with more research. There is no good and thorough evidence that other options (Homeopathy, Ayurveda, natural therapies or Naturopathy) helpto control SLE disease. Many patients trying these therapies develop organ damage which is irreversible. This is because if lupus is not well controlled, it can lead to organ damage. Allopathy can also have side effects, but it is the only form of therapy which has been shown to work without doubt in SLE patients. Allopathy has also been proven to prevent organ damage in SLE patients.

There are many herbs or supplements which can activate the immune systemand cause kidney and liver failure. This can be harmful for lupus patients as their main problem is overactive immunity. If you are planning to take any extra supplements along with your allopathy treatment, please discuss this with your doctor before trying anything new.

What can I do from my end to keep my lupus undercontrolor feel better?

• Have a healthy lifestyle : It can help lupus patients a lot. Eat healthy diet - lots of vegetables, fruits, nuts, dairy products, avoid sugar and refined foods etc. Stay active. Even mild home based exercises, walking and using stairs whenever possible etc are good ways to stay active – It helps Lupus patients to keep muscles and bones strong. Avoid smoking or other addictions.Try to avoid / manage mental and physical stress. One can consider doing relaxation exercises – like meditation or mindfulness etc.
• Avoid excess sun exposure :Sunlight can cause a lupus rash to flare and may even trigger a serious flare of the disease itself. Use a good sunscreen with sun protection factor (SPF) of at least 30 or take doctor’s advice.
• Show an expert in lupus (like a rheumatologist) : Follow their directions
• Get educated about SLE :It is very important for patients to have good information and be educated about their disease, so that they can take better treatment decisions. They shouldask their doctor to provide with patient information material.
• Plan pregnancy : Do let your rheumatologist / doctor know if you want to plan pregnancy. It should be avoided if you have active disease. The doctor can guide with appropriate contraception methods or ways to avoid pregnancy till disease gets controlled.

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What is fibromyalgia?

Fibromyalgia (FM) is a disease or sympton complex characterised by widespread pain and profound fatigue.

What causes FM?

The exact cause of FM is not known. It is likely to be multifactorial. Genetic predisposition with disease running families is well recognised. Environmental insults including viral infections, stress (both emotional and physical) and depression in some cases can contribute to the onset of illness. FM can coexist with rheumatic disease like rheumatic arthritis, systemic lupus erythematosus and Sjogren's syndrome.

Who suffers from Lupus?

Lupus is about nine times as common in women as in men.

Lupus is more common in younger women. Lupus also affects children but only rarely. We don't know exactly why this happens.

How common is FM?

It is very common. Upto 3% of the population suffers from it. It is most common around the 4th decade. FM is more common in women but it can occur in men and children too.

How is FM diagnosed?

There is no single diagnostic test for fibromyalgia unlike blood sugar test for the diagnosis of diabetes. The diagnosis is base on the combinations of symptoms, physical examination. Widespread aches and pains affecting both sides of the body are the hallmarks of FM. Neck pain and back pain are the common symptoms. Extreme fatigue, early morning stiffness, non-refreshing and non-restorative sleep, subjective feeling of swelling of limbs and joints, numbness of peripheries are also common. Migraine like headaches, abdominal symptoms like bloating, heart burn, tendency to visit toilet frequently, particularly after food ( irritable bowel syndrome ) and urgency to pass urine frequently (irritable bladder) are other associated symptoms. FM patients also have multiple tender points over the body, which the doctor can identify on examination. So it is the combination of symptoms and the presence of tender points that lead to the diagnosis of FM.

As mentioned earlier, there are no laboratory tests in the diagnosis of FM. Many patients are suspected to have other diseases and are investigated extensively before FM is diagnosed. Your doctor would have ruled our diseases like cancer and arthritis.

What does current research say?

FM is shown now to be a syndrome of low pain threshold and altered pain perception. The volume setting for pain perception is found to be higher in FM patients compared with the normal population. Because of this FM patients would feel more pain compared with non-FM persons for the same amount of stimulus. This process is called central sensitisation, high lighting that the origin of pain is form nervous system rather than in the places where pain in felt. Electrophysiology study of sleep has shown disturbance in sleep apnoea syndrome. Alteration in pain related neurotransmitters, Serotonin and substance P have been demonstraded in cerebrospinal fluid. Abnormalities in sympathetic in cerebrospinal fluid. Abnormalities in sympathetic nervous system, hypothalamo-pituitary adrenal axis, growth hormone secretion have been demonstrated in FM. This might indicate defective mechanisms to fight stress. Some association with depressive illness and other psychiatric illness diseases like chronic fatigue syndrome, non cardiac chest pain, non ulcer dyspepsia, chronic pelvic pain, depression, anxiety and fibromyalgia indicating shared aetiology.

How is FM treated?

Usually FM symptoms are mild and patients mange to lead a normal life in spite of the pain. In some cases, pain can be severe and is comparable with the pain of patients with Rheumatoid Arthritis.

There is no cure. But the symptoms can always be helped. Painkillers like paracetamol and NSAIDs like lbuprofen may be of some help. Unlike the pain of arthritis, the pain of FM does't respond to the above drugs well. It is a different type of pain requiring a different type of medicines. Antidepressant drugs used in doses much lower than what is needed to treat depression are useful is correcting sleep disturbance and in improving pain threshold. Amitriptyline is one such drug. Dothiepin, nortriptyline, Duloxentine, milnacipran are some of the anti depressant drugs found to be useful in managing the symptoms of FM. Anti convulsant drugs ( Anti fits drugs ) like pregablin and gabapentin also help the pain of fibromyalgia.

Cognitive behavioural therapy (CBT) will help patients to take control of his of her illness. This is usually done by trained pain psychologists. Chronic pain leads to in changing the way one think about the illness and encougaes patients to lead a more productive life. Stretching five times a day ) are an important aspect of the therapy.

Walking swimming and cycling are some of the exercise strategies to improve one's stamina and physical conditioning. Pain and fatigue make one de conditioned. Graded increase in the intensity and the duration is essential to overcome post exercise increase in pain. Relaxation techniques like yoga, Tai Chi and low impact dancing and aerobics may help many.

Fibromyalgia is generally treated by a team of pain specialists including rheumatologists, pain consultants, physiotherapists and pain psychologists. More importantly, the patient is an active member of the treatment team.

How to cope up with Fibromyalgia?

• knowing that FM, though a chronic painful disease is not a life threatening or a crippling should reassure you.
• Learn to relax, pace your activities according to pain levels and energy levels.
• Pain does not always mean tissue damage. So don't stop your activities totally.
• Ignore some discomfort, count on functional improvement.
• Be prepared for some bad days and some good days.
• A brief period of rest in between work ( micro-rest) and an afternoon nap can be enterprising.
• Hot water shower and heat in any form will refresh you. A shower in the evening may help you to fresh at dinner time.
• Regular sleep habits will help. Avoid caffeine and cola drinks after 6 PM. Avoid watching movies from the bed. Condition your mind that bed for sleeping. Having the fan on can act as the white noise filter extraneous noises at night.
• Be open with parents, and friends so that they will understand your illness and be more supportive.
• By understanding the nature of the illness, you may be able to avoid unnecessary investigations and harmful therapy.
• Be regular with your exercise and taking the prescribed medicine.
• Discuss with your physician, your doubts and the concerns regarding the disease and the medications.

What is Scleroderma ?

Scleroderma literally means " hard skin," which is a common finding to this group of diseases. It accurs due to the abnormal growth of connective tissue. There are broadly two categories of scleroderma: localized scleroderma ( affects skin and rarely muscles ) and systemic sclerosis ( affects skin and internal organs like heart, lung, intestines etc).

Localized scleroderma generally remains limited and does not progress to the systemic form. Localized scleroderma further can two types; morphea and linear.

Systemic sclerosis affects the skin, muscles, blood vessels and internal organs. It is often divided into diffuse and limited disease. Diffuse systemic sclerosis is a rare disease that can be severe and sometimes life-threatening.

What causes it ?

he exact cause of scleroderma is not known. However, it has been known that body makes too much of collagen ( substance that heals and gives us scars ) that gets deposited in the skin and other body organs, causing the skin to tighten and harden and the organs to dysfunction. Another component is abnormal function of cells in the lining of blood vessels, which leads to Raynaud's phenomenon (pallor, blue fingers or toes) and telangiectasias (red spots). These abnormalities are triggered by abnormal functioning of our own immune cells, some environmental agents of hormones that stimulates cells to produce excess collagen.

Symptoms

Localized Scleroderma

The symptoms of localized scleroderma are isolated ot the skin and underlying tissues. Two types are recognized: morphea and linear scleroderma.

Morphea : These are local patches of hardened skin. Red patches of skin develop white centers with purplish borders. Lesions remain active for weeks to several years. Spontaneous softening that leaves a darkened area of skin often occurs. It may be localized or generalized.

Morphea : These are local patches of hardened skin. Red patches of skin develop white centers with purplish borders. Lesions remain active for weeks to several years. Spontaneous softening that leaves a darkened area of skin often occurs. It may be localized or generalized.

Linear: A single line or band of thickened and discolored skin develops. The line usually runs down and arm or leg, but sometimes it runs down the forehead.

Systemic Sclerosis

This disease affects not only the skin and underlying tissues, but also affects the blood vessels and major organs of the body. Two types of systemic disease are recognized: limited and diffuse.

Limited: In this form, sin thickening is generally limited to the fingers, forearms, legs, face and neck. Raynaud's phenomenon ( blue fingers ) may be present for years before any other symptoms develop. People with this form are less likely than people with diffuse disease to develop severe organ involvement.

Diffuse: In this form, skin thickening may occur anywhere on the body, including the trunk. Only a short interval of time will elapse between the onset of Raynaud's phenomenon and significant organ involvement. Damage typically occurs over the first three to five years, after which most patients enter a stable phase that varies in length. During this phase, your skin will stay about the same and the rate of damage to interval organs slows or stops. After the stable phase is over, your skin will start to soften and more serious damage to internal organs is unlikely to occur.

Depending on the form and severity of the disease, you may experience these different symptoms:

Raynaud's Phenomenon: Cold temperatures or emotional distress cause constriction of blood vessels in hands feet leading to cold extremities and whitish or bluish discoloration of fingers and toes.Once the vessels open back up ( after approximately 10 to 15 minutes), the hands turn red. More than 90% of people with scleroderma have this problem, it is often the first symptom of the disease. Skin ulcers on the fingertips can result from severe Raynaud's phenomenon.

Skin changes: In the early stage skin may appear edematous and it may progressively harden with loss of flexibility. As the disease progresses, the skin will become more thickened, sweat and oil glands will stop functioning, and the skin surface will become very dry and itchy. This stage will persist for one to three years, at which time the skin will begin to soften and thin.

Sclerodactyly: Thickening of the skin of the fingers or toes.

Calcinosis: Calcium deposits can form under the skin or in the muscles. These deposits may cause recurrent ulcers on the overlying skin.

Telangiectasias: Red spots due to dilated capillaries near the surface of the skin can be seen.

What is juvenile idiopathic arthritis ( JIA )

JIA is the most common cause of chronic (lasts more than 6 week) arthritis in children. It is of different types depending on the clinical signs and symptoms. In JIA child has joint pain associated with swelling and along with this may have fever, skin rash, lymph node enlargement, backache, red eye, or pain in sole/heel.

Why did my chlid get it?

The exact reason why it occurs is not know. Genetic and environmental factors are thought to play a role but it is not a hereditary disease as only 5% of children have a family history.

What are its common symptoms?

It usually with joint pain associated with swelling, which may involve one to several joints. The child may have malaise, fever fatigue and stiffness in the morning. Some children have high grade fever, skin rash and gland enlargement along with joint pain.

How is it diagnosed?

There is no diagnostic test for JIA. The diagnosis is made by presence of symptoms and signs. Some simple tests are done to excule other diseases and to know the severity of disease.

How to confirm the diagnosis?

A diagnosis could take months as the disease unfolds and as the doctor is able to rule out other possible causes of your symptoms. Diagnosis is made clinically by the doctor familiar with the disease. There is no direct blood test that can confirm the diagnosis. Special tests may be ordered to evaluate your lung status ( such as a chest X-ray, pulmonary function tests) and gastrointestinal tract function.

How is it treated?

To provide immediate pain relief most children are treated with NSAIDs like Naproxen, Ibuprofen etc. In a child with a few joint affected injection of cortisone into the joint is an affective way of controlling disease. Since it is chronic disease a significant proportion of children require disease modifying drugs like Methotrexate. Other drugs used are Salazopyrin, Leflunomide and biologics. Along with medication the child needs balanced diet, splints to prevent contractures, physiotherapy and psychological support.

What dietary precautions should the child take?

No relationship between any special food and JIA has been shown. Potato, pulses etc do not increase joint pains. Balanced diet is must for maintenance of muscle mass, bone strength and adequate hemoglobin in blood. A child who is getting cortisone should avoid food rich in fat and salt.

How long would my child need to take medication?

In oligoarticular variety of JIA the child may need only short term treatment but in majority, long term treatment is required. Drugs are gradually reduced after the disease is controlled and can be stopped once the disease is in remission for 1 year. In some types of JIA treatment is given for long term.

Can the disease be cured?

About one third of children may outgrow the disease and may not have symptoms in adulthood. In the rest the disease follows a relapsing remitting course. In a small fraction the disease may be present throughout.

Can my child go to school?

All effort should be made to help the child attend school and indeed most children with JIA can attend school. Some children may need assistance during disease flares. A discussion with the class teacher often helps.

Will my child be able to do job?

If the disease is managed early and well, most children can study and do a profession. However some children have physical limitation and thus cannot do jobs that involve manual labor. It is good to have a session with your physician when you are making decision regarding career.

What is the long term outcome of this disease?

JIA is a disease with good outcome however 50% of children would have some joint pains during adulthood. Most children can attain good education level and are employable. Good outcome depends on early and effective treatment to control disease activity.

What are its complications?

In systemic variety ( So JIA ) child have fluid around the heart ( pericarditis ) around lungs (pleuritis), myocarditis, marked weight loss rarely a serious condition called macrophage activation syndrome. In other varieties limb length discrepancy, hip joint damage and joint deformities may occur. Uveitis ( inflammation in eye ) can present with redness of eyes, blurring of vision or gradual visual loss. Thus regular eye checkup is needed.

Complications can also be related to therapy like weight gain, short stature, acne related to cortisone. Methotrexate, sulphasalazing and leflunomide may rarely cause lowering of blood counts or liver enzyme abnormalities.

Does it have any effect on puberty?

In most children if the disease is well controlled there is no impact on pubertal growth. In children with SoJiA or polyarticular JIA puberty may be delayed due to persistent disease activity.

What is Sjogren’s syndrome?

Sjogren’s syndrome is a disease that affects the glands that make moisture. It causes dryness of mouth and/or eyes. It may also cause joint pains, fatigue and internal organ disease.

Who are likely to develop Sjogren’s syndrome ?

Women are 9 timesmore likely to develop Sjogren’s syndrome than men. Average age of diagnosis is 40 though it can affect all ages and sexes.

What causes Sjogrenssyndrome?

Exact cause is not known. Sjogren’s syndrome is an autoimmune disease in which body’s immune system mistakenly attacks its own organs. In this disease the immune system predominantly attacks organs which are responsible for production of saliva (salivary glands in mouth) and tears (lacrimal glands in eyes).An immune attack on these glands leads to decreased production of saliva and tears leading to dryness of mouth and eyes respectively.

What are the symptoms of Sjogren’s syndrome?

Though dryness of various body organs is the most common symptom in Sjogrens syndrome, as it is a multisystem disease it can present with varied symptoms

• Dry eyes
• Foreign body sensation or grittiness in eyes
• Dry mouth
• Difficulty in swallowing ,talking and chewing
• Dry skin
• Increased tooth caries/decay
• Joint pains
• Excessive Tiredness
• Dry nose
• Dry cough
• Muscle pain / weakness
• Red rashes in the skin
• Thyroid problems
• Numbness and tingling in hands and feet
• Heartburn
• Vaginal dryness
• Painful intercourse

How is Sjogrens syndrome diagnosed ?

This disease is often misdiagnosed or under diagnosed. Rheumatologist is the doctor trained in diagnosing and treating Sjogrens syndrome. After a detailed history, appropriate clinical examination your Rheumatologists will order for some investigations which include blood tests, urine tests and special tests in the eye and mouth. You may be examined by an ophthalmologist (eye doctor), simple tests may be performed on the eye to test the tear flow. Lower Lip biopsy to look for involvement of salivary glands is usually part of diagnostic tests. It is relatively painless minor procedure usually done by dentist. Special immunological tests like Rheumatoid Factor, ANA (Antinuclear Antibody) and ANA profile may also be usually ordered.

Is there a cure for Sjogren’s syndrome ?

Currently there is no cure for Sjogrens syndrome. But early diagnosis and treatment can prevent complications

How is Sjogrens syndrome treated ?

Treatment varies from patient to patient depending on the organ affected.

Dry eyes and mouth :

In addition to artificial tears and saliva, medications like pilocarpine and cevimeline may be prescribed to increase the secretions.

Pain killers and steroids :

Pain killers and steroids may be prescribed as and when needed to treat joint pains. Steroids are also used to treat severe internal organ diseases

Immunosupressives :

Some patients are prescribed immunosupressives like methotrexate, hydroxychloroquine, azathioprine, mycophenolate depending on the internal organ involved.

Life style modifications for dry mouth

• Eat soft, moist foods
• Eat smaller and more frequent meals to stimulate salivary flow
• Avoid salty, acidic, spicy, crunchy tough foods and carbonated drinks which interfere with digestion
• Maintain good oral hygiene by proper brushing, flossing .
• Use alcohol and sugar free mouthwashes
• Regular dental check ups
• Drink plenty of liquids as advised by doctor
• Chew sugar free gum or lozenges or suck sugar free candies to increase saliva flow
• Apply moisturizing gels/vitamin E to dry or sore parts of mouth or tongue for relief

Life style modifications for dry eyes

• Wear sunglasses, shields to prevent moisture evaporation
• Protect eyes from strong air currents that may irritate and aggravate dryness
• Clean the eye lids with clean warm water and mild soap
• Use non preserved artificial tears as advised by doctor
• Avoid regular application of chemicals, commercial products and make up to your eyes
• Ointments and gels can blur the vision, if prescribed must be used in the nights
• Use humidifier at nights to prevent dryness of eyes

Life style modifications for dry skin

• Use warm water instead of hot water for bathing.
• After taking bath, apply Vaseline/moisturizing cream or oil immediately to seal the moisture
• Use sunscreen lotion with minimum SPF 30 on sun exposed areas while going outdoors

Life style modifications for dry nose

• Use Saline sprays, humidifiers to keep the nose moist and crust free
• Avoid air conditioned environment especially in dry mode

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What is osteoporosis ?

Osteoporosis is globally the most common metabolic bone disease.Osteo means bone and porous means pore. Osteoporosis means loss of bone density.

What are the types of Osteoporosis? Which type do I have?

Our bones are made up of outer dense cortical bone and inner less dense trabecular bone.Type 1 (early) osteoporosis is characterised by excessive loss of trabecular bone.Type 2 (senile) osteoporosis is characterised by loss of both trabecular and cortical bone which is usually an age related disease.Ask your doctor for the type of osteoporosis.

What are the symptoms of osteoporosis?

Decrease in bone density is usually painless and is diagnosed mostly after patient has sustained a fracture. This is important as In view of lack of symptoms, you may presume you have no osteoporosis even when diagnosed by your physician.

What are the possible complications with osteoporosis?

As long as our bone density is normal,our bones are resilient to low trauma fractures.If bone density decreases there is high risk of fractures even with a minor fall. Ask your doctor what are the chances of fracture?

What are the common sites of osteoporotic fractures?

Common sites include are hip,spine,wrist and ankle.

Why is osteoporosis prevention important ?

• 50% of fractures in the world occur in Asia
• Beyond 50 years one in three females and one in five males sustain fractures due to osteoporosis.
• After sustaining an osteoporotic hip fracture 20-25% die within an year.
• A global survey brought out an interesting fact that number of days spent in hospital is more for osteoporosis and its complications in comparison to the much feared cancers and cardiac ailments.

Who are at risk for osteoporosis ?

The following populations are at risk for developing osteoporosis and need to be aware about the screening and treatment options available.

• Elderly
• Post menopausal women
• Low Body Mass index (BMI)
• Addictions - smokers and chronic alcoholics
• Patients suffering from Rheumatological diseases like Rheumatoid arthritis, Ankylosing spondylitis, Psoriatic arthritis, Lupus and many more
• Use of steroids
• Chronic endocrine diseases like thyroid disorders, diabetes and hyperparathyroidism.
• Malabsorption like celian or Inflammatory Bowel Disease

What are the Screening methods for detection of osteoporosis ?

Dual energy Xrayabosrptiometry DEXA scan is currently the method adopted for measuring bone mineral density.There are two types of DEXA scan - peripheral DEXA which are inaccurate handheld devices used for mass screening purposes and Central DEXA which is an accurate measure of bone mineral density.DEXA scan results are interpreted by your doctor in conjunction with the clinical scenario.

Tips for prevention of osteoporosis

Diet

Its high time we love our bones.Our bones love calcium.Hence the habit of intake of high calcium in diet must start from childhood.Foods rich in calcium are easily available like eggs,milk,curd,cheese,almonds,fish,coconuts,soya,oranges and greens.

Vitamin D

Vitamin D is considered now to be more of a hormone than just a vitamin.It plays a major role in maintaining good bone health.Even a diet rich in calcium becomes useless if our body does not have adequate vitamin D.One and only source of vitamin D that is available in plenty all around us is the sunlight.On exposure to sunlight human skin synthesies vitamin D which is vital for bone health.So daily exposure to sunrays for atleast 20-30 minutes must become a routine habit for all who want their bones to be strong.

Habits

• Avoid smoking
• Restrict coffee or tea to a maximum of two small cups a day ,as excess intake decreases the calcium absorption
• Alcohol >14 units(women) >21 units(men) per week accelerates loss of bone density.
• simple exercises 30 minutes a day for atleast 5 days a week will improve bone strength.

Do’s and Dont’s to prevent falls in elderly

It is of utmost importance to avoid falls in elderly to prevent fractures of hip bone which is the most dangerous fracture beyond 65 years of age in view of the associated mortality and morbidity.

DO'S

• Ensure proper vision
• Good lighting in the room
• Night lamps
• Use crane/crutches/walker/hand railings/modified foot wear according to individuals needs for effective mobilisation
• Use railings for cot to prevent accidental fall from bed

DONTS

• Avoid walking on slippery and polished surfaces
• Avoid walking fast
• Avoid high heels
• Never let mobility restricted people unsupervised or unattended for long periods

Treatment

"Rheumatologist" and endocrinologist are the specialists who usually treat once osteoporosis develops.Therapeutic options for osteoporosis treatment include drugs like oral and intravenous bisphosphonates,hormones like teriparatide and calcitonin,monoclonal antibodies like denosumab.Calcium and Vitamin D supplements according to the severity of the disease is a part of every osteoporosis prescription. These drugs need to strictly taken only under medical supervision.

Those at risk should follow doctors advice on prevention of osteoporosis.

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What is osteoarthritis ?

Broadly speaking, arthritis means any joint pain associated with signs of inflammation (swelling, redness, warmth etc). Osteoarthritis (OA) is one of the most commonest arthritis seen in general population. It is a painful condition can that can involve one or more of the joints in the body. It is commonly a disease which occurs with increasing age.

What actually happens in osteoarthritis ?

Often you would hear that there is no or decreased “lubricant” or oil in the joint! Major joints in the body are formed by two end of bones coming together. This end of bones are covered by a cushion, which is known as cartilage. These bone ends along with the cartilage in between forms the joint. This cushion of cartilage is very important in normal functioning of the joint. However in osteoarthritis,there is degeneration and wearing out of the out of this cushion or cartilage. In OA the cartilage thins out along with some other changes in the surrounding bone of the joint and this leads to various problems of osteoarthritis

What are the most common joints involved in osteoarthritis ?

Osteoarthritis can virtually affect any joint. OA most commonly occurs in knees, hips, spine hands,and feet.

What causes osteoarthritis in the joints ?

We are not exactly sure what causes osteoarthritis. However, it is strongly associated with increasing age. Hence age related degeneration of the joint plays a major role. But it is not as simple as that. Many people can develop osteoarthritis at an early age. Many people with osteoarthritis do not have much pain. Many people have osteoarthritis which is much more advanced at an unexpected age. Different patients have variable levels of pain even with same amount of osteoarthritis. Family history is important as well. We arestill trying to understand many of these factors.

What are the risk factors associated with osteoarthritis ?

As mentioned above, we don't totally understand what causes osteoarthritis. However we do know that certain factors play a role in increasing risk of having osteoarthritis.

Age : Advancing age is one of the most commonest risk factors for osteoarthritis. Ingeneral public above 60 years of age, at least 80% have some evidence of osteoarthritis, in at least one of their joints. This may be just seen on X rays and patient may or may not have pain. However as mentioned above, not everyone with the same degree of osteoarthritis will have the same amount of pain.

Gender : For some unknown reasons, females have more chances of osteoarthritis than males. Females also tend to have more pain compared with same degree of osteoarthritis in men.

Obesity and weight : Osteoarthritis occurs more frequently in people who are obese (weight is well above required for that age and height). There is also some evidence that people who reduceweight can decrease the risk of developing osteoarthritis in the future.

Sports and rigorous physical activity : There is evidence that playing excessive injury sports like football, wrestling or repeated kneeling and squatting jobs can increase the risk of osteoarthritis. Having any injury in the ligament in the knee or any other joint can also crease the risk of osteoarthritis in the future . There is good evidence to suggest that routine, non-competitive running or exercises done for personal fitness does not increase the risk of osteoarthritis.

Previous ligament or meniscus injury : Any person who has had a history of injury to their supporting structures in joints like ligaments, meniscus etc at a young age, have higher chances of osteoarthritis in future. This is commonly seen in knee joint ligament and meniscus injuries. Even if one undergoes surgery to repair same, they are still at higher risk for developing osteoarthritis of respective joint in the future.

Family history: Osteoarthritis, particularly, nodal OA, can have remarkable familial predisposition.

Do all patients with age get Osteoarthritis?

No, not all patient get OA and it depends on multiple other factors, some of them have been outlined as above. We don’t have exact figures from India, but OA is more common in women and increases after an age of 50 years and plateaus at 70 years. Western literature shows increasing prevalence over time due to longer life expectancy, obesity and sedentary life style. It is estimated that 10% and 18% men and women are affected respectively.

What are the symptoms associated with osteoarthritis?

Pain :Pain is the most common symptom associated with osteoarthritis. When osteoarthritis starts, the pain can be intermittent and variable. It might be aggravated by certain activities. Often it is more common in late afternoon and evening.The patient can have good days without pain and bad days with pain.

For example : The first symptom of osteoarthritis in the knee is usually having some discomfort or pain while patient is climbing or coming down the stairs.

Site of Pain: Pain more commonly occurs around the joint line except in hip and shoulder when pain can occur away from the joint.

Stiffness or gelling phenomenon : The osteoarthritis patients can have stiffness which is usually aggravated when the patient takes rest in a certain position for more than few minutes. The patients are stiff in the morning but the morning stiffness is usually less than 30 minutes and not very intense like rheumatoid arthritis.

For example : When the patient sits too long with knee osteoarthritis, after getting up, initial few steps are painful. But after walking few steps patient is fine.

Swelling :Some patients with osteoarthritis can have mild to moderate swelling in the joint. This swelling might be soft and compressible due to collection of some fluid in the joint. This can also be hard swelling due to formation of bone spurs (extra new bony protrusions) in the osteoarthritic joint.

Crepitus or crackling sound : In osteoarthritic joint one can have some crackling noise for crackling sound when the joint moves. This is known as crepitus.

For example : Patient with knee joint osteoarthritis can feel crackling or crepitus from their joints, especially when they keep palms over their joint while movements.

In most young – middle aged patients, clicking sounds heard from joints without much pain is normal and one should not start fearing osteoarthritis due to same

How is osteoarthritis diagnosed ?

There is no single test which can diagnose osteoarthritis on its own. Age, weight, family history and pattern of symptoms aid in diagnosis. Other types of inflammatory arthritis, though less common, needs to be ruled out.

Blood tests for osteoarthritis : There is no specific blood test to diagnose OA. Most blood tests done in patients with suspected OA are usually done to rule out other arthritis.

Imaging methods for OA: Sometimes X rays, ultrasound and MRIare helpful in confirming osteoarthritis, but they are not required in most patients. Also, X-ray can be normal in most patients with early OA. Clinical history is most important in early OA. Imaging methods are most useful to identify degree and severity of OA in a particular joint. And it is important to note that pain or clinical findings may not corelate with X-ray findings.

The diagnosis of osteoarthritis is usually made by expert like a Rheumatologist or Orthopedician doctor after collectively taking into account various factors.

How will osteoarthritis progress and affect my daily life ? Will I become permanently disabled ?

Most people will have mild to moderate osteoarthritis with progressive age. In most cases it will lead to mild to moderate pain and usually this pain is intermittent. Most of the osteoarthritis patients can function with good quality of life without doing much interventionsexcept for exercises, assistive devices or being physically active. Howevermany patients will have moderate or progressive osteoarthritis, which can lead to pain and deformities in the future.

In some patients osteoarthritis will disability due to progression. However, there are many non-surgical and surgical treatment options available, even if one has advanced osteoarthritis with disability.

What is treatment for Osteoarthritis ?

General principle of osteoarthritis treatment :

Osteoarthritis is a chronic disease and there is a component of age-related wear and tear (degeneration) of the cartilage in the joint. Because age is a factor, osteoarthritis usually progresses with advancing age. The progress is gradual in most cases and it takes years for patients with early osteoarthritis to develop advanced osteoarthritis and disabilities.

There is no treatment for osteoarthritis which can slow down or stopthe progression of osteoarthritis, except for possible weight control. Most treatment of osteoarthritis is to make the patient symptoms better and to give them a good quality of life.

Osteoarthritis treatment can include a range of options, which can include non-medication based treatment and medication based treatment and surgery. Please understand that every patient is different and every patient with osteoarthritis can have different issues and joints involved. Treatment depends on patient’s exact problems, daily activity demands and their desired expectations from treatment. (Figure 1)

Treatment of osteoarthritis without medication is recommended as a first line of treatment. This line of treatment can be helpful to all patients without any side effects and should be a part of treatment of all OA patients.

Controlling excessive weight or planning weight loss : We have already mentioned that obesity or excessive weight can increase the risk of osteoarthritis. If the patient has already developed osteoarthritis in a particular joint, weight lossmay help to slow down the progression. If Knee or hip joint OA patient loses weight by 10%, there is evidence to suggest that they can have 50% decrease in pain. If one is serious about weight loss, one should strongly consider showing a dietitian who can guide them accordingly with the weight loss program.

Physical exercises and physiotherapy : Exercises are very important part of management of osteoarthritis. They don't improve or stop the progression of the worn-out joint. However they keep to help the surrounding muscles strong and may decrease the pain. So a patient with osteoarthritis who continues to exercise, is more active compared to those who do not exercise. Consider starting exercise gradually and take advice from a trained physiotherapist. They can give specific exercises for affected joint.

Exercise may not give immediate relief and it may take some weeks for exercises to show its benefits. Also, exercises may increase the pain in initial few weeks before they show benefits. The general rule one should follow is any increase in pain after exercise should reach to pre-exercise levels within 24 hours. If that is not the case, one should be more gradual in building up to a desired exercise regimen or take help of a trained physiotherapist to modify the exercises.

Also any form of physical activity in these patients keeps their muscle strong and can be very helpful to help their comorbidities like diabetes, heart disease, hypertension, osteoporosis etc.

Splints and assistive devices : Some patients with osteoarthritis, especially osteoarthritis in the base of the hand can be helped by using hand splints.This splint does not prevent the progression of osteoarthritis in thumb base. However it is helpful inpreventing excess deformity of the thumb base joint. It also helps decreasing the pain at thumb base while movements.

Patients with foot and ankle osteoarthritis may have some specific benefits with some specific insoles. This is generally true if patients have specific issues like flat feet or deviated ankles.

Usually knee braces or stockings are not advisable as they make the muscles surrounding the joints weak (patients muscles are not used and loading is taken by the supportive device). The weak muscles surrounding the joint can further increase the pain and may lead to instability in patient’s movements. However, one might use the supportive devices for intermittent use to provide stability while walking, for short term use before surgery or in cases where surgery is not feasible. Always take advice of a clinical specialist (like a doctor, physiotherapist or occupational therapist).

In patients with advanced osteoarthritis, use of walkers, walking cane or sticks for support etc may be helpful and will prevent falls.

Getting educated and finding some support for patients with osteoarthritis

If one is educated about various aspects of osteoarthritis, they can manage many aspects of their osteoarthritis. This empowers them to deal with this chronic disease more effectively on a daily basis.

Osteoarthritis pain might have a functional component and many people with the same degree of osteoarthritis can have more pain if they don't have a good social support. It is best if such patients can be given some kind of mental or physical support to help with activities at home. Is also helpful if somebody positively encourages to them to do the exercises on a regular basis. It is also very helpful if such patients can join group sessions of people with osteoarthritis. Such groups help them to identify people with similar problems, they can encourage each other to do exercises, provide a listening ear, emotional support etc.

Osteoarthritis treatment with medications/ Pharmacological treatment of osteoarthritis

Most patients with osteoarthritis can be managed with non-pharmacological measures of weight loss, exercise, splints etc. These things should be a part of patient’s management even if any medications are given to them.

Some patients do require medications for management of osteoarthritis. Please understand that there is no medication conclusively proven to halt or slow down the progression of osteoarthritis. Whatever medications we have available right now, are to manage the symptoms of osteoarthritis, so that the patients have better quality of life with less pain and more mobility.

We again re-emphasize that it is very important for the patient to concentrate on exercise and weight loss in most cases, without which the pharmacological interventions maynot have much benefit.

Topical NSAID lotion / gels / therapies for osteoarthritis joints- Topical anti-inflammatory gels / lotions contain drugs called as nonsteroidal anti-inflammatory drugs (NSAIDs).Thesedrugs when applied to the skin over the joint can help in relieving the pain of osteoarthritis. This isespecially true in the hands, knee and other superficial joints. They cannot be usedin relieving pain of hip osteoarthritis as it is a deep joint. Usually topical gels contain very low quantity of NSAID drugs with very low absorption and hence they usually do not have any major side effects. However, in patients with blood pressure, kidney or heart issuesone should discuss safety issues with their doctors.

Nonsteroidal anti-inflammatory drugs (NSAIDs)- Nonsteroidal anti-inflammatory drugs (e.g.: ibuprofen, diclofenac, Naprosyn, indomethacin etc) are commonly known as pain killers by general Indian public. Theynot only help relieve pain but can also help to decrease inflammation (redness, swelling etc). They are very effective drugs in relieving the pain and inflammation associated with osteoarthritis. However, one should always discuss their use with doctor as their consumption in patients with acidity (heartburn), heart, kidney, blood pressure issues etc can be harmful.

Experts might use NSAIDS in short or intermittent courses to help the patients. They will be used in the lowest possible dosesfor the shortest possible duration to avoid side effects.They should not be taken without an expert advice. Some patients might be given low dose of these drugs for prolonged periods. In such cases patients should be educated about side effects and their kidney, liver and other parameters should be regularly checked.

NSAIDS gels (discussed in topical therapies above) have very low doses of these drugs and are absorbed in very little quantities when applied over joints. They are generally much safer to use than NSAID tablets.

Paracetamol - Paracetamol is generally very safe in elderly population of osteoarthritis. The maximum total daily dose of paracetamol is 3 to 4 gram per day. Paracetamol is not as effective as NSAID drugs (discussed above) as it does not have an anti-inflammatory and dramatic pain-relieving effect. However, it is much safer if given for prolonged periods also and can give decent relied to OA patients. In recommended doses it doesn’t tend to affect heart or kidneys.

Paracetamol is commonly used in dose of 500 milligram (mg) for fever 3-4 times per day. However, 500 mg is not usually effective for pain. One should use doses of 650mg-1gm two to three times a day for pain relief in OA. One should be careful with paracetamol doses and should not exceed a dose of 3gram – 4 gram of paracetamol in a day (see table below).

One should always talk to their doctor before trying to find their maximum possible dose of paracetamol which can be taken safely, and one should take it with regular checking up of liver parameters.

Non NSAID pain relieving drugs: Opioid drugs like tramadol (or tapentadol) tablets or capsules, buprenorphine patches etc are used quite frequently in Indian context. However, there is quite strong evidence that these drugs may cause dependence, can cause a variety of issues including constipation, giddiness, nausea etc. They are generally considered to be unsafe in elderly people and should only be use very sparingly. They are generally not recommended to relieve OA pain routinely.

Neuromodulators for relieving pain: Pain in osteoarthritis and any other disease can be multifactorial. There is some evidence that some patients with OA have over sensitisation of their nerves and this may lead to increase pain. Some experts recommend a trial of low dose neuromodulator drugs like duloxetine, pregabalin, gabapentin etc to give symptomatic relief in OA patients. They might be especially useful in patients with osteoarthritis of spine, especially if there is some compression of nerves. Technically these are not pain relievers, but they possibly work by modulating the pain carried in nerves. Again, these drugs should always be taken under expert guidance.

Joint injections - Glucocorticoid or steroid injections can be useful in certain patients with osteoarthritis. They are especially useful in those with some amount of inflammation in the form of swelling and warmth. They are generally considered to be safe.However, some evidence says that repeated steroid injections in the knee may lead to slightly faster progression of the osteoarthritis. Hence, usually doctors don't give more than three to four injections in a year for a given osteoarthritic joint.

Therapies of uncertain benefits in osteoarthritis

Gel injections in joints:Injection of a certain types of gel in the knee called hyaluronic acid gels are also available(example brand name Hylan,Synvisc,Durolane etc.). Their benefitsareuncertain, don’t last very long and they can be very expensive.

Platelet rich plasma injections in the knee: In this procedure, patients own blood is collected and platelets are separated and injected in the affected joint (mostly knee). It is uncertain if it has any significant benefits. Many patients claim relief but again its uncertain whether they would have got relief anyways from conventional therapies.

Stem cell injections in the OA joints:Off late many centres in India have been propagating use of patients own stem cells to be injected into the OA joint. These are expensive, there is no conclusive benefit, there is no clear-cut guideline or regulatory authority for such kind of procedures. One should at this moment refrain from using these kinds of injections. In most cases utilising the expenses meant these kinds of procedure on replacement surgery is far more beneficial. This is especially true in cases of advanced knee and hip OA.

Glucosamine and other similar supplements: Various tablets / supplements containing glucosamine and chondroitin sulphate are routinely prescribed to or used by patients with osteoarthritis. Many practitioners also prescribe diacerein for patients with osteoarthritis. However, there is no conclusive evidence that any of the above supplements work in relieving the pain of osteoarthritis. There are some good trials which have shown benefit and some good trials which have not shown benefit. There is generally no major harm in using them, but again one should consult their doctor.

Herbal remedies and natural substance supplements for OA: A lot of herbal / natural therapies are there in the market which are claimed to give miraculous relief in osteoarthritis patients. Some patients also claim a lot of relief with these therapies.The list includes many supplements.For example: Turmeric tablets, curcumin tablets, fenugreek tablets, chinese herbal therapies, herbal topical agents, boswellia extract, rose hip extract, Ayurveda therapy tablets or oils etc. These therapies are usually expensive and there is no proven conclusive benefit. However, since they are generally safe the doctors generally do not aggressively discourage the patients from taking these supplements.

One should always be careful of herbal therapies which have the potential to damage liver or kidneys. Many of them claim to have no side effects which can be untrue. Patients should always discuss / disclosetheir herbal therapies they with their respective expert doctors.

Multiple other examples: There are multiple other fancy therapies in unregulated Indian healthcare sector propagated widely to be very effective for osteoarthritis pain. For example: naturopathies, electric stimulation, magnetic therapy, ceragem massages, blood chelation, joint manoeuvring, prolotherapy, cupping etc. They are often expensive, have no proven benefit, might give some placebo effect and may do more harm at times. One should refrain from such therapies or talk to a well-qualified doctor before trying same.

Osteoarthritis surgery

Surgery is usually used as a last resort in osteoarthritis patientsspecially who have advanced osteoarthritis and are not benefited by conservative management. The patients with advanced osteoarthritis have severely worn out cartilage, deformities of the joint and the pain is much more severe.

The various type of surgeries available:

Replacement surgeries:The most common surgery done is knee and hip replacement surgery which can be a partial replacement of a complete replacement.

Replacement is usually done after 55 to 60 years of age as usually replaced joints last for an average of 15 years. Patient’s usually requires a repeat replacement after that. Generally speaking,repeat replacement surgeries are more difficult. As the average Indian age lifespan is around 70-75 years of age, doctors recommend surgery to osteoarthritis patient at around 60 years of age or later. This is so that they are less likely to require another surgery on the same joint in their lifetime.

Fusion surgery: Fusion surgery (medically known as arthrodesis) is recommended in very severe osteoarthritic joint where there is no possibility of a replacement and there is lot of pain.Fusion surgeries are usually done in ankle joint OA where. In fusion surgeries joint margins are fused so that this leads to restriction of joint movement and much lesser pain. However, the movements are obviously restricted after fusion surgery. Such surgeries are more for pain relief at the cost of flexibility of the joint. They can be very helpful in properly selected patients.

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