News from Medicine

IMPORTANT NOTE: In its early stages RA may be present as fatigue and early morning joint stiffness. RA attacks joints first in the hands and wrists and then moves into the elbows, shoulders, cervical spine, hips, knees and ankles. Unlike other forms of arthritis, the joint involvement in RA affects the same joints on both sides of the body at the same time (symmetrical and bilateral). In more severe forms of RA, other organ systems may be involved including skin, peripheral nerves, GI tract, blood, and lungs.

IMPORTANT NOTE: There are three groups of lab studies that are important to know: blood testing, synovial joint fluid testing and x-ray studies. No single lab test will conclusively diagnose RA.

Blood Studies

The two most common blood studies are the erythrocyte sedimentation rate (ESR) and the rheumatoid factor (Rh factor).

Erythrocyte sedimentation is also called a "sed rate" and is a nonspecific test. When abnormal (elevated), it indicates that inflammation is present somewhere in the body. Many diseases cause an elevated ESR including infections.

Rheumatoid factor is also called Rh factor. This blood test measures an autoantibody titer level that is associated with RA. However, only 85% of patients with RA will have a positive Rh factor. Up to 25% of older normal people will have an elevated abnormal Rh factor and DO NOT have RA. In people who have confirmed RA with a positive Rh factor, a rising Rh factor usually indicates the disease is getting worse.

Synovial Fluid Studies

The fluid removed from a painful joint is called synovial fluid. Testing of synovial fluid identifies a number of factors (i.e. inflammatory cells) that are helpful in attempting to diagnose RA.

Radiographic Studies

Persistent joint inflammation results in permanent joint destruction. Many times x-rays of the affected hands or feet will show cartilage loss (joint space narrowing) and or bone erosion. Radiographic evidence of RA seldom occurs in the first year or two of R.A.

There are four (4) classes of medications used in treating RA:

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
Cortisone and other related steroids
Disease modifying anti-rheumatic drugs (DMARDs)
Biological Response Modifiers

IMPORTANT NOTE: In the last few years, drug treatment strategies for RA have changed. Until then, most RA patients were managed with nonsteroidal anti-inflammatory medications (NSAIDs) and cortisone and steroid related drugs. As the disease intensified, other drugs, with potentially serious side effects, were used including some common anticancer drugs like methotrexate or cyclsporine. The problem with the old strategy is that the first two types of drugs reduced inflammation but did not stop the progressive destruction of the disease. Now physicians employ an early intervention strategy with disease modifying anti-rheumatic drugs (DMARDs and Biological Response Modifiers) alone or in combination with NSAID drugs.

Nonsteroidal anti-inflammatory Drugs (NSAIDs)

These drugs help control inflammation and pain by inhibiting the body’s production of prostaglandin. While giving the patient some relief of symptoms, these medications do not prevent joint destruction or future disability.

For a complete list of NSAIDs, including Cox-2 and Salicylates, see this link: http://www.arthritis.org/Answers/DrugGuide/nsaids.asp

Corticosteroids

Corticosteroids or steroid drugs are useful to control inflammation. It is unclear if these drugs stop the progression of the disease. Steroids are best used in bursts (i.e. a few weeks at a time) for severe arthritis flare-ups to prevent long-term side effects.

For a complete list of Corticosteroids see this link: http://www.arthritis.org/Answers/DrugGuide/glucocorticoids.asp

Disease Modifying Anti-Rheumatic Drugs (DMARDs)

DMARDs are a major tool in the treatment of RA. There are used early in the course of the disease to prevent irreversible damage. DMARDs usually have a delayed onset taking one to six months of provide a benefit.

For a complete list of DMARDs see this link: http://www.arthritis.org/Answers/DrugGuide/dmards.asp

Biological Response Modifiers

Biological Response Modifiers are the newest medications employed to treat RA. They block the molecule in the inflammatory process called TNF (tumor necrosis factor). These medications are used with patients who do not respond to DMARDs (i.e. methotrexate). Biological Response Modifiers are "added" to the DMARD being used (multi-drug therapy).

For a complete list of Biological Response Modifiers see this link: http://www.arthritis.org/Answers/DrugGuide/brms.asp

IMPORTANT NOTE: Many of the DMARDs and Biological Response Modifiers have significant toxic side effects requiring careful monitoring. The drugs with the most serious side effects are usually reserved for the most serious forms of RA.

Clients with RA present a difficult underwriting challenge in obtaining LTC coverage. Not surprisingly, a high level of these clients are declined. However, RA of itself is not an automatic decline. The clients with the best chance of obtaining policies will have the following profile:

1. Clients who are in "remission" (i.e. no documented evidence of current joint inflammation).

2. Clients with no functional limitations (i.e. normal IADLs and ADLs). Unfortunately, the majority of RA clients will eventually experience some form of disability.

3. Clients currently being treated with a single medication as opposed to a multi-drug program. It is important to remember that drug intervention with RA is done sooner and with stronger medications to delay to progression of the disease. Medications in the past that may have led to an immediate declination (i.e. Prednisone or methotrexate) are now seen by underwriters in a different and more positive light.