The people affected with Rheumatoid arthritis quite often neglect the symptoms as it starts with simple indications and takes few years to develop. In fact Rheumatoid arthritis is an autoimmune and inflammatory disease, which means that your immune system attacks healthy cells in your body by mistake, causing inflammation (painful swelling) which in turn affected parts of the body. The number of patients in India are increasing, but there are less number of specialists to address this disease. Renowned Rheumatologist & Immunologist and the President of Indian Rheumatology Association Dr Chandrashekara.S, MD, DNB, DM of ChanRe Rheumatology & Immunology Center & Research, shares his insight about the Rheumatoid arthritis in detail with Jaishankar Jayaramiah of The OnLook.
Dr Chandrashekara.S the president of Indian Rheumatology Association and has been awarded with ‘Sir. C. V. Raman Young Scientist State Award in the field of Medical Sciences’ by the Govt. of Karnataka for the year 2013. He has 150 publications in international and national journals, more than 40 papers in Conferences / seminars, 20 reference books in Rheumatology & 9 patients education books among many more in addition to being the Editor of Internet Journal of Clinical Immunology & Rheumatology.
Can you please throw broader view on Rheumatoid arthritis across India?
is Rheumatoid arthritis is one of the commonest auto immune problem that the people face, it is not just in India but across the globe,. It almost affects around 0.6% to 1.2%. Why this range means it is reported in different proposition in different part of the world. This is one disease that we generally say it will not spare East or West or South or North and rich or poor across the globe.
What happens if one is affected with Rheumatoid arthritis?
If disease is not handled properly – in 2/3rd of the patients gradually develop damages in the joints, all the more the joints of hand, knee, foot and hip. And these damages result in handicap. After the joints are damaged, they start affecting internal structures like lungs, blood vessels called vasculitis and it can affect even the heart.
How the patients will come to know that they are suffering with Rheumatoid arthritis and what are the beginning symptoms?
Normally from the patient perspective, it starts with the pain in the joints, most commonly in hand joints or joints of the foot. it is accompanies with some swelling, stiffness especially in the morning. Generally in a normal person especially during the cold seasons, the stiffness in the joints one can see 5-10 minutes. But if the stiffness goes beyond 30 minutes, one should seriously consider of having possibility of Rheumatoid arthritis. Generally, it starts with one joint and gradually it affects joint by joint. Somehow in Rheumatoid arthritis, the joints in the back are spared. So it usually gets affected late in the course of the disease. So when you get these kind symptoms with stiffness, swellings in the joint for more than 2-3 weeks, it is best to see a Rheumatologist.
By any chance will it start with fever?
When patient comes with the above complaints, we usually ask whether they had fever before the onset of this arthritis. The reason is viral fever, urine infection and even stomach infection can create some sort of arthritis called reactive arthritis, which is usually temporary transient and disappear in majority. That’s why we approach the patient in all possible angles including taking the history of fever into account. Infact sometime in Rheumatoid arthritis, the fever could be only the initial presentation. The patients may run with fever for couple of weeks and then joints pain may start. In this case, the blood test will help us to identify the exact cause like whether it is Rheumatoid arthritis or reactive arthritis. If it is unattended for 3-5 years, the patients may get skin rashes, dry mouth, dry skin followed by lungs involvement.
How do you diagnose and what are the methods adopted to identify the disease?
Critical test for us is ESR and CRP. They suggest if arthritis joint pain is because of inflammation. In addition, we do some tests like Rheumatoid factor, anti CCP and anti-nuclear antibodies (ANA).
Whether these tests can be included in Master health checkup?
We recommend not to do any of the Rheumatoid arthritis related tests like Rheumatoid factor anti CCP and ANA under master checkup. Because it will more confuses us than helping. It misguides rather than helping you. Getting misguided and taking some treatment is more harmful. One should not do these tests unless they suspect Rheumatoid arthritis problem with above symptoms and without directions of Rheumatology specialist.
Is this disease treatable and how about the medicines?
Yes. Definitely treatable. I am in the field of Rheumatology treatment for the past 30 years. There is tremendous change in these years. When I started practicing this field three decades ago, there were only three medicines to treat Rheumatoid arthritis. We use to treat only with medicines like Methotrexate, Sulfasalazine and Hydroxychloroquine. In between we were using some pain relievers. But in the past two decades the medical field witnessed development of around 30-40 different group of drugs that can be used in treating Rheumatoid arthritis. The effectiveness of the treatment of these drugs are also far superior than the three drugs that we had earlier. Still we continue to use those three drugs also but we have better drugs better choices especially to the patients who don’t response to these preliminary drugs. So with these available medicines, the treatment for Rheumatoid arthritis has significantly changed.
Whether this disease is covered under Insurance schemes?
None this disease is covered under the insurance or third party payments. And we as Indian Rheumatologists Association is trying to convince the state and central medical departments to include this under insurance coverage as well as under government health schemes but till today it has not happened. Still policy makers have not paid much attention on this as they have not addressed this as a serious disease.
So it will be good to approach the right specialists at right time know?
Yes. I can recollect in 90s and early 2000s, we used to see the patients with lot of deformities and some developing complications. Now with advent of these many drugs, we rarely see such patients. And most of the patients with deformities whom we are currently seeing are mostly misguided or have not reached the specialty centers in right time often not believing in the right way of treatment, taking some alternative medicines and losing time. Because the most critical here is that before the deformity develops or before the complication develops, if they approach the specialists, we can prevent them from all these complications happening. So early treatment yields better results. With early treatment we can even withdraw the medicines in 40-50% of the patients as the problem can be completely shut down. So it shows that it can be treatable if the patients approach the right specialists at early stage.
In India how intense is this disease and how about the awareness?
It is a universal disease, present not only in India but across the globe. But I can say that there is 0.1% difference in incidents between rural and urban population. With urban having little small increase of 0.1%, which is not a big difference. But when we compare to European population, somehow the Rheumatoid arthritis in India comes very early in the age group as we see it affects the people from 30 years onwards. If we see western population, the majority of people under this bracket are 45 years and above. We are also still wondering why this difference, but still medical field is not able to take a call on this.
What is the current size of Rheumatologists in India and whether it is enough to cater the needs of patients?
Earlier may be 5 years back there were only 100-150 qualified Rheumatologists across India. In the past five years, the situation is little bit improved with lot of medical institutions focusing on this disease. Now around 300-350 trained Rheumatologists are there in India. But this is not enough. As per data available, at least 6,000 patients with Rheumatoid problem present in every one lakh people population in India. Atleast one Rheumatologist should be available for every 6,000 patients but now estimated that one Rheumatologist is available for more than 50,000-1,00,000 population. Actually every districts in India should have atleast 2-3 trained Rheumatologists. But it is very low figure here. Even with the available 300-350 Rheumatologists, many of them are in metropolitan cities. For example, Bangalore city itself has 35 Rheumatologists. We need atleast 3,000 Rheumatologists across the country. Anyway now Rheumatology is highly sought out super specialty in hospitals.
Can you please narrate about the academic eligibility to become specialist in Rheumatology?
One can become become specialist in Rheumatology after completing his MD medicine or paediatrics’. Currently trianing post MD is imparted in two ways- one by three years course of DM and DNB and another with two-year fellowship programme. In India around 8-10 institutions are offering the facility that imparts DM and DMB which is a three years. In addition, we have around 15-20 fellowship training centres.. We in Chanre Rheumatology & Immunology Center & Research also conduct fellowship training programme.
Is there any specific research centre in India for Rheumatoid arthritis?
We don’t have any designated centres where Rheumatoid arthritis research alone is happening. There are centers like Sanjay Gandhi Postgraduate Institute of Medical Sciences in Lucknow and centers like All India Institute of Medical Science, where the research on Auto Immune disease is being undertaken but there is no specific centers only focused on Rheumatoid arthritis. They are doing research on all Auto Immune Diseases including for Rheumatoid. But Chanre Rheumatology & Immunology Centre & Research is doing research lot in Rheumatoid area.
Can you throw more light on Chanre Rheumatology & Immunology Centre related to Rheumatology treatment and its fellowship programs?
In Chanre, we are specially focusing on Rheumatoid arthritis in personalizing the treatment. And this the only private institution doing research in Rheumatoid arthritis. As an institution we have crossed 21 years offering treatments and research in Rheumatoid area. We are also offering two-year fellowship training after completing their MD. Already 20 fellows have passed out of Chanre. They are working in different parts of the country and majority of them are in Karnataka. Even the doctors from faraway places like Nepal and Jammu & Kashmir are trained here. Always we take two fellowships every year in Chanre as residential program.