Scleroderma

Arguably one of the more exciting presentations delivered at the recently concluded Caribbean Autoimmune Diseases Summit, local Rheumatologist Dr. Haramnauth Dyaanand of the Gulf View Medical Centre, delved excitedly into the local context for autoimmune diseases. Starting off largely where Dr. Rose left off in his presentation on the common thread in autoimmune diseases, Dr. Dyaanand concurred that they are generally defined by a genetic susceptibility, combined with environmental triggers and the actually process onset itself - with most rheumatic patients presenting with arthritis or inflammation of the joints.

Stating that there are numerous types of arthritis (over 100 according to webmd.com), Dr. Dyaanand pointed out that patients should inquire of their medical professionals as to what type of arthritis they have, as the ensuing dialogue would help inform and determine its causes, and the recommended courses of testing and treatment.

Of the autoimmune diseases he has worked with, Rheumatoid Arthritis (RA), Systemic lupus Erythematosus (SLE), and Scleroderma were more common. Osteoarthritis and Gout are the more common non-autoimmune forms of arthritis found locally as well.

RA typically starts with joint pain, joint swelling, and significant early morning stiffness (lasting for at least half an hour). In the long term, joint damage can occur. Without treatment, deformity or disability would ensue, making work and daily activities difficult and often impossible. These activities include walking, showering, and the opening and closing of doors. Other organs can become involved with RA, such as the lungs, eyes, and blood vessels (vasculitis).

With Lupus, joint pain and swelling and stiffness can present similar to that of RA. Skin rashes develop in on the arms, chest, and the face (as the hallmark butterfly rash), though not as common. If no treatment is undertaken, then there can also be long term deformity and disability. Lupus is more likely to involve other organs, including the kidneys, bone marrow, the blood vessels, brain and nerves, and the heart.

Disappointingly though, Dr. Dyaanand’s presentation did not delve into his work with Scleroderma patients. It was gleaned that RA and Lupus patients were far more in numbers, than his Scleroderma patients. Despite this, Dr. Dyaanand went on to discuss the importance of the proper investigation of patients and their conditions, citing that diagnosis cannot be given just on sight or by interviewing the patient.

Tests are often required. These include blood, x-rays, urine tests, CT’s and MRI’s, EEG’s, NCS (nerve conduction studies), and biopsies (kidney, skin, and bone marrow). Patients should understand that whilst the testing may take time and frustrating awaiting results, they are essential to their personal care and treatment.

For the treatment of RA and SLE, there are a number of local treatments available;

• Symptomatic - painkillers, steroids, and physiotherapy
  
• Disease specific - steroids, hydroxychloroquine (available locally), methotrexate (drug of choice, gold standard), sulphasalazine, cyclophosphamide (oral and IV), and azathrioprine
  

Despite being relatively new, yet readily available in Trinidad and Tobago, newer treatments for RA include;

• Etarnacept
• Infliximab
  
• Adalumimab
• Rituximab
  
• Tozaluzimab
  

Dr. Dyaanand noted that other drugs were available, but these were recommended and worthwhile, with minimal differences in cost. All of the drugs have associated risks and side effects however, which should be evaluated prior to use. They can also be used in combination with other drugs, such as anti-inflammatory. In closing, he showed that the regular testing of the blood when on treatment is essential, as it helps monitor treatment progress and assess for the effectiveness of the drugs being administered.