How Do I know if My Rheumatoid or Inflammatory Arthritis is Getting Better/Worse?
by Hope Starkman, MD
For a Rheumatologist, the question of whether a patient’s arthritis is getting better or worse are questions asked daily. These questions seem like they would be easy to answer, but this is not always the case.
“Dr.-How did I know if my arthritis is getting better? – I am on all this medication and I still have bad days with pain, at times.
There are many measures that providers and patients can use to determine if their arthritis is getting better. Not all work for all patients or physicians. Probably, the most common objective measure of clinical improvement is the tender/swollen joint count. Even patients can be taught to do this. Tenderness and Swelling of joints can be counted and registered in a log which can be monitored over time and even plotted on a bar or line graph. This technique is very helpful to determine the effects or impact of medication. Additionally, a measure of morning stiffness in minutes to hours can be helpful. Post rest stiffness, particularly in the morning upon rising is the hallmark of inflammatory arthritis. The length of morning stiffness can also be logged and plotted on a graph. This is probably most effective when logged by the patient daily or weekly. Subjective complaint of fatigue is also important but again hard to measure.
Lab monitoring s also important. Blood testing such as the erythrocyte sedimentation rate (ESR or SED rate), C reactive protein (CRP) can be followed over time as well. Additionally, often patients with active inflammatory arthritis related anemia. This is called, the anemia of chronic disease or chronic inflammation and is not related to low iron levels. Taking iron supplements will not help this anemia and may make inflammatory arthritis worse. Anemia frequently improves with improvement of inflammatory arthritis.
X-ray changes over time are another more longer term way to follow the response of Rheumatoid or inflammatory arthritis over time. This is a slower process because X-ray changes take a longer time to appear. Improvements in arthritis are not easy to see on radiography but progression and worsening arthritis is more easy to see. X-rays may show loss of normal space between bones, erosions which are like bites taken out of bone, bone loss, swelling of the surrounding tissues. The MRI is more sensitive for these changes and may help identify changes earlier, however serial MRI testing is not a practical, cost effective approach for following improvements of progression of inflammatory arthritis over time.
Visual analog scores are determined by measurement a patient or provider makes on a straight line with ten intervals (i.e. ten cm, or ten points). This score can be followed over time.
In clinical practice rheumatologists and researchers use other measures such as ACR (American College of Rheumatology Scores) ACR 70, ACR 50, ACR 20, DAS (disease activity scores) RAPID scores (Rapid 3 and rapid 5), for Rheumatoid arthritis, SLEDAI and SELENA scores for Lupus and BASDAI scores for Ankylosing Spondylitis. These are very complicated. They add up points given to specific disease criteria and some multiple by other factors to come up with score results. These are not practical for patient use.
It is very important and is becoming even more important for patients and providers to have measures of disease activity and improvement. Many of the medications used to treat inflammatory conditions are both risky and expensive. It does not make sense to continue therapy with a risky and expensive treatment that is medically futile (not likely to be effective). Therefore, patients, providers and insurance companies need a way to objectively measure disease activity, progression and remission to determine if the best and most cost-effective therapy is being rendered. More and More often, insurers are requiring providers to document and chart measures of disease activity. It is, thus, important for patients to ask their providers how they can help in this process. It is critical that patients remain involved in their care in this way and that they continue to ask questions about the evaluation of their clinical improvement.