Q&A with IBJI Rheumatologist Angela Crowley, MD

What Is Arthritis?

Dr. Crowley: Arthritis is anything affecting the joints that's causing pain and inflammation. The two broad categories of arthritis would be degenerative and inflammatory. 

What Is Inflammatory Arthritis?

Dr. Crowley: These are primarily caused by an overactive immune system. Essentially the body is recognizing the joint tissues as something foreign that it needs to fight off. It sends inflammatory mediators to fight off the tissue and that causes a lot of damage to the joints. Rheumatoid arthritis is the most common inflammatory arthritis. Other kinds of autoimmune arthritis would include ankylosing spondylitis, psoriatic arthritis and lupus. We don’t really know what causes inflammatory arthritis.

What Is Degenerative Arthritis?

Dr. Crowley: I like to explain to patients that degenerative arthritis or osteoarthritis is when joints are wearing out and things can get painful. It affects about 30 million Americans a year. 

What Are the Differences in Symptoms Between the Two?

Dr. Crowley: There are a lot of ways to tell the difference. With inflammatory arthritis it can come on suddenly. It’s more of a systemic process with multiple joints involved as opposed to one joint. Patients might have other symptoms like fatigue, weight loss, and fevers.

With degenerative arthritis, there are common joints that get affected: the knees, the hips, at the base of the thumb for women, and the pain tends to come on more gradually as you get older. Pain increases with activity but is relieved by rest.

How Do You Arrive at a Proper Diagnosis?

Dr. Crowley: When I see people in the clinic I do specialized studies involving x-rays and bloodwork. I review their symptoms, look at their family history, other medical conditions, and then on a physical exam, I look for something called synovitis of the joints, which is swelling and inflammation that is more typical with inflammatory arthritis. With imaging we look to see if there are proper spaces between the joints. We might see that the joints are rubbing on each other with osteoarthritis. 

With inflammatory arthritis, I might see erosions, which look like someone has taken a bite out of the bone. This can also be seen with gout. Examples of blood tests would include uric acid levels, which is a test for gout, an ANA - antinuclear antibody test, which might show lupus, and rheumatoid factor could indicate rheumatoid arthritis. 

Are Inflammatory Arthritis and Degenerative Arthritis Hereditary?

Dr. Crowley: Both arthritis types can be genetically passed down. There does seem to be a hereditary component to arthritis.

What Can a Patient Expect When Visiting You? 

Dr. Crowley: After an initial appointment where I take images and bloodwork, patients will come back about two weeks later to review the test results. Hopefully, I will be able to give a diagnosis and treatment plan that day.

For example, for a patient with rheumatoid arthritis, I might see on exam multiple symmetrical swollen joints and I might see antibody markers in their blood, meaning that they would have a positive rheumatoid factor. That would meet criteria for rheumatoid arthritis and at that point we would start them on medication.

Are There Cases That Are More Challenging to Diagnose?

Dr. Crowley: Sometimes bloodwork and x-rays show normal findings. Depending on our level of suspicion, we might order more specialized tests such as ultrasounds or MRIs to look further. We will dig deeper to find the cause of the pain.

Are There Actual Cures for Arthritis Today?

Dr. Crowley: The bad news is that there is no cure, but the good news is that we have new therapies coming out all the time. Common arthritis medicines are directed toward altering the immune system because that’s the source of the problem for inflammatory arthritis. We have so many options that we can minimize risks and side effects. The patients usually feel like they’re back to normal and they don’t have any joint pain or inflammation.

What Are Some of the Medications Used to Treat Arthritis?

Dr. Crowley: Methotrexate is one drug that is commonly used. Biologics are really exciting because they work really quickly. They have minimal to no side effects. They are life-changing because they can make all of the symptoms go away. There are also injections and IV therapies. We can really tailor treatment to each specific patient, whatever works best for them. 

When Should A Patient See a Rheumatologist?

Dr. Crowley: If you have had sudden onset of multiple joint pain. Maybe it takes an hour or more in the morning to feel like you can move because you’re so stiff. Certainly there can be multiple ways that arthritis presents. Everyone doesn’t fit a textbook diagnosis, but the one important thing to stress is that with inflammatory arthritis having treatment is really important. The sooner you can be treated, the less damage you will have. We try to stress that. You’re not doing yourself any favors by trying to tough it out. It will be harder to treat the longer you wait. Ideally we would like to get someone in remission in four to six months.

How Does Inflammatory Arthritis Do Damage to the Body?

Dr. Crowley: Your system is attacking itself. Inflammatory mediators are sent to the joints which lead to joint damage. This leads to the classic deformities when you look up rheumatoid arthritis and people can really start to lose function of their hands. That doesn't happen very often anymore because the treatments work so well.

When Does Arthritis Strike?

Dr. Crowley: I would say late 50s and above would be when you would start to look for degenerative arthritis. Rheumatoid arthritis is more common in middle-aged women, but even children can get it. It depends. Gout is more common in men.

How Is Gout Treated?

Dr. Crowley: Gout is not really an autoimmune disease. Your body loses the ability to break down uric acid so you get crystals in the joints. We treat them with medications that help to break that down in the blood. We are able to treat severe gout better than we used to since we have a new IV therapy. The treatment just dissolves all the crystals from the joints which can cause large growths. Generally patients would get IV treatment every two weeks, which takes a couple of hours, and do that for six months. After they’ve completed the six-month therapy, they can keep it at bay with other medications.

How Successful Is the Treatment?

Dr. Crowley: I recall one patient who could hardly walk. A few months later, he ran into the office. He said he hadn’t been able to walk in 30 years. It was amazingly life changing for him.

Can Arthritis Be Misdiagnosed?

Dr. Crowley: Yes. One common disease that this happens with is ankylosing spondylitis. People may think they have back pain and so they see an orthopedic doctor. They may think they have a herniated disc. The average length of time from symptoms to diagnosis for ankylosing spondylitis is 10-15 years. There are no good blood tests for this condition so it takes close attention to imaging and symptoms in order to suspect and diagnose ankylosing spondylitis. The good news is that once this condition is identified, we have great treatments which can prevent further damage and resolve the back and joint pain. 

Think You May Have Arthritis?

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