​What are NSAIDs, DMARDs and biologics?
 NSAIDs (non-steroidal anti-inflammatory drugs): These are the common pain relievers.
They are divided into COX-1 and COX-2 inhibitors (COX is cyclooxygenase enzyme).
Cox-2 inhibitors (i.e., coxibs) are safer than cox-1 inhibitors so far as gastric and
renal toxicities are concerned. The examples of cox-1 inhibitors are ibuprofen,
diclofenac, indomethacin, etc.
 DMARDs (disease-modifying anti-rheumatic drugs): The common drugs are
methotrexate, hydroxychloroquine, sulphasalazine, leflunomide, etc. They are used
in persistent inflammatory synovitis present in different autoimmune diseases.
 Biologics: These are revolutionary drugs to treat autoimmune diseases when
traditional DMARDs fail. The common drugs used are TNF- blockers (etanercept,
infliximab, adalimumab), abatacept (selective T-cell co-stimulation modulator),
rituximab (anti-CD 20) and tocilizumab (interleukin-6 inhibitor). These drugs are
used parenterally and are more expensive than DMARDs. Recently, an oral biologic
[janus kinase (JAK) inhibitor] has been introduced for treatment of RA i.e., tofacitinib.

​What are the common blood tests done in rheumatology?
Common blood tests done in rheumatology are TC and DC (total count and differential
count), ESR, CRP, RF, anti-CCP (antibody to cyclic citrullinated peptide; found in RA),
ANA (antinuclear antibody; found in SLE), ANCA (anti-neutrophil cytoplasmic
antibody; found in Wegener’s granulomatosis), ASO titre (antistreptolysin O, found
in acute rheumatic arthritis), anti-ds DNA (antibody to double stranded DNA; common
in SLE) and HLA-B27 (positive in spondyloarthropathies). Moreover, serum uric acid,
calcium and phosphate level, alkaline phosphatase and 25-OH vitamin D level help in
diagnosis.

Synopsis of a few disorders/phenomenon.
Felty’s syndrome: A seropositive RA which is common in aged females and is associated with anaemia, neutropenia, thrombocytopenia and splenomegaly.

Caplan’s syndrome: It is seen in coal miners who is having RA with pneumoconiosis of the lung.

​Systemic lupus erythematosus (SLE): It is an inflammatory, autoimmune, multisystem disorder
with arthralgia and skin rash as the most common clinical presentation.
It virtually affects most of the systems in the body while renal and cerebral involvement pose serious
problems. SLE is common in women of 20–40 years age group. Malar rash , discoid rash, photosensitivity, oral ulcers (commonly painless palatal ulcer), arthritis/arthralgia, serositis (e.g., pleurisy or pericarditis),
neurological (e.g., psychosis), renal (e.g., proteinuria), and haematological (e.g., leucopenia or thrombocytopenia) manifestations are common. The patient may present with ‘pyrexia of unknown origin (PUO)’. The morbidity (refers to the distressed and unhealthy state of the individual) and mortality (the state of being subject to death) is high in SLE.

Gout : It is a crystal-induced arthritis where monosodium urate (MSU) crystals are deposited in joints, tendons, bursa, etc. Gout is always associated with hyperuricaemia but all hyperuricamic patients do not suffer from gout. Acute gout usually affects the 1st MTP joint of the foot, especially after an alcoholic debauch (any joint may be affected) which is tremendously painful; if acute gout is not treated properly, the patient develops into chronic gout which may give rise to tophi formation (MSU crystal deposition in tendon, ligament or soft tissues) or renal involvement.

Sjögren’s syndrome: It is another autoimmune disease which affects the entire body. The patient presents with dry eyes (xerophthalmia), dry mouth (xerostomia), myalgia, arthralgia and fatigue. Older women are commonly affected. Bilateral parotid swelling may be a presenting feature. There is an increased chance of
development of lymphoma.

Osteoarthritis: It is the commonest form of arthritis in clinical practice and is usually regarded as a degenerative process due to ageing. Now it is thought that some amount of inflammation is also present in its pathology which affects the cartilage, subchondral bone, meniscus, ligaments, synovium and capsule of
the joint. It may affect any weightbearing joint but in India, knee joint is commonly affected while hip joint
involvement is seen in western world. DIP joints of hands are commonly involved. As there is no definite treatment of this disease, it is the commonest cause of disability in the older population.

Osteoporosis: It is defined as low bone density, which results in a micro-architectural deterioration of bone tissue and leads to increased bone fragility with enhanced risk of fracture. Common risk factors are
female sex, post-menopausal women, prolonged immobilisation, CRF, diabetes, drugs (e.g., heparin), increasing age and smoking. Osteoporosis is being treated by calcium, vitamin D, bisphosphonates and recombinant human parathyroid hormone.

Osteomalacia: It is the defective mineralization of newly formed bone matrix due to vitamin D deficiency in an adult; the patients may have bone pain (bone tenderness too) and muscle weakness. When this defective mineralization (as a result of vitamin D deficiency) occurs in epiphyseal growth plate in children before puberty, it is known as rickets.

Fibromyalgia: It is one of the common soft tissue rheumatism. The disease is common in females who complain of widespread body pain, ongoing tiredness and tender points detectable on application of pressure on their muscles. The disease is often associated with irritable bowel syndrome (IBS), migraine, dysmenorrhoea, tension headache, etc. The diagnosis is clinical and is commonly due to disturbed or unrefreshing sleep. The disease is due to ‘abnormal pain perception’ by the patient. The response to treatment is unsatisfactory.

​Raynaud’s phenomenon: It is a vasospastic disorder, manifested clinically by ‘triphasic colour response’ i.e., sequential development of pallor, cyanosis and rubor (i.e., redness), commonly seen in fingers and toes. Exposure to cold precipitates Raynaud’s phenomenon in a susceptible individual. The common causes are scleroderma, SLE, thoracic inlet syndrome, hyperviscosity syndrome (e.g., multiple myeloma), and ergot or -blocker-induced. It is being treated by different vasodilators.

What is seronegative spondyloarthropathy (SpA)?
These are group of inflammatory arthritis which are characterised by inflammatory
low back pain in addition to peripheral arthritis. They are diagnosed by the presence
of:
- Asymmetrical oligoarthritis (lower limb >upper limb)
 -Association with HLA-B27 allele
 -Sacroiliitis and/or inflammatory spondylitis
 - Enthesitis
 - Anterior uveitis
 - The rheumatoid factor (RF) is persistently negative.

SpA includes these five disorders:
1. Ankylosing spondylitis (M:F = 3:1, peak incidence in 2nd or 3rd decade with recurrent episodes of back pain which is marked in the morning; this inflammatory arthritis commonly affects the sacroiliac joint and spine (axial involvement), and ultimately progresses to bony fusion of the spine with marked stiffness in the body along with severe pain; there may be alternating buttock pain along with different peripheral joint involvement. Rest increases but exercise improves pain. There may be extra-articular manifestations like plantar fasciitis, Achilles tendonitis or aortic incompetence).

2. Reactive arthritis (previously known as Reiter’s syndrome): The classical triad of urethritis, conjunctivitis and arthritis following gastrointestinal (Salmonella, Shigella, Campylobacter or Yersinia-induced) or genitourinary (non-gonococcal urethritis or sexually acquired infection with Chlamydia) infection usually results in ReA. This inflammatory arthritis typically affects young men (or women), 1–3 weeks after an episode of bloody diarrhoea or sexual exposure with involvement of large joints of lower limbs. Circinate balanitis, keratoderma blennorrhagica  and nail dystrophy are extra-articular manifestations.

3. Psoriatic arthropathy: The patients have psoriasis with different types of joint involvement like oligoarthritis, polyarthritis, involvement of DIP joints , spondylitis (back pain) or mutilation of
joints with deformity (arthritis mutilans).

4. Arthritis associated with inflammatory bowel diseases i.e., ulcerative colitis and Crohn’s disease (known as enteropathic arthritis).

5. Undifferentiated SpA.
NB: According to a few rheumatologists, the sixth group is juvenile-onset SpA.

​What is meant by collagen vascular disease (CVD) and connective tissue
disorders (CTD)?
Though these two terms are pronounced in same breath, there is a minute difference
like:
 CVDs are heterogenous group of autoimmune diseases characterised by presence
of autoantibodies like SLE, RA, systemic sclerosis, polymyositis and dermatomyositis,
mixed connective tissue disease (MCTD). Here collagen and blood vessels
are affected and the disease is autoimmune in nature.
 CTD (affects the collagen tissues of the body):
– Autoimmune: Same as CVDs
– Heritable: Marfan’s syndrome, Ehlers-Danlos syndrome, osteogenesis imperfecta.

​What is fleeting or migratory arthritis?
In fleeting arthritis when one joint is being affected, the inflammation of previous joint
is subsided. But in additive arthritis, one fresh joint is involved over and above other
involved joints (e.g., RA, ReA). Common causes of fleeting arthritis are:
1. Rheumatic arthritis i.e., from acute rheumatic fever (commonest).
2. Viral arthritis
3. SLE
4. Arthritis from inflammatory bowel disease (IBD), septicaemia, serum sickness.