Why did you choose rheumatology as your specialty?
I really didn't find this specialty very attractive at first when I was studying internal medicine. Compared to the complex processes that take place in the heart, for example, or the ingenious functioning of the kidneys, the swollen fingers of grandmothers treated at home with Brufen and at the baths with mud did not excite me much. At least, that was the general idea of rheumatology at that time. It was a bit of a neglected Cinderella next to the prestigious specialties. But a Japanese proverb speaks of a small inconspicuous entrance through which you enter a huge cave full of treasures, and that is what this specialty gradually became for me. With the development of new, incredibly sophisticated instruments and methods, it has been possible to enter the interior of the cell, to map and unravel secrets previously unknown. And this has simultaneously made it possible to develop new modern drugs capable of interrupting unwanted chain reactions in cells at the most appropriate and precise point with more than microscopic precision. I consider myself fortunate in life that my generation has been able to experience this exciting development from its timid beginnings to today's amazing achievements. There is no doubt that rheumatology is now a respected interdisciplinary field that, far from being concerned only with joints, has great overlap with other branches of medicine.
What rheumatic diseases do you encounter in your practice?
Rheumatic diseases have very different causes, diverse manifestations and therefore different treatments. They are mainly divided into inflammatory, degenerative, metabolic and infectious, but there are others. Among the group of inflammatory diffuse connective tissue diseases, I very often encounter rheumatoid arthritis, a serious general disease affecting not only the joints but also other vital organs. Its formerly rather symptomatic and insufficiently effective treatment has undergone a revolutionary development and has seen tremendous progress, especially with the discovery of biological drugs. Other inflammatory diseases include lupus erythematosus, scleroderma, inflammation of blood vessels and muscles, Sjögren's dry eye syndrome, thrombosis causing antiphospholipid syndrome and other often overlapping diseases with quite similar treatments. Inflammatory diseases that I commonly encounter include Bechterew's disease.
How does this disease manifest itself?
It is an affliction of the spine and sacroiliac joints, ossification of the discs and ligaments, with deformity and stiffening of the spine to resultant vertebral collapse. The patient usually cannot reach the ground and has very reduced cervical spine mobility. The disease also affects the tendons, peripheral joints, skin, lungs, blood vessels, and the eyes are dangerously affected. Bechterew's disease is more common in men, especially in carriers of the HLA B27 gene. This is particularly severe in the respiratory movements of the chest. The main emphasis is therefore on breathing exercises, consistent rehabilitation and therapeutic exercise. Medically, this disease was previously difficult to control, but modern drugs are bringing change and great hope to these patients.
What about degenerative rheumatic diseases?
Of the degenerative diseases, osteoarthritis, localized or generalized, is the most common. It is a gradual loss of articular cartilage and a reduction in its elasticity. This can be caused by excessive stress on a healthy joint or normal stress on a joint already affected in some way. At the same time, the adjacent bone reacts by forming growths called osteophytes. The disease often manifests itself in painful thickening of the finger joints, or in exertional pain in the knees and hips. The incidence increases with age and heredity plays a significant role. Osteoarthritis is particularly painful before joint movement and with increased stress, but has a better prognosis than general rheumatic diseases and does not affect other organs. Prevention, i.e. saving the joints, reducing excessive body weight, sufficient vitamin intake and the use of chondroprotective agents, such as Geladrink capsules, are of great importance. However, the pharmacological options for stopping radiological progression are still limited and the disease often results in the need for joint replacement.
Metabolic diseases are a separate chapter, the most common of which is osteoporosis. What are the options for its prevention and treatment today?
In the case of osteoporosis, there is sometimes even talk of an epidemic. Simply put, it is a gradual loss of bone mass. It is more of a threat to women, especially after the menopause, and heredity, diabetes or treatment with corticosteroids also have a significant impact. Its main danger lies in the absence of subjective complaints, and it is sometimes referred to as the “silent thief”; in the later stages of the disease, it can lead to life-threatening fractures, especially in young people. The development of osteoporosis can be prevented by early vitamin D and calcium supplementation, fish consumption, adequate physical activity and sun exposure, it just needs to be thought of early. Also, try to prevent falls. x-ray, and especially densitometric examination, has an important diagnostic role. Fortunately, in more serious cases, we have a range of very effective drugs.
Another very common disease of metabolic origin is gouty arthritis, commonly known as gout. Can it be prevented?
In gouty arthritis, due to a disturbance in the metabolism of so-called purines, the amount of uric acid in the blood increases, leading to its deposition in the joints, where it can crystallize and cause an inflammatory reaction. The characteristic features are extremely painful periodic attacks of arthritis, usually resolving spontaneously, typically affecting the toes. Uric acid sodium salt crystals can be visibly deposited as “gouty tophi” not only around the joints but also in the ears and can lead to kidney damage. Higher levels of purines are usually the result of increased dietary intake, most commonly in obesity from excessive consumption of mainly meat and alcohol. Therefore, the best prevention is a healthy and balanced diet limiting meat products and alcoholic beverages. The need to follow a strict meat-free diet has been less emphasized recently, but the recommendation for a rational lifestyle and maintaining a reasonable weight persists. However, there are also slim and healthy patients who have come by their difficulties somewhat "innocently". In the case of gouty arthritis, it may also be an enzymatic disorder in the breakdown or excretion of purines, or their increased re-formation in some serious diseases. It may also be a complication of the administration of certain drugs, such as diuretics. It is rather interesting to note that the frequency of inflammation does not always correspond completely with the level of uric acid in the blood.
You also mentioned infectious rheumatic diseases.
Joint inflammation can also be caused by an infection in the joint itself, or it can be a reaction to an infection elsewhere in the body, such as in urinary and intestinal inflammation, psoriasis or Lyme disease. In extra-articular rheumatism, inflammation affects tendons, bursae or discs. Painful shoulder, back and sacroiliac joint syndromes, inflammation of the elbows or carpal tunnels are extremely common. Relief is brought by rest, fixation, shock wave, special exercises or corticosteroid spraying. Rheumatic polymyalgia is also relatively common and is usually well managed with corticosteroids, but concomitant inflammation of the temporal arteries or eye involvement must be ruled out. With unexplained fatigue, fever, shortness of breath and swelling of the ankle, for example, it is good to think of the relatively rare sarcoidosis, which is best confirmed by x-ray. Corticosteroids are the drug of choice and early detection of the disease has a good prognosis.
Is it possible to explain in layman's terms what is happening in the affected joint in rheumatic diseases and what is the root of the problem and the resulting pain and movement limitations?
Rheumatic diseases have different causes, so there are several mechanisms when it comes to joint damage. In the case of inflammatory diseases, we assume that certain external influences trigger an exaggerated immunological defense reaction in the susceptible individual. This disproportionate and poorly targeted reaction then auto aggressively damages its own cells and its product is various inflammatory substances (e.g. inflammatory cytokines, TNF alpha, interleukins, Janus kinases, phosphodiesterases, etc.) and activated cells. Their effects could be likened to poisons or corrosives to give an idea. They penetrate into the joint where they cause joint lining thickening and joint effusion. They then gradually erode the cartilage and adjacent bone. This leads to joint destruction, deformities and deviations of the axis, and of course pain. In addition to inflammation of the joint, other organs are severely affected.
Do typical joint problems differ according to age – in children and adolescents, adults and seniors? Can children have rheumatism?
The likelihood of developing, for example, arthrosis, osteoporosis or gouty arthritis does indeed increase with age, as with most diseases. However, it is a mistake to think that joint diseases affect only the elderly. This is not true for many diagnoses. For example, so-called juvenile rheumatoid arthritis affects young children. The course is aggravated in comparison with adulthood by the possible impaired growth of the affected limbs. This can be manifested, for example, by the development of shorter, so-called paw-shaped fingers, an underdeveloped lower jaw (so-called bird face), and sometimes destruction and ossification of the joints. There is also a high likelihood of damage to the eyes and other organs. In addition, the parents also experience this tragedy painfully with their child. Fortunately, modern medicine has now brought very real hope for a better fate.
What are the biggest risk factors that promote the development of joint problems and pain? To what extent are they influenced by lifestyle and to what extent by genetic predispositions?
In general, genetics, age and gender play a role. A number of other possible triggers are suspected and investigated for rheumatoid arthritis, but smoking, for example, is quite demonstrably harmful. In gout, it is often a poor lifestyle with subsequent obesity. For arthritis it is age, previous injury or joint abnormalities and overuse of the joints, the likelihood of developing arthritis of the knees increases after meniscus surgery. Osteoporosis is more threatening in older and petite women with calcium and vitamin D deficiency and lack of exercise. It is sometimes suggested that vaccination may also trigger the development of rheumatic diseases, but this does not appear to be a trigger for rheumatism from past experience. However, the utmost caution should be exercised in ongoing treatment with immunosuppressive drugs, especially in the case of live vaccines.
Can you advise any effective preventive measures against the development of joint problems? What products are useful in promoting joint health?
Healthy lifestyle, maintaining a normal body weight, avoiding extreme sports and other overloading of joints, timely corrective exercise in indicated cases. Taking chondroprotectives (e.g. Alavis or Geladrink) and sufficient vitamins, not smoking, regular medical check-ups including laboratory tests, especially for women, regular x-rays and bone densitometry.
Joint pain is caused by many things and is sometimes a temporary condition, for example in the case of flu, joint congestion, etc. By what symptoms can people recognize that this is not a temporary condition but a sign of incipient joint disease and that they should see a doctor as soon as possible?
It is advisable to monitor the dynamics of the general non-specific manifestations of the disease, i.e. temperature, fatigue, sweating, lack of appetite with weight loss, morning stiffness, hair loss, presence of urinary or intestinal infection, skin manifestations, whether the person has had a tick, etc. I also recommend checking for any family history of joint disease or psoriasis. More specific to the diagnosis are local painful or inflammatory manifestations on the joints. If they appear, I advise you definitely not to postpone an examination by an experienced physician, the results of an laboratory examination will tell you more.
What role does time play in rheumatic diseases in terms of early diagnosis?
Time is of the essence here, because it is better to extinguish a spark than a fire. Early deployment of the right treatment can slow down or even stop the development of destructive processes and changes that may be irreversible in later stages. I therefore recommend regular dispensation, i.e. active medical supervision of persons with specific risk factors.
What are the options for modern diagnosis of rheumatic diseases and which of them is available at Health+?
The Health+ has state-of-the-art early diagnosis options using imaging methods. As a rheumatologist, I appreciate the accessibility of specialized immunological and genetic sampling, which until recently was barely conceivable, and the ability to work closely with other specialists within the clinic, as rheumatology is an interdisciplinary field. And in referral cases, there is no problem in transferring patients smoothly to the Institute of Rheumatology in Prague for eventual hospitalization.
Could you briefly outline the current treatment options for the most common joint problems? Which of them is Health+ able to provide directly to clients?
Traditionally, the basis of the treatment of joint disorders are the so-called non-steroidal antirheumatic drugs (Brufen, Aulin, Diclofenac, etc.), which differ mainly in their duration of action and degree of aggressiveness towards the gastric mucosa. They reduce inflammation and pain, but do not affect the disease itself, similar to analgesics. Corticosteroids (Prednisone, Medrol, etc.) are incomparably more effective. They are administered generally or locally as intra-articular injections. They have a number of side-effects, but these are often exaggerated and feared by the lay public. With correct dosage and respect for all principles, the administration of these preparations is relatively safe and completely irreplaceable. Next, there is the group of immunosuppressive and disease-modifying drugs (DMARDs), in which Methotrexate, supplemented with folic acid, is still the basic drug. Despite the scary-looking package insert, it is a great first-choice drug. Other drugs in this group include Plaquenil, Sulfasalazine, Leflunomide, Cyclosporine, Azathioprine and D-penicillamine. Traditional gold salts are typically not seen in treatment today. A revolution in rheumatology and other fields was brought about by the discovery of so-called biologics. Their indications and combinations are now the subject of intensive research and require specialized centers. Their cost is high, but the benefit to patients is substantial. Many once virtually incurable diseases have finally found a cure.
Can you explain for the lay reader how these biologics work?
To put it very simply, a number of disease process triggers and their specific mechanism of action have been identified. This consists in the triggering of dangerous chain reactions, at the end of which an unwanted and dangerous product is produced, pro-inflammatory substances (TNF, JAK, IL and others) that stimulate the development of rheumatic diseases. The discovery of these triggers has enabled the development of biological drugs that completely target and stop this domino effect at a precise point.
What have been the most important developments in rheumatology in recent years and where are the next steps in this specialty?
Are there advances only in treatment or also in diagnosis and prevention? In therapy, the most important innovations have been the discovery of biological drugs such as JAK inhibitors and phosphodiesterase inhibitors, and in diagnostics, especially the possibility of determining citrullinated peptides (anti-CCP), PCR tests, magnetic resonance imaging (MRI), computed tomography and positron emission tomography (CT and PET), as well as scintigraphy, arthrosonography and densitometry. We have the option of much more detailed laboratory testing and the availability of state-of-the-art medical equipment. There have also been developments in physical therapy and rheumatology. The advances within rheumatology are truly enormous.
Thank you for the interview.