Coeliac Disease and Arthritis

Coeliac Disease and Arthritis Liam Martin MB, MRCPI, FRCPC Division of Rheumatology University of Calgary

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Objectives • Discuss what ‘Arthritis’ is • Discuss what is not ‘Arthritis’• Discuss the joint conditions that are associated with coeliac disease (CD) • Discuss the management of joint conditions

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Complaints • Many people complain of joint pain• Often these symptoms are referred to as ‘arthritis’ • There is always concern that the ‘arthritis’ will lead to disability – ‘like my granny who ended up in a wheelchair’ • Alternatively people without symptoms are heard to state that – ‘it’s only arthritis’

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What is meant by the term ‘Arthritis’?

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What is Arthritis? • The term ‘Arthritis’ refers to an inflammatory condition which affects joints • The joints affected are usually diarthrodial joints – they have two bones which move against each other like a hinge • The joints have cartilage lining the surface of each bone – ‘articular cartilage’ • The joints are surrounded by a capsule which has a lining on the inner surface referred to as the ‘synovium’ • The joints have blood and nerve supplies

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What does a joint look like?

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ARTHRITIS • Arthritis is one of the oldest known diseases • Vertebrate skeletons from 100 million years ago have changes of arthritis • The most common form of arthritis is osteoarthritis • The most common form of inflammatory arthritis is rheumatoid arthritis

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What is not ‘arthritis’? Or Are my aches and pains due to arthritis?

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Are my aches and pains due to arthritis? • The simple answer is ‘Not always’ • Many patients with aches and pains have muscle pain • Frequently when patients describe themselves as having ‘hip’ pain they have pain in the muscles of their buttocks • Similarly shoulder aches are often due to aching in the shoulder muscles

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Joint Pain • ‘Arthralgia’ is a medical term which is used to describe joint pain • It is not a disease, it is a symptom• There are many situations in which arthralgias can occur • These include viral illnesses, over use, exercise, joint ligament laxity

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Are there different types of Arthritis? • There are many different conditions that fall into the category of ‘Arthritis’ • These conditions can be divided into – inflammatory– non-inflammatory • Another way of looking at these categories is to describe the arthritis as having ‘local’ or ‘widespread’ effects

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What do you mean by arthritis with ‘local’ effects?

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Local Effects • This term refers to the most common form of arthritis – osteoarthritis • Most people will have a little or a lot of osteoarthritis particularly as they age • The disease affects – weight-bearing joints such as the knee or hip– joints that have been injured– Joints through which a lot of repetitive force is applied such as the joint at the base of the thumb • There is some inflammation in the affected joint

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What do you mean by arthritis with ‘widespread’ effects?

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Widespread effects • This term refers to joint disease where many joints are affected with significant amount of inflammation in the joints And • Where the disease causes those affected to feel unwell • Other organ systems in the body may also be affected • The term ‘Systemic’ is used to portray this idea • The prototypical diseases in this context are RA and SLE

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Okay, so what are the signs and symptoms or arthritis? or How do doctors know what is or is not arthritis?

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Signs and symptoms or arthritis • There are 5 signs or symptoms of arthritis• Pain• Swelling• Redness• Stiffness• Loss of functionThese symptoms are chronic which means present consistently for over 6 weeks

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Is there anything in particular about these signs and symptoms that helps in making a diagnosis of arthritis?

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Pain • Arthritis pain is chronic• It is present all the time but the severity may vary • It is usually relieved by rest and made worse by exercise • It is localised to the affected joints• May be relieved by anti-inflammatory medications or the application of heat or cold

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Swelling • The swelling is chronic• It is present all the time but the amount of swelling may vary with activity • It is localised to the affected joints• May be relieved by anti-inflammatory medications or the application of heat or cold

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Redness • The redness occurs in the skin overlying the joint • It is the least common of the signs or symptoms • It is usually localised to the affected joints • May be relieved by anti-inflammatory medications or the application of heat or cold

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Stiffness • Stiffness occurs in the affected joints but also in the surrounding muscles • The stiffness associated with inflammation lasts at least 45 minutes in the morning • It may improve with activity, a hot shower• It can recur after resting• May be relieved by anti-inflammatory medications

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Loss of Function • Loss of function occurs in the affected joints • Patients have difficulty doing the activities for which the joint is used – dressing themselves if the shoulder is affected – Walking if the hip or knee is affected • May be relieved by anti-inflammatory medications

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WHAT CAUSES PAIN IN ARTHRITIS? • The joint capsule has a rich supply of nerve endings • The lining of the joint, the synovium, has nerve endings • Inflammatory mediators are released into the joint in arthritis – cytokines, chemokines and vasoactive proteins • The nerve endings in the capsule and lining are stimulated

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Does what I eat cause arthritis?

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Diet and arthritis • Good question and one which is frequently asked • The answer is ‘no’ unless a patient knows this to be the case • There are no studies that show foods of different types cause arthritis • However patients frequently observe that too much red meat, acidic foods or other foods cause their arthritis symptoms to flare

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Does what I eat cause arthritis? • A nutritional study in RA patients investigated whether diet played a role in disease control • Patients were divided into 2 groups – Normal diet and Vegetarian diet • Vegetarian diet group were brought to a spa where their diet was closely monitored • There was no difference in RA disease control between the groups after 6 weeks

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Coeliac disease and arthritis

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Coeliac disease and arthritis • Many case reports of arthritis in patients with CD • One study from Italy reported an increased frequency of arthritis in 200 CD patients • 52 patients had arthritis – Some in the sacroiliac joints and spine– Some in 1 to 5 peripheral joints– Some had an overlap

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Rheumatoid Arthritis and Coeliac Disease • Another study of arthritis examined the frequency of CD in RA patients • 160 patients had antibody tests for CD• 2 patients had endomysial antibodies – 1 was known to have coeliac disease– 1 patient with positive antibody test had normal biopsies • The frequency of CD was 1/160 or 0.63% – similar to the general population

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Can coeliac disease present as an arthritis? • Patient presented to Dr. Beck some years ago with bowel symptoms but also had inflammation in a number of joints • Investigations on her bowel showed changes of CD • A gluten-free diet was introduced and her bowel and joint symptoms settled

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What is the effect of gluten in RA in patients with CD? • Patient with severe RA that I have followed for 10 years • She was not responding to any of the available disease modifying agents for RA • I found out she had CD when we did antibody studies on her serum • She had been diagnosed 15 years ago on small bowel biopsy – never told me • Did not think it was important!• She is now on a gluten-free diet but her disease is still difficult to control

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Managing my arthritis What should I do if I think I have arthritis?

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Management • The most important issue in managing arthritis is to confirm a diagnosis • As discussed not all musculoskeletal pain is due to arthritis • Not all forms of arthritis are managed in the same way • All forms of arthritis respond better to treatment when they are diagnosed and treated early

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I think I have arthritis –what should I do? Speak to your doctor• Describe your symptomsYour doctor will • Examine your joints• Order appropriate laboratory tests and x-rays • Decide on treatment or refer you for further assessment if needed

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Summary • Arthritis is a common disorder• The frequency of the disorder increases as we age • Not all aches and pains are due to arthritis• Speak to your physician if you think that you have a arthritis – you can be helped to manage your arthritis • CD is not necessarily associated with an increased of developing arthritis

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Thank you for your attention

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Q U E S T I O N S?

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