Rheumatology in India: Specialists

Which conditions does a rheumatologist treat?

A rheumatologist treats diseases in which the immune system or inflammation attacks the joints, the spine, the muscles, the blood vessels or the connective tissues, and which medicines rather than operations control. They include rheumatoid arthritis; axial spondyloarthritis, which includes ankylosing spondylitis; psoriatic arthritis; gout; systemic lupus erythematosus; Sjögren's syndrome; systemic sclerosis; inflammatory muscle disease; and inflammation of the blood vessels. In children, juvenile idiopathic arthritis is the main condition. Dr. Sajal Ajmani, who conducted a Jivo Masterclass on diagnosis and management of rheumatoid arthritis for international doctors on 1 September 2024, set out how rheumatoid arthritis is recognised early and treated to a target; his article series on rheumatoid arthritis follows the same path.

What are the early signs of rheumatoid arthritis?

Rheumatoid arthritis typically causes painful, swollen joints on both sides of the body, most often the small joints of the fingers, wrists and feet, with stiffness that lasts well into the morning. Anyone with persistent joint swelling of this kind needs prompt referral to a rheumatologist, because the disease is most responsive in its first months. Dr. Ajmani stresses that the diagnosis rests on the clinical picture: rheumatoid factor on its own does not make the diagnosis, since the test is also positive in tuberculosis, infection of the heart valves, hepatitis B and C and some healthy people over 70, and anti-CCP antibodies can be positive in psoriatic arthritis, hepatitis and tuberculosis. The current classification criteria were written to recognise the disease early, before the late signs on which older criteria relied: at least one swollen joint that no other disease explains, scored by the number and size of joints involved, the antibodies, the duration of symptoms and the blood markers of inflammation. Dr. Ajmani points to ultrasound with Doppler, which can show early inflammation of the joint lining and erosions and complements X-rays.

Two earlier forms need watching. In palindromic rheumatism, brief, intense attacks affect usually one joint at a time and settle completely between attacks, with normal uric acid, unlike gout; a share of these patients go on to rheumatoid arthritis. In the pre-clinical stage, joints ache without swelling while the immune process is already under way, and a positive anti-CCP test signals a high chance of progression.

How is rheumatoid arthritis treated, and why does early treatment matter?

Current recommendations start disease-modifying medicines from the moment of diagnosis and aim for every patient to reach remission, or at least low disease activity, with review every few months while the disease is active and a change of treatment if the target is not reached. Methotrexate is the anchor drug; where it is unsuitable, for example in a woman planning pregnancy or in liver disease, sulfasalazine is used, since sulfasalazine is compatible with pregnancy while methotrexate and leflunomide are not. Steroids serve only as a short bridge while a new medicine takes effect, tapered as fast as possible. If the first medicine fails and the disease carries poor prognostic features, such as erosions on X-ray, deformity or high antibody levels, a biologic or a targeted synthetic medicine is added. In clinic, Dr. Ajmani notes, disease activity is judged from the number of swollen and tender joints, the ESR and a global assessment, and remission must be sustained for at least a year before treatment is reduced. Patients treated within 12 weeks of the first symptoms have the least joint destruction and the best chance of remission without medicines.

Which other symptoms should prompt a rheumatology opinion?

Back pain that begins before 40, comes on gradually, improves with exercise but not with rest, and wakes the patient at night suggests axial spondyloarthritis. Joint swelling in someone with psoriasis, or a whole finger or toe that swells, suggests psoriatic arthritis. A sudden, red, hot, intensely painful joint, often the big toe, is typical of gout. Joint pain with a facial rash, mouth ulcers, hair loss or protein in the urine raises lupus. A new headache with scalp tenderness, jaw pain on chewing or disturbed vision in an older person can signal inflammation of the temporal arteries and needs same-day treatment to protect sight. When a joint has already been destroyed, replacement is the work of orthopaedics.