Coeliac Disease and Arthritis

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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 - its 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 function
• These 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 symptoms
• Your 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?