Which "Arthritis"? Which Treatment?
by Constance Young

Arthritis has been making front-page news since the mega drugmaker Merck & Company yanked off the market one of its biggest moneymaking drugs, a mainstay of arthritis treatment. The recalled painkiller, Vioxx (generic name, rofecoxib), was withdrawn because it appeared to cause deaths from heart attacks. Vioxx was one of a new class of nonsteroidal anti-inflammatory drugs (NSAIDs) called COX-2 inhibitors. A study found that after 18 months of continuous treatment Vioxx had more than tripled the number of heart attacks and increased the risk of strokes. Ironically, Vioxx was developed originally to be a new and safer alternative to aspirin and similar drugs such as ibuprofen, which can cause gastrointestinal bleeding and other problems. The Vioxx recall triggered investigations of other COX-2 inhibitors, including Celebrex and Bextra, but the verdict is still out on the results of new and ongoing studies.

The big question for people with arthritis now is "What do I do now to help ease arthritis pain?" While there is no definitive answer, I can give you some clues. Aspirin and other painkillers can cause gastrointestinal bleeding, and there are concerns about some of the other painkillers. The choice of painkiller must be based first on the answer to another basic question, "What kind of 'arthritis' do you mean?"

Fortunately, there are many medications available to help ease arthritis pain, and in some cases stop progression of the disease. Certain lifestyle changes and non-traditional healing techniques also can put a brake on the symptoms and possibly on the disease itself.

What is "arthritis"?
There are about 100 different conditions lumped together under the name "arthritis," so it is important to know which disorder you're talking about to know how to treat it and what might be in store down the line.

Most people think of arthritis as either rheumatoid arthritis or osteoarthritis, but such diverse conditions as bursitis, gout, and systemic lupus erythematosis (also called "lupus") are also considered types of arthritis. These are truly a mixed bag of disorders. Many, but not all of these disorders have joint inflammation as a common element, but some affect other bones and muscles without inflammation. Because there are so many complex rheumatic disorders (a name used interchangeable with the term "arthritis"), I will concentrate largely on the most common arthritic condition, osteoarthritis, as well as rheumatoid arthritis.

"Wear and tear" arthritis
As a person ages, pressure on the joints wears away cartilage between the joints, and the bone beneath also frequently becomes dense and worn, and bony "spurs" may develop. This condition, called osteoarthritis, develops in more than 20 million Americans, mostly women, mostly middle-aged and older. Osteoarthritis is a degenerative disorder that can range from very mild to very severe. It affects the hands and weight-bearing joints such as knees, hips, feet and the back

The usual recommendation for people with osteoarthritis is to make certain lifestyle changes. These include keeping one's weight under control, exercising regularly, and eating a healthful diet full of the protective antioxidants such as vitamins C, E, and D, as well as the mineral calcium. Vitamin C is found in abundance in citrus fruits, potatoes, and broccoli; and vitamin E in sunflower seeds, wheat germ, and corn and safflower oil. Vitamin D helps the body absorb calcium and both are needed for strong bones. Foods rich in calcium include dairy products and greens (such as kale, collard and turnip greens); also, many packaged foods are fortified with vitamin D. In temperate climates vitamin D can be absorbed through unprotected skin after about 15 minutes of midday sun. Sometimes a physician will recommend taking supplements. In addition to the above, the application of heat can sometimes ease arthritis pain, and devices such as orthotics inserted into footwear can help properly align the body to prevent further wear and tear on the joints. Over the counter (OTC) drugs such as acetaminophen, which include the popular brand Tylenol, and the NSAIDs discussed at the beginning of the article (as well as the NSAIDs aspirin and ibuprofen), are used for pain. Surgery is sometimes an option.

Some are autoimmune disorders
Rheumatoid arthritis is one of about 80 disorders that are considered autoimmune disorders, all of which develop when the immune system goes haywire, turns on itself, and harms normal tissues. In rheumatoid arthritis, the body wages its inner "war" primarily on the joints. In so doing, the complex organization of cells and antibodies that make up the immune system, which are designed to "seek and destroy" foreign invaders such as infections, attacks the joints, causing inflammation there and sometimes in other bodily organs. Exactly why this occurs is a mystery, but scientists suspect specific external triggers, such as smoking, stress, and occupational exposures, as well as a person's genetic inheritance.

While rheumatoid arthritis is a chronic illness, meaning it can last for years, people with arthritis often experience long periods without symptoms. Typically, however, rheumatoid arthritis is progressive, causing joint destruction and interfering with a person's ability to function normally.

In making their diagnosis, doctors usually take X-rays as well as blood tests, since abnormal blood antibodies are usually present. In particular, about 80 percent of people with rheumatoid arthritis have an antibody in their blood called "rheumatoid factor." The final diagnosis is usually based on the pattern of symptoms, distribution of the inflamed joints, and blood and x-ray findings. For example, the inflammation in the small joints of the hands, wrists, feet, and knees typically affects both sides of the body. When the disease is active, symptoms can include fatigue, lack of appetite, low-grade fever, muscle and joint aches, and stiffness. Muscle and joint stiffness are usually most notable in the morning and after periods of inactivity.

Historically, rheumatoid arthritis has been treated with a stepwise approach—beginning with rest, over-the-counter drugs called salicylates (including aspirin and Anacin), other NSAIDs; then progressing to anti-rheumatic drugs (DMARDs) such as methotrexate and gold therapy. For all but minor manifestations of the disease, doctors frequently prescribe DMARDs and a category of drugs called biologic response modifiers, or simply "biologics" (such as etanercept, brand name Enbrel; and infliximab, brand name Remicade). Frequently, a few drugs are given at the same time. Sometimes a physician will inject a steroid into the joint to reduce inflammation and ease the pain.

Choosing a painkiller
More than 20 million Americans use a NSAID on a regular basis and some NSAIDs are among the most prescribed drugs. Celebrex is one of the 20 most prescribed brand-name drugs; ibuprofen is high on the list of most prescribed generics (it comes under the brand names Motrin, Advil and Ibuprin). Some other popular NSAIDs include naproxen (brand name Naprosyn) and piroxicam (brand name Feldene).

NSAIDs are usually used whenever there is inflammation. They are, for example, usually the first drug recommended for inflammatory conditions such as rheumatoid arthritis. Simple painkillers, such as Tylenol, do not work on inflammation.

Traditional NSAIDs can interfere with normal blood clotting by preventing the blood platelets from clumping together, which can lead to prolonged bleeding and bruising. COX-2 inhibitors do not cause such problems, but may cause other heart and blood vessel problems (still under investigation). NSAIDs can cause fluid retention and interact with many other drugs. It is best to check with a pharmacist to see if the other drugs you are taking can be taken safely with an NSAID.

People who should not take NSAIDs include anyone with an allergic reaction to aspirin or another NSAID or who have symptoms of allergy such as a runny nose, hives, trouble breathing, or swelling of the tongue or throat. People who are allergic to sulfonamide drugs, such as the antibiotics Bactrim and Septra, should not take a COX-2 inhibitors. For other details, read the labeling on the package or consult your doctor or pharmacist. Women who are pregnant or hoping to become pregnant should check first with their doctor before taking any medication.

Alternative treatments
According to a 1997 survey, four out of ten Americans visit a complementary and alternative medicine practitioner. Complementary practitioners include acupuncturists, chiropractors, natural healers, and spiritual healers. These practitioners use and recommend a wide array of healing techniques for arthritis. They include spiritual healing, acupuncture, chiropractic medicine, herbs, magnets, copper bracelets, electrical stimulators, vinegar mixtures, dietary supplements (such as glucosamine/chondroiton), over-the-counter salves such as Aspercreme, and daily multivitamins. Despite the popularity of these techniques, objective information about the outcome of these treatments is either sparse or lacking.

For further information, ask your physician or health care expert, contact the public affairs departments of local hospitals, or visit:

www.nlm.nih.gov/medlineplus/tutorial.html

www.webmd.com

www.healthatoz.com