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DAVID MARKS, MD: Welcome to our webcast. I'm Dr. David Marks. The symptoms of arthritis can range from a mild ache to severe, debilitating pain. There are a number of treatments available to relieve arthritis pain. Choosing the right medication depends on the individual, as well as the type of arthritis.
Joining us to talk about the various ways to treat arthritis are two special guests, Dr. Allan Gibofsky, Professor of Medicine and Public Health at Cornell, and a rheumatologist at the Hospital for special surgery. Welcome.
And Dr. Steven Smiles, Clinical Assistant Professor of Medicine at NYU.
DAVID MARKS, MD: Thanks for being here. The first treatment that people are always interested in are lifestyle changes, that can be done very easily. Do they work for arthritis?
STEPHEN SMILES, MD: David, I think the first thing we need to do is establish the proper diagnosis for the patient that we're going to form a treatment plan for. I think once establishing a treatment plan and a proper diagnosis, then we can go through a series of choices. Lifestyle change, to begin with, is rather important.
If we're dealing with an individual who has problems with his legs, then maybe we have to look at the proper shoe wear that he has or his activity. If we're dealing with an individual who has a problem with is upper extremities because of problems with their computer that they might be working with, then I think that changing the ergonomics for them would be also very important in establishing a first plan towards establishing a treatment prior to thinking of a pharmaceutical. Allan, don't you agree?
ALLAN GIBOFSKY, MD: I would agree Steve. I would say that you've correctly pointed out that the word arthritis really refers to a number of different conditions. It's important to determine which form of arthritis people have. For example, patients with a form of arthritis known as gout require different diets than patients with other forms of arthritis. So patients with gout need to have their diet changed. Patients who have other forms of arthritis, it may not be necessary.
DAVID MARKS, MD: What about the very common form of osteoarthritis? Even exercise, of course, is a lifestyle change to some extent. Losing weight? Can any of these things help?
ALLAN GIBOFSKY, MD: They can help, but it's often very difficult to get patients to comply with lifestyle changes to the point where it's going to radically alter the natural history of the disease. Certainly, if you have a morbidly obese patient, you're not going to take that patient for a surgical procedure, knowing that the same body bulk is going to be put back on that joint. So you might recommend some weight loss.
If the patient has other medical conditions that lend themselves to what we refer to as a tuneup, you might do that before prescribing certain medications or therapeutics. But getting patients to change their lifestyle radically enough to alter the natural history of the disease is very, very difficult to do.
DAVID MARKS, MD: What about just resting an inflamed or painful joint?
STEPHEN SMILES, MD: There is no question that rest of a particular joint, because of the nature of the origin of the pain, works. But then again, you have patients who have arthritic problems that are truly inflammatory. When they arise in the morning and when they have not used it, and the joint has been left alone and has gotten swollen because of the biologic reason for them to have the arthritis, they'll get up it the morning, and they'll have what we call morning stiffness.
For some patients with diseases like rheumatoid arthritis, morning stiffness can last for an extended period of time. We even use it as a clinical monitor of the medicines that we give to the patients.
ALLAN GIBOFSKY, MD: Rest is a good thing, but too much of a good thing can be bad. We've all seen instances where patients have rested a joint, only to find that the muscles and soft tissue around that joint have become frozen as well.
Rest is not as simple as it sounds. Rest and exercise need to both be used judiciously in the treatment of joint pain. That's where we as physicians turn to our colleagues in physical therapy and occupational therapy and sports medicine to help us understand the mechanical stresses on the joint and when to modify them.
DAVID MARKS, MD: Let's talk about medications. Of course, antiinflammatories and other medications are very commonly prescribed for arthritis. Go over some of the more common classes of medicines that people will hear about.
ALLAN GIBOFSKY, MD: Before we do that, let me suggest that we can think about three classes of medications, and then I'll let Steve help me fill in the blanks. Let me suggest that we have antiinflammatory medications which deal with reducing the swelling, which is the primary sign of the arthritis. We have analgesic medications which just take away pain. Then we have a class of agents called disease-modifying agents, where we're trying to alter the natural history of the disease. There are a number of commonly used agents that fall into each of those classes.
STEPHEN SMILES, MD: The commonly used agents that fall into these classes are medications that for one, treat pain; from the simplest type like Tylenol or acetaminophen to a more impressive medication like some narcotic medication like Percocet or Percodan or Vicodin. They're needed to take care of patients who have significant pain related to severe arthritis of their neck or their low back.
DAVID MARKS, MD: And they're not touching the underlying inflammation?
STEPHEN SMILES, MD: They are not touching the inflammation. These are purely painkilling medications. Antiinflammatory medications go from medications that are present over the counter. Motrin being one medication that is presently in an over the counter size. Naprosyn is a part of over the counter, which is called Aleve in an over the counter size. Both of these medicines are available from physicians in a pharmacologic dosage.
There are now dozens of antiinflammatory medications. Presently, there are two new very exciting antiinflammatory medications, which are called cyclooxygenase-2 inhibitors. The benefit of this is not so much that they are better from their efficacy point of view, to the medications that are out on the market prior to them, but that their safety profile as far as irritation to stomach and their risk of bleeding has been enhanced.
DAVID MARKS, MD: These are the so-called COX-2 inhibitors. Some people call them super aspirin. Those are the ones that you are talking about.
STEPHEN SMILES, MD: I think that super aspirin really is unfortunately a misnamer. From an efficacy point of view, these are really equivalent drugs to ones that have been before them. I think their safety profile enhances them from the point of view of a physician dealing with the medicine to a group of patients and what are the risks that are involved in giving them.
ALLAN GIBOFSKY, MD: And these drugs act very differently. The analgesics like acetaminophen act by reducing pain, usually by a central action. The antiinflammatories also reduce pain, but by local action, by reducing inflammation. So they're not primarily designed to reduce pain, but they do that.
DAVID MARKS, MD: When you say central, you mean in the brain.
ALLAN GIBOFSKY, MD: In the brain. Then the third class of agents, of course, would be the disease modifying agents; drugs which are biologic agents or drugs which are immune suppressant agents.
DAVID MARKS, MD: Give me some examples of those.
ALLAN GIBOFSKY, MD: These would be drugs like Remicade or etanercept.
DAVID MARKS, MD: What do they do?
ALLAN GIBOFSKY, MD: These drugs actually attack the cause of arthritis. They interfere with the immune process that leads to the joint destruction. These drugs are used in rheumatoid arthritis and to a very limited extent, in other forms of arthritis as well
DAVID MARKS, MD: Gold, of course, has been used for many years for arthritis too. Is it still used?
STEPHEN SMILES, MD: Gold is still used by some physicians, but I think that it has waned. I think that it's origin comes from the fact that heavy medals were used for infections during the turn of the century. The idea behind the use of gold had to be for the use in tuberculosis. And it failed. But at that time, when hospitals were full with tuberculosis patients and they gave it to many, obviously there was a possibility that somebody would improve on it. Patients with inflammatory joint disease did.
Gold had a number of problems in giving it. There were some risks involved with the medicine. It also required patients to return. The amount of efficacy of gold truly was maybe two out of three.
DAVID MARKS, MD: When a person is put on medicines for arthritis, are they stuck with them for the rest of their lives?
ALLAN GIBOFSKY, MD: That would vary with what kind of arthritis they have and what it is that one is trying to achieve. Sometimes in patients with osteoarthritis or degenerative arthritis, they may be on medications to treat their symptoms. At a point in time where they have surgery done to the affected joint, that may be all that they need. They can discontinue the antiinflammatory or analgesics after that.
It's usually not so simple for a patient with rheumatoid arthritis. Ordinarily, they will generally need to be on, if not an antiinflammatory, as well as a disease-modifying agent, certainly an antiinflammatory for a chronic period of time.
DAVID MARKS, MD: So they may be stuck with it for the rest of their life?
ALLAN GIBOFSKY, MD: For many patients with rheumatoid arthritis that may well be the case.
DAVID MARKS, MD: Do these medications cure arthritis, or do they just treat the symptoms?
ALLAN GIBOFSKY, MD: No. There are very, very few cures. Again, it depends on the kind of arthritis that we're talking about. But by and large, these medications can treat the symptoms, and to a limited extent control the progression of the disease. If we can slow down the rate of progression of arthritis, in many instances we have achieved a cure.
DAVID MARKS, MD: Physical therapy is also commonly prescribed for arthritis. Does it work? How often should people be getting it?
STEPHEN SMILES, MD: There is no question that the addition of physical therapy, be it directed towards the conditioning of muscles that are around the joint, what we would call the periarticular structures, go ahead and enable weight, trauma, and stress on the joint to be distributed to the muscles which are reparative and that patients can make stronger, rather than the tissues that are around the joint that are static rather than dynamic. So laxity from the trauma that can occur to tendons and ligaments, that can lead to making, as we've spoken before, make a normal joint into an abnormal joint so that it wears increasingly. Physical therapy can make quite a difference.
DAVID MARKS, MD: Are you saying it helps take some of the stress off of the joint? Is that what you mean?
STEPHEN SMILES, MD: If you strengthen inducible tissues, it will take some of the stress off of the static tissues that represent the joint.
ALLAN GIBOFSKY, MD: But again, the challenge is to use physical therapy as part of an overall routine. The physical therapist then becomes part of the healthcare team.
The healthcare team includes not just the physician, but the patient as well as all of the other individuals like the physical therapist, the nutritionist where appropriate, and so on.
DAVID MARKS, MD: How about the role of surgery for arthritis? Is there a place for it?
ALLAN GIBOFSKY, MD: There definitely is. Depending upon the degree of joint destruction, surgery may be the appropriate thing to be resorted to. One clear thing about surgery, it relieves pain. There is no pain in two pieces of metal like there was in two inflamed pieces of bone.
DAVID MARKS, MD: You're talking about an artificial joint? A joint replacement?
ALLAN GIBOFSKY, MD: Joint replacement or joint implants that are sometimes done even before a joint replacement. Artificial finger hinges, for example. Other kinds of joint surgery can be done in terms of shelving or scraping away the degenerative portions of a knee, for example.
It is the real challenge of a physician to determine when it is appropriate to do the surgical procedure, but clearly there is a role for it as a pain reliever and function improver. Steve, would you agree?
STEPHEN SMILES, MD: Absolutely. I think at the introduction of major artificial joints, like the introduction of the hip joint in 1960 and the improvement of the total knee joint that has come through the 70s and now presently has altered lifestyle for millions of people and made them go from being debilitated and housebound to really fully active. They're getting back to participating with family, with friends, doing their jobs and even participating in some relatively active sports.
DAVID MARKS, MD: So the message really is that there are a whole lot of treatment options for people, and if they go see their doctor, get the right diagnosis, then you can embark upon the right course of treatment.
ALLAN GIBOFSKY, MD: Absolutely correct. I think we go the gamut of lifestyle modification to medical management, to physical therapy, to surgery and the judicious physician is able to work with the patient to be able to determine exactly what modality to use when.
DAVID MARKS, MD: Excellent. Thank you very much for helping us.
And thank you for joining our webcast. I'm Dr. David Marks. Goodbye
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