pproximately 43 million Americans suffer with some form of arthritis. The disease causes joint pain or stiffness, and depending on its severity, it can turn simple, everyday activities into arduous tasks. There are, however, a number of effective medications for the treatment of arthritis.
Below, rheumatologists Dr. Allan Gibofsky and Dr. Steven Smiles discuss how to reduce arthritis pain.
Do lifestyle changes help treat arthritis?
STEPHEN SMILES, MD: First, it's important to establish the proper diagnosis for the patient, then we can consider a series of treatment choices.
If we're dealing with an individual who has problems with his legs, then maybe we have to look at the proper shoe wear. If we're dealing with an individual who has a problem with the upper extremities because of computer use, then I think that changing the ergonomics for them would be very important in formulating a first plan towards establishing a treatment, prior to thinking of a pharmaceutical. This means looking at the arrangement of the workstation and making sure that it is optimally positioned for comfort and healthy posture.
ALLAN GIBOFSKY, MD: It's important to first 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. This may not be necessary for people struggling with other forms of arthritis.
What are some lifestyle modifications that can help people with the common form of osteoarthritis?
ALLAN GIBOFSKY, MD: Diet and exercise modifications 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 their 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 "tune-up", you might address this tune-up before prescribing 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.
What about just resting an inflamed or painful joint?
STEPHEN SMILES, MD: There is no question that rest of a particular joint is helpful. But then again, you have patients who have arthritic problems that are truly inflammatory: when they arise in the morning they'll experience stiffness because the joint has been left alone and has gotten swollen due to the arthritis.
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.
Could you describe the most common medical treatments for arthritis?
ALLAN GIBOFSKY, MD: We have anti-inflammatory medications that help to reduce swelling, which is the primary sign of the arthritis. We have analgesic medications that just take away pain. Then we have a class of agents called disease-modifying agents, which are used 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 narcotic medications like Percocet, Percodan or Vicodin. These prescribed medications take care of significant pain related to severe arthritis of the neck or low back.
Do the medications alter the underlying inflammation?
STEPHEN SMILES, MD: No. These are purely painkilling medications. Motrin is an anti-inflammatory sold over the counter, as is Aleve, and both of these medicines are available from physicians in a pharmacologic dosage.
There are two new anti-inflammatory medications, which are called cyclooxygenase-2 inhibitors. They aren't necessarily more effective than the other anti-inflammatories, but their safety profile (irritation to stomach and their risk of bleeding) has been improved.
What is the third class of drugs?
ALLAN GIBOFSKY, MD: The third class of agents are the disease modifying agents; drugs which are biologic agents or drugs which are immune suppressant agents. These would be drugs like Remicade (Infliximab) or Enbrel (etanercept).
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.
When a person is put on medicines for arthritis, can they expect to be on them for the rest of their lives?
ALLAN GIBOFSKY, MD: It depends on the type of arthritis, and a patient's goals. Sometimes in patients with osteoarthritis or degenerative arthritis, they may be on medications to treat symptoms. On the other hand, if they have surgery on the affected joint, that may be the definitive treatment, and all that they need. They can discontinue the anti-inflammatory or analgesics after that.
It's usually not so simple for a patient with rheumatoid arthritis. Ordinarily, they are on an anti-inflammatory and a disease-modifying agent. If not both, then certainly an anti-inflammatory for a chronic period of time.
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.
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.
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 helps. Laxity can occur to tendons and ligaments, leading to the development of an abnormal joint, which wears down faster than a normal joint. Physical therapy can make quite a difference.
How about the role of surgery for arthritis? Is there a place for it?
ALLAN GIBOFSKY, MD: Depending upon the degree of joint destruction, surgery may be the most appropriate approach. One clear thing about surgery is that it relieves pain. There is no pain in two pieces of metal like there is in two inflamed pieces of bone.
Are you talking about joint replacement?
ALLAN GIBOFSKY, MD: Joint replacement or joint implants. 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.
The real challenge is 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.
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