Ups and Downs

With so many kinds of arthritis, which can appear and progress unpredictably, diagnosis and treatment can be trying for both physician and patient. Diagnosis depends on integrating a host of factors, including the possibility that a person may have two forms of the disease.

The normal ups and downs of chronic, painful disease further complicate matters. "Just about any painful condition will wax and wane on its own," says rheumatologist Dennis Boulware, M.D., University of Alabama, Birmingham.

A worsening or reappearance of the disease is called a flare. Remissions bring welcome relief, but can also obscure whether symptoms decreased on their own or due to treatment.

Proper treatment depends on correct diagnosis of the specific disease, and varies with severity and location, as well as from person to person. But treatment need not wait for a final diagnosis because initial treatment options, such as anti-inflammatory drugs and exercise, are similar for many forms of the disease. Treatment should begin early to reduce joint damage.

The drugs used for treating most types of arthritis are drawn from many categories, but can be thought of in a few broad groups, such as anti-inflammatory drugs and disease-modifying drugs. For treating gout, there are also drugs that reduce the amount of uric acid in the blood. More than one medication may be required for treating arthritis.

Anti-inflammatory agents generally work by slowing the body's production of prostaglandins, substances that play a role in inflammation. Many have an analgesic, or painkilling, effect at low doses. Usually, higher, sustained doses are required to see sufficient anti-inflammatory activity for treating arthritis. The most familiar anti-inflammatory agent is aspirin, often a good arthritis treatment. Like aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) fight pain and inflammation. More than a dozen NSAIDs are available, most by prescription only. At press time, FDA was considering whether labeling changes to prescription-strength NSAIDs are necessary, due to gastrointestinal side effects.

FDA has approved three NSAIDs for over-the-counter (OTC) marketing: ibuprofen (marketed as Advil, Nuprin, Motrin, and others), naproxen sodium (sold as Aleve), and ketoprofen (marketed as Actron and Orudis). Although these drugs are available OTC, a doctor should be consulted before taking any medication for arthritis symptoms.

"People shouldn't be mixing these medications," says Linda Katz, M.D., of FDA's Center for Drug Evaluation and Research, and anyone regularly taking NSAIDs should carefully read the labels of OTC products to make sure they don't contain similar drugs. For example, many cough and cold preparations contain analgesics such as aspirin, acetaminophen or ibuprofen.

The most potent anti-inflammatories are corticosteroids, synthetic versions of the hormone cortisone. Like prednisone and dexamethasone, the generic names often end in "-one." They're usually reserved for short periods of use during intense flares or when other drugs don't control unrelenting disease. Relief can be dramatic, but long-term use causes side effects, such as weight gain, high blood pressure, and thinning of bones and skin. Usually given orally, they can also be injected directly into a joint to reduce side effects.

Disease modifiers slow the disease process in autoimmune diseases such as rheumatoid arthritis or systemic lupus erythematosus. Patients taking these drugs are closely monitored. It may take weeks or months to learn if a drug works. During that wait, it's important to keep taking other medications such as NSAIDs. Gold salts have been used to treat rheumatoid arthritis for 60 years, although nobody knows why this treatment works. Penicillamine, methotrexate, and antimalarials such as hydroxychloroquine are also used. Doctors usually reserve other powerful drugs that suppress the immune system for extremely serious disease.

Most people with arthritis never need surgery, but when all else fails, it can dramatically improve independence and quality of life by reducing pain and improving mobility. The surgeon may remove damaged or chronically inflamed tissue, or replace the joint entirely. Artificial replacements are available for all of the most commonly affected joints.

Use It or Lose It

In the past, doctors often advised arthritis patients to rest and avoid exercise. Rest remains important, especially during flares. But doing nothing results in weak muscles, stiff joints, reduced mobility, and lost vitality. Now, rheumatologists routinely advise a balance of physical activity and rest. Exercise offers physical and psychological benefits that include improved overall fitness and well-being, increased mobility, and better sleep.

For example, twice a week for three years, Elsie Sequeira, 81, of Concord, Calif., has attended a water-based exercise class sponsored by the Arthritis Foundation. "It's helped me a lot," she says. Sequeira has rheumatoid arthritis in her shoulders and legs. She had also had a mild stroke and got to her first classes with the help of a walker and an attendant.

A few weeks passed before she saw any improvement, but within a few months she no longer needed either the walker or the attendant. "The warm water is very soothing and we can do things in the water that we couldn't do on land," Sequeira says. She enjoys the social contact, and feels better able to take care of herself. "I don't feel so hamstrung," she says.

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Tags: Arthritis

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FDA is A United States government body that oversees medical devices, including contact lenses, intraocular lenses, excimer lasers and eyedrops. In the US, these products must be approved by the FDA before they can be marketed.