Arthritis : Timely Treatments for an Ageless Disease

by Carol Lewis

MYTH: Arthritis affects only older people.

FACT: Arthritis affects any age, including children. There's no question that the incidence of arthritis increases with age, but nearly three of every five sufferers are under age 65.

MYTH: Arthritis is just minor aches and pains.

FACT: Arthritis can be permanently debilitating.

MYTH: Arthritis cannot be treated.

FACT: FDA recently approved several new treatments for osteoarthritis and rheumatoid arthritis.

The fact is, these myths keep people from seeking a doctor's help against the number one cause of disability in the United States, according to the national Centers for Disease Control and Prevention. Arthritis disables more Americans than heart disease and stroke, and CDC says it's what Americans don't know about the disease that can hurt them.

"People ignore arthritis both as public and personal health problems because it doesn't kill you," says Chad Helmick, a medical epidemiologist at CDC. "But what they don't realize is that as Americans work and live longer, arthritis can affect their quality of life and eventually lead to disability." Current costs to the U.S. economy total nearly $65 billion annually--an impact equal to a moderate recession.

And the extent of the suffering is going to get worse. Arthritis already affects more than 42 million Americans in its chronic form, including 300,000 children. By 2020, CDC estimates that 60 million people will be affected, and that more than 11 million will be disabled.

The Arthritis Foundation and the American College of Rheumatology agree that awareness, early diagnosis, and an aggressive treatment plan developed by a doctor are key to stopping arthritis from taking over your life.

What Is Arthritis?

Although the term literally means joint inflammation, arthritis really refers to a group of more than 100 rheumatic diseases and conditions that can cause pain, stiffness and swelling in the joints. Certain conditions may affect other parts of the body--such as the muscles, bones, and some internal organs--and can result in debilitating, and sometimes life-threatening, complications. If left undiagnosed and untreated, arthritis can cause irreversible damage to the joints.

The two most common forms of the disease, osteoarthritis and rheumatoid arthritis, have the greatest public health implications, according to the Arthritis Foundation.

Osteoarthritis, previously known as "degenerative joint disease," results from the wear and tear of life. The pressure of gravity--the load of living--causes physical damage to the joints and surrounding tissues, leading to pain, tenderness, swelling, and decreased function. Initially, osteoarthritis is noninflammatory and its onset is subtle and gradual, usually involving one or only a few joints. The joints most often affected are the knee, hip and hand. Pain is the earliest symptom, usually made worse by repetitive use. Osteoarthritis affects more than 20 million people, and the risk of getting it increases with age. Other risk factors include joint trauma, obesity, and repetitive joint use.

Rheumatoid arthritis is an autoimmune disease that occurs when the body's own immune system mistakenly attacks the synovium (cell lining inside the joint). This chronic, potentially disabling disease causes pain, stiffness, swelling, and loss of function in the joints.

To see an illustration of the cross section of a normal knee joint and the effects of osteoarthritis and rheumatoid arthritis, select the graphic at right.

While the cause remains elusive, doctors suspect that genetic factors are important in rheumatoid arthritis. Recent studies have begun to tease out the genetic characteristics that can be passed from generation to generation. However, the inherited trait alone does not cause the illness. Researchers think this trait, along with some other unknown factor--probably in the environment--triggers the disease.

But rheumatoid arthritis can be difficult to diagnose early because it may begin gradually with subtle symptoms. According to CDC, this form of arthritis affects more than 2 million people in the United States, and two to three times more women are affected than men.

Finding Effective Treatments

For years, the pain and inflammation of arthritis have been treated with varying success, using medications, local steroid injections, and joint replacement. Seldom did the therapies make the pain go away completely or for very long, nor did they affect the underlying joint damage. Just ask Jo Ellen Gluscevich, who has tried more drugs and treatments than she can remember, to no avail.

"It seems I've tried them all," says the 50-year-old from Frederick, Md., who was diagnosed with rheumatoid arthritis 10 years ago. "Every year continues to be a challenge for me medically."

But now there are some new treatments available, and patients should consult with their doctors to determine which are the most appropriate for their conditions.

Osteoarthritis

When taken regularly and at high doses, traditional nonsteroidal anti-inflammatory drugs (NSAIDs) used for pain relief can cause gastrointestinal (GI) bleeding or ulcers. But a new type of NSAID, cyclooxygenase-2 inhibitors, better known as COX-2 inhibitors, has joined the old standbys and helps suppress arthritis with less stomach irritation.

Cyclooxygenases are enzymes needed for the synthesis of hormone-like substances called prostaglandins. There are two types of cyclooxygenases: the COX-2 enzyme that mediates inflammation and pain, and the COX-1 enzyme that helps maintain other physiological functions in the body. Traditional NSAIDs inhibit both enzymes. The new NSAIDs, however, block mostly the COX-2 enzyme, offering a new treatment option for people who have had difficulty tolerating the old NSAIDs.

"COX-2 inhibitors are just as effective in treating osteoarthritis as other NSAIDs," says Maria Villalba, M.D., a medical officer with FDA's Center for Drug Evaluation and Research. "And they have similar renal effects, liver effects and the potential for allergic reactions. But they seem to have a better GI safety profile than traditional NSAIDs."

FDA approved the first COX-2 inhibitor, Celebrex (celecoxib), in December 1998 to treat rheumatoid arthritis and osteoarthritis. Vioxx (refecoxib) became the second COX-2 inhibitor to receive approval, in May 1999, but only for the treatment of osteoarthritis, dysmenorrhea (pain with menstrual periods), and the relief of acute pain in adults, such as that caused by dental surgery.

Both drugs, taken orally, were found to substantially lower the risk of stomach and upper intestinal ulcers detected by endoscopy in clinical trials, compared with other NSAIDs. Additional studies are needed to determine whether Celebrex and Vioxx actually cause fewer serious stomach problems, including GI ulceration, bleeding and perforation. Until such studies are done, FDA is requiring the drugs' labeling to include the standard warning about the GI risks that are associated with NSAIDs.

Two non-drug alternatives for the treatment of pain in osteoarthritis of the knee were approved by the Center for Devices and Radiological Health in 1997 for patients who have failed to respond adequately to simple analgesics, such as acetaminophen, and to conservative nonpharmacologic therapy. Hyalgan and Synvisc are viscous solutions composed of hyaluronan (hyaluronic acid, a lubricant found naturally in the joints), and are injected directly into the knee joint. Both are believed to increase the quality of synovial fluid, although the mechanism of action for these products is not well understood. The most common side effects reported from these treatments--injection site pain and knee pain and/or swelling--were found to be temporary. For patients who cannot tolerate oral medications and who are not candidates for surgical knee replacement, these treatments may be an ideal option.

Rheumatoid Arthritis

In recent years, the typical treatments for rheumatoid arthritis relied on combination NSAIDs, such as ibuprofen and aspirin. These drugs reduce swelling and alleviate pain but do little to change the course of the disease. Another class of treatments relied on disease-modifying, antirheumatic drugs (DMARDs), such as methotrexate and sulfasalazine. DMARDs work to slow inflammation and can, in many cases, alter the course of the disease. Because of their adverse effects, most doctors reserved these more powerful drugs for patients who failed to respond to other therapies. Now, many physicians are using DMARDs early and aggressively in the hope of slowing disease progression and preventing damage to joints and internal organs.

The most recently approved treatment regimen for rheumatoid arthritis is one that combines the genetically engineered biological drug Remicade (infliximab) with the drug methotrexate. (Not all patients with rheumatoid arthritis can tolerate or respond to methotrexate alone, a standard treatment for the disease.) Remicade is the second in a new class of drugs known as biologic response modifiers, which bind to and block the action of a naturally occurring protein called tumor necrosis factor (TNF), believed to play a role in joint inflammation and damage. Elevated levels of TNF are found in the synovial fluid of rheumatoid arthritis patients.

Remicade, which is administered intravenously by a health-care professional in a two-hour outpatient procedure, was approved by FDA in November 1999 to reduce the signs and symptoms in patients who have not experienced significant relief from methotrexate alone.

Approved in November 1998, Enbrel (etanercept) is the first biologic response modifier to receive FDA approval for patients with moderate to severe rheumatoid arthritis. Taken twice weekly by injection, Enbrel was shown to decrease pain and morning stiffness and improve joint swelling and tenderness. In June 2000, the drug's uses were expanded to include delaying structural damage.

Jeffrey N. Siegel, M.D., a medical officer with FDA's Center for Biologics Evaluation and Research, says that Enbrel is an exciting breakthrough because it helps a majority of patients who have not responded to any of the other commonly used therapies. Although it is injected, the treatment can be administered at home. In addition, Enbrel has been shown to be effective for children with the juvenile form of rheumatoid arthritis. In clinical trials, Enbrel was generally well tolerated, and one of the most common side effects was an injection site reaction.

Both Remicade and Enbrel show promise in treating rheumatoid arthritis, although the long-term risks and benefits of these drugs are unknown.

Arava (leflunomide) is the first oral treatment approved for slowing the progression of rheumatoid arthritis. Although its effects are similar to those of methotrexate, this drug works by a different chemical mechanism, blocking an enzyme in certain lymphocytes (a type of white blood cell that is part of the immune system) and thereby retarding the progression of the disease.

Arava is not a cure, however, and studies have suggested that the drug may cause birth defects. Therefore, its labeling carries a special warning for pregnant women, women of childbearing age, and those who want to become pregnant.

The first non-drug alternative for adult patients with moderate to severe rheumatoid arthritis and longstanding disease who have failed or cannot tolerate DMARDs was approved by FDA in March 1999. The Prosorba column, which was initially approved in 1987 to treat an immune blood disorder, is a single-use medical device, about the size of a coffee mug, containing a material that binds antibodies and antigen-antibody complexes.

In a two-hour process performed in a hospital or specialized treatment center, a patient's blood is removed and passed through a machine that separates the blood cells from the plasma (the liquid portion of the blood). The plasma is then passed through the Prosorba column, recombined with the blood cells, and returned to the patient. Although this filtering process is believed to remove proteins that may inadvertently attack the joint cells, the mechanism of action of the Prosorba column is not well understood. The treatment is given once a week for 12 weeks. The most common side effects include joint pain and/or swelling, fatigue, hypotension (low blood pressure), and anemia.

"For those patients who have failed or are intolerant to DMARDs, including Arava and the anti-TNF agents," says Sahar M. Dawisha, M.D., a medical officer in FDA's Center for Devices and Radiological Health, "the Prosorba column may be an additional treatment option."

Exercise and Arthritis

Proper exercises performed on a regular basis are an important part of arthritis treatment, according to the Arthritis Foundation. Twenty years ago, doctors advised exactly the opposite, fearing that activity would cause more damage and inflammation. Not exercising causes weak muscles, stiff joints, reduced mobility, and lost vitality, say rheumatologists, who now routinely advise a balance of physical activity and rest.

According to the 1996 Surgeon General's Report on Physical Activity and Health, regular, moderate physical activity is beneficial in decreasing fatigue, strengthening muscles and bones, increasing flexibility and stamina, and improving the general sense of well-being. The National Institutes of Health advises that the amount and form of exercise should depend on which joints are involved, the amount of inflammation, how stable the joints are, and whether a joint replacement procedure has been done. A skilled physician who is knowledgeable about the medical and rehabilitation needs of people with arthritis, working with a physical therapist, can design an exercise plan for each patient.

Three main types of exercises are recommended:

• Range-of-motion--moving a joint as far as it will comfortably go and then stretching it a little further to increase and maintain joint mobility, decrease pain, and improve joint function. These can be done daily, or at least every other day.
• Strengthening--using muscles without moving joints to help increase muscle strength and stabilize weak joints. These can be done daily, or at least every other day, unless there is severe pain or swelling.
• Endurance--aerobic exercises such as walking, swimming and bicycling to strengthen the heart and lungs and increase stamina. These should be done for 20 to 30 minutes, three times a week, unless there is severe pain or swelling.

Unproven Remedies

Many people with arthritis become discouraged with typical treatments because the disease progresses over time and the symptoms worsen. Consequently, they search for alternative therapies aimed at arthritis. But arthritis patients need to be careful because treatments not shown to be safe and effective through controlled scientific studies may be dangerous. According to the Arthritis Foundation, the benefits of a treatment in controlling arthritis should be greater than the risk of unwanted or harmful effects. Since arthritis symptoms may come and go, a person using an unproven remedy may mistakenly think the remedy worked simply because he or she tried it when symptoms were going into a natural remission.

Two controversial nutritional supplements, not approved by FDA, have catapulted into the spotlight because of claims that they rebuild joint tissues damaged by osteoarthritis--or halt the disease entirely. But at this time, the use of glucosamine and chondroitin sulfate supplements warrant further in-depth studies on their safety and effectiveness, according to the Arthritis Foundation. NIH plans to study the effectiveness of these supplements.

Both glucosamine and chondroitin sulfate occur in the body naturally and are vital to normal cartilage formation, but the Arthritis Foundation says there's no evidence that swallowed chondroitin is absorbed into the body and deposited into the joints. Moreover, no one knows how much glucosamine and chondroitin sulfate are in the bottles since current law does not require dietary supplements to be manufactured under the same good manufacturing practice standards as pharmaceuticals. As reported in the December 1999 UC Berkeley Wellness Letter, "It's a hit-or-miss proposition because there's no standardization and no guarantee that you're getting what the label says."

The Arthritis Foundation urges anyone considering using these supplements to become "fully educated about potential positive and negative effects." In addition, people are encouraged to consult their physicians about how the supplements fit within their existing treatment regimens. Above all, do not stop proven treatments and disease-management techniques in favor of the supplements.

The Arthritis Foundation also says that copper bracelets, mineral springs, vibrators, magnets, vinegar and honey, dimethyl sulfoxide, large doses of vitamins, drugs with hidden ingredients (such as steroids), and snake venom are all unproven remedies. And any unproven remedy, no matter how harmless, can become harmful if it stops or delays someone from seeking a prescribed treatment program from a knowledgeable physician.

Prevention Measures

There are ways to help prevent arthritis. Both CDC and the American College of Rheumatology recommend maintaining ideal weight, taking precautions to reduce repetitive joint use and injury on the job, avoiding sports injuries by performing warm-ups and strengthening exercises using weights, and by choosing appropriate sports equipment.

Lyme arthritis may develop after a bacterial infection is transmitted to humans through tick bites. To prevent this type of arthritis, health experts advise people to use insect repellents, wear long-sleeved shirts and pants while walking near wooded areas, and check for and remove ticks to help reduce the risk of getting the disease. CDC also recommends the prompt use of antibiotics for Lyme disease symptoms. In December 1998, FDA approved the first vaccine, Lymerix, to help prevent Lyme disease.

Hope for the Future

The recent rise in the number of effective new arthritis treatments offers the hope that still better therapies are just over the horizon. For Jo Ellen Gluscevich, the results have not been so dramatic. She remains mostly housebound and must avoid crowds because her immune system is compromised and susceptible to infection. But as the population ages and arthritis becomes a growing problem, the Arthritis Foundation believes that "more physicians are recognizing the severity of the disease and the need for a broader approach toward treatment."

Other Forms of Arthritis and Related Conditions

In addition to rheumatoid and osteoarthritis, there are a number of diseases and conditions that can cause joint pain and stiffness.

Juvenile arthritis is a general term for all types of arthritis that occur in children. Juvenile rheumatoid arthritis is the most prevalent form in children, and there are three major types: polyarticular (affecting many joints), pauciarticular (pertaining to only a few joints), and systemic (affecting the entire body). The signs and symptoms of juvenile rheumatoid arthritis vary from child to child. There is no single test that establishes conclusively a diagnosis of juvenile arthritis, and the condition must be present consistently for six or more consecutive weeks before a correct diagnosis can be made. Heredity is thought to play some part in the development of juvenile arthritis. However, the inherited trait alone does not cause the illness. Researchers think this trait, along with some other unknown factor (probably in the environment), triggers the disease. The Arthritis Foundation says that juvenile arthritis is even more prevalent than juvenile diabetes and cerebral palsy.

Gout is a disease that causes sudden, severe attacks of pain, tenderness, redness, warmth, and swelling in some joints. It usually affects one joint at a time, especially the joint of the big toe. The pain and swelling associated with gout are caused by uric acid crystals that precipitate out of the blood and are deposited in the joint. Factors leading to increased levels of uric acid and then gout include excessive alcohol intake, hypertension, kidney disease, and certain drugs.

Ankylosing spondylitis is a chronic inflammatory disease of the spine that can fuse the vertebrae to produce a rigid spine. Spondylitis is a result of inflammation that usually starts in tissue outside the joint. The most common early symptoms of spondylitis are low back pain and stiffness that continues for months. Although the cause of spondylitis is unknown, scientists have discovered a strong genetic or family link, according to the Arthritis Foundation. Most people with spondylitis have a genetic marker known as HLA-B27. Genetic markers are protein molecules located on the surface of white blood cells that act as a type of "name tag." Having this genetic marker does not mean a person will develop spondylitis, but people with the marker are more likely to develop the disease than those without. Ankylosing spondylitis usually affects men between the ages of 16 and 35, but it also affects women. Other joints besides the spine may be involved.

Systemic lupus erythematosus is an autoimmune disease that can involve the skin, kidneys, blood vessels, joints, nervous system, heart, and other internal organs. Symptoms vary among those affected, but may include a skin rash, arthritis, fever, anemia, hair loss, ulcers in the mouth, and kidney sediment or function abnormalities. In most cases, the symptoms first appear in women of childbearing age; however, lupus can occur in young children or older people. Studies suggest that there is an inherited tendency to get lupus. Lupus affects women about 9 to 10 times as often as men. It is also more common in African-American women.

Related Arthritis Conditions

Bursitis, tendinitis and myofascial pain are localized, nonsystemic (not affecting the whole body) painful conditions. Bursitis is inflammation of the sac surrounding any joint that contains a lubricating fluid. Tendinitis is inflammation of a tendon, and myofascial pain is a problem that results from the strain or improper use of a muscle. These conditions may start suddenly, and usually stop within a matter of days or weeks.

Carpal tunnel syndrome is a condition in which pressure on the median nerve at the wrist causes tingling and numbness in the fingers. It can begin suddenly or gradually, and can be associated with another disease, such as rheumatoid arthritis, or it may be unrelated to other conditions. If untreated, it can result in permanent nerve and muscle damage. With early diagnosis and treatment, there is an excellent chance of complete recovery.

Fibromyalgia syndrome is a condition with generalized muscular pain, fatigue, and poor sleep that is believed to affect approximately 2 percent of the U.S. population, or 5 million people. The name fibromyalgia means pain in the muscles, ligaments and tendons. The condition mainly affects muscles and their attachments to bones. Although it may feel like a joint disease, the Arthritis Foundation says it is not a true form of arthritis and does not cause deformities of the joints. Fibromyalgia is instead a form of soft tissue or muscular rheumatism.

Infectious arthritis is a form of joint inflammation that is caused by bacteria, viruses or fungi. The diagnosis is made by culturing the organism from the joint. Most infectious arthritis can be cured by antibiotic medications.

Psoriatic arthritis is similar to rheumatoid arthritis. About 5 percent of people with psoriasis, a chronic skin disease, also develop psoriatic arthritis. In psoriatic arthritis, there is inflammation of the joints and sometimes the spine. Fewer joints may be involved than in rheumatoid arthritis, and there is no rheumatoid factor in the blood.

Reiter's syndrome involves inflammation in the joints, and sometimes where ligaments and tendons attach to bones. This form of arthritis usually develops following an intestinal or a genital/urinary tract infection. People with Reiter's syndrome have arthritis and one or more of the following conditions: urethritis, prostatitis, cervicitis, cystitis, eye problems, or skin sores.

Scleroderma is a disease of the body's connective tissue that causes thickening and hardening of the skin. It can also affect joints, blood vessels, and internal organs. There are two types of scleroderma: localized and generalized.

Carol Lewis is a staff writer for FDA Consumer. This article originally appeared in the FDA Consumer magazine, published by the U.S. Food and Drug Administration, in the May-June 2000 issue.