TREATING RHEUMATOID ARTHRITIS



There is no cure for Rheumatoid Arthritis. The best approach for treating Rheumatoid Arthritis is a team approach between the patient and health care providers, family physician, rheumatologist, and a doctor specializing in internal medicine.

Treatment will be tailored to your needs taking into account, severity of your disease. General treatment includes medication to relieve Symptoms or modify the disease itself, physical and occupational therapy as well as exercise, proper rest and a healthy diet . Support groups are often recommended, helping a patient learn about their condition as well as giving a feeling of not being alone in their pain.

Surgery used in treating Rheumatoid Arthritis, such as joint replacement, tendon reconstruction and synovectomy (removal of inflamed synovial tissue, generally used in combination with tendon reconstruction) are options in patients with a prolonged or severe form of rheumatoid arthritis.

The goals of treating rheumatoid arthritis are as follows:

    - Relieve pain

    - Reduce inflammation

    - Slow down or stop joint damage

    - Preserve full range of motion

    - Improve the patient’s sense of well-being and ability to function



Drug Treatments

The drugs used in treating Rheumatoid Arthritis are placed into various categories based on the areas each one addresses, listed below are the categories as well as some of the known side effects and limitations they create.

NSAIDs (Nonsteroidal Anti-inflammatory Drugs) Considered to be the least potent of the drugs used in treath Rheumatoid Arthritis. NSAIDs are often the first treatment considered to avoid toxic effects.

These are non steroidal anti-inflammatory drugs used to relieve pain by reducing inflammation in the joints.

If a patient does not find relief after 4 – 6 weeks of treatment with NSAIDs, more potent drugs are added.

Some of the most common over the counter types are; ibuprofen (Advil, Motrin IB, Nuprin, Rufen), naproxen (Aleve, Naprosyn) aspirin and ketoprofen (Actron, Orudis KT) Common prescription types include; celecoxib (celebrex), diclofenac(voltaren), etodolac (lodine), fenoprofen(nalfon), indomethacin (indocin) ketoprofen (orudis, oruvail), oxaprozin (daypro), nabumetone (relafen), tolmetin (tolectin) and refecoxib (vioxx) Vioxx was removed from the market September 30, 2004. FDA analysts estimate that Vioxx caused between 88,000 - 139,000 heart attacks, 30 to 40 percent of which were probably fatal, in the five years the drug was on the market.

Side Effects and Complications related to taking NSAIDs

Regular use of NSAIDs, prescription, or over-the-counter brands, create complications and somewhat serious side effects as listed below.

The American Heart Association, February 26, 2007 made a statement recommending doctors change their approach to prescribing pain relievers for patients with or at risk for heart disease. To read more on this visit The American Heart Associate

    - Upset stomach causing nausea and vomiting

    - Ulcers and gastrointestinal bleeding

    - Increased blood pressure

    - Dizziness or ringing in the ear

    - Headaches

    - Drug interference as regular use may delay the emptying of the stomach. This is noted especially in elderly patients.

    - Skin Rash

    - Depression

    - Confusion

    - Possibility of higher risk for kidney damage. Any sudden weight gain or swelling needs to be reported to a physician.

    - Liver Toxicity

    - Complications with drug interaction for Diabetics taking oral hypoglycemics, careful monitoring is required to adjust dosage accordingly.

No NSAIDs should be used for long-term pain relief without direction from a physician due to complications with drug interactions and side affects from long term usage.

DMARDs (Disease-Modifying Anti-Rheumatic Drugs)

Early treatment with DMARDs appears to improve a patient’s long-term outcome and quality of life. These are the standard second line drugs in the treatment of RA. Many DMARDs were used for other diseases where they were found accidentally to help RA patients slow down the progression of this disease.

Some common DMARD’s include;

Hydroxychloroquine (Plaquenil)

Originally used for preventing malaria, now used in mild, slow progressing cases of RA. The benefits include; pain relief, improved mobility and has the least toxic effects.

This treatment generally takes three to six months to achieve full benefit and does not appear to slow the progression of Rheumatoid Arthritis.

Side Effects and Complications related to Hydroxychloroquine

    - Gastrointestinal complaints are fairly common

    - Mild headaches and eye problems

    - Damage to the retina (not generally seen with low doses and damage can be repaired if caught early).

    - Has been known to aggravate psoriasis

    - Slight risk for birth defects

Sulfasalazine (Azulfidine)

Developed in the 1930’s for treating Rheumatoid Arthritis and has recently regained popularity in both adult and juvenile forms of RA and is considered most effective when the disease is confined to the joints.

Relief of symptoms generally occurs in four weeks.

Patients who have allergies to sulfa drugs or salicylates should not take sulfasalazine as well as people with intestinal or urinary obstructions.

Side Effects and Complications related to Sulfasalazine

    - Stomach and intestinal distress

    - Skin rashes

    - Sensitivity to sunlight

    - In rare cases, lung problems

Methotrexate

Methotrexate acts as an anti-inflammatory agent and is currently the most commonly used DMARD in treating Rheumatoid Arthritis because of its success in long term usage.

Relief of symptoms generally occurs within a few weeks.

Methotrexate has been found most effective when used in a combination with other DMARDs or agents.

Side Effects and Complications related to Methotrexate

    - Kidney and liver damage

    - Possibly osteoporosis when used in high doses

    - Increased risk for infections

    - Increased risk of Lung disease

    - Risk of birth defects when taken by a pregnant woman

    - Report of lymphomas, disease appears to go into remission when the drug is stopped.

Gold, Injected (Solganal, Myochrysine) and Oral (Ridaura)

Gold is administered either orally (less side effects) or through an injection. Pregnant women or people with conditions of the heart, kidney, liver, skin and blood should be very cautious about this line of therapy.

Injected gold is consider the most toxic of all the DMARDs during the early stages of treatment, however over the long term it may be among the least toxic.

Side Effects and Complications related to Gold

    - Skin rash and mouth sores (both oral and injected forms of gold)

    - Kidney damage (injected gold)

    - Decreased white blood cell count (injected gold)

    D-penicillamine (Cuprimine, Depen)

Usage of penicillamine is declining and more than half the patients using this treatment withdraw because of side effects.

This treatment can take up to one year to be effective in reducing the effects of RA.

Side Effects and Complications related to D-penicillamine

    - Stomach and intestinal complications similar to gold treatment

    - Can leave a metallic taste in ones mouth or no taste at all

    - Inflamed muscles

    - Skin blisters and fever

    - Liver and kidney damage

    - Problems in the lungs.

Cyclosporine (Sandimmune, Neoral)

Cyclosporine is an immunosuppressant proven to be an effective and safe agent used in combinations or on it’s own in treating Rheumatoid Arthritis. Originally considered a third line drug but often now listed as one of the DMARDs.

Combining Cyclosporine with Methotrexate use appears is particularly effective.

Side Effects and Complications related to Cyclosporine

    - gum disease

    - hair growth

    - flare-up in the joints

    - reports associating cyclosporine with an increased risk for cancer

Combining DMARDs with each other or with drugs in other categories appears to offer patients the greatest results. Methotrexate is now the most frequently used, particularly for severe cases. Unfortunately DMARDs tend to lose effectiveness over time and patients rarely use one for more than two years, although methotrexate has the best record to date for long term use.

Corticosteroids (Steroids)

Corticosteroids are used to control inflammation in the joints and the pain associated with RA, giving rapid relief. Oral corticosteroids are considered about as effective as aspirin and often used as an alternative to NSAIDs for patients who have severe problems with NSAIDs. Use of oral corticosteroids is considered useful when used in combination with DMARDs, as this combination significantly enhances the benefits of the DMARDs.

Steroids can be injected directly into joints for relief of flare-ups when only a few joints are affected. Steroid injections into the joint may be a safe and effective treatment for juvenile rheumatoid arthritis however experts suggest no more than three or four injections per year.

Corticosteroid pulse therapy or intravenous administration may be as helpful as DMARDs.

Side Effects and Complications related to Oral Corticosteroids

Long term use of Oral Corticosteroid create serious side effects, however these side effects appear to be reduced using low doses. With long term use a person may suffer from osteoporosis, cataracts, glaucoma, diabetes, fluid retention, increased risk of infections, weight gain, hypertension, capillary fragility, excess hair growth, acne, wasting of the muscles, irregular menstrual cycles, irritability, insomnia and psychosis.

No one should discontinue use of steroids without consulting a physician and continued follow up. It can take the body a while (up to one year) to regain its ability to produce natural steroids after long term treatment with Corticosteroids.

Biologic Response Modifiers

Biologic Response Modifiers are genetically engineered drugs that interfere with specific components of the autoimmune response in RA. They are the first agents to produce the dramatic effects originally seen with corticosteroids.

In RA patients the synovial fluid shows signs of elevated levels of tumor necrosis factor (TNF) which is believed to play a role in joint inflammation and damage. The biologic response modifiers bind to and block the action of this naturally occurring protein (TNF).

Remicade (infliximab)

Remicade was approved in August of 1998, administered intravenously by a health-care professional in a two hour outpatient procedure. This treatment can be used alone or in combination with methotrexate to reduce the signs and symptoms in patients who have not experienced significant relief from methotrexate alone. The combination appears to halt progression of joint damage in many patients.

Enbrel (etanercept)

Enbrel was approved in 1996 as the first biologic response modifier to receive FDA approval for patients with moderate to severe rheumatoid arthritis. Taken by injection twice weekly Enbrel was shown to decrease pain and morning stiffness and improve joint swelling and tenderness. There are signs that Enbrel will delay structural damage as well.

Both Remicade and Embrel show promise in the treatment of RA however the long-term risks and benefits of these agents are not known. Caution should be used in patients with a history of recurring infections or with underling conditions that may predispose patients to infections.

Side Effects and Complications related to Biologic Response Modifiers

The side effects of the two agents are similar. The most common adverse effects are minor reactions at the injection site, but there are a few other immediate side effects.

    - Possible severe infections, particularly in people for people susceptible such as those with uncontrolled diabetes or anyone with an active infection.

    - There have been a few reports of aplastic anemia

    - In rare cases both treatments have been associated with nerve damage that resembles multiple sclerosis resulting in confusion, numbness, changes in vision and difficulty walking. Some experts recommend patients with multiple sclerosis avoid these agents until further research is completed.

    - Leukopenia - low white blood cell count

    - Neutropenia - low number of neutrophils, a type of white blood cell

    - Thrombocytopenia - low blood platelet count

    - Pancytopenia - A shortage of all types of blood cells, including red and white blood cells and platelets

Immunosuppressants

Third-Line Drugs used for treatment of very severe active rheumatoid arthritis include Azathioprine (Imuran), Cyclophosphamide (Cytoxan) and Chlorambucil . The role of this treatment is to suppress the body’s immune system.

Of the three, Azathioprine is the most commonly used. All are potentially very toxic and should be used only in cases where other drugs are ineffective. Blood counts need to be monitored to check for anemia and more serious blood problems during treatment.

Side Effects and Complications related to Immunosuppressants

    - Anemia

    - Increase in certain cancers has been associated with the use of these agents.

    - Increased risk of infection

    - Toxic



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NON DRUG ALTERNATIVES

The first non-drug alternative for adult patients with moderate to severe rheumatoid arthritis and longstanding disease was approved by the FDA in 1999.

Prosorba Column

This procedure removes inflammatory antibodies from the patient’s blood with a device called the Prosorba column. Studies have indicated that the therapy can slow or even halt the progression of RA in a third to half of the patients being treated with this method.

The procedure involves.

- Removal of the blood from the patient’s body through a catheter.

- The blood is passed through a column about the size of a coffee mug. This column is coated with a substance called protein A, which binds to the antibodies.

- The blood, after passing through the column is then returned to the patient

- This procedure is repeated weekly for 12 weeks with each treatment session lasting approximately two and a half hours.

Side Effects and Complications related to the Prosorba Column

    - Anemia

    - Fatigue

    - Fever

    - Itching

    - Drop in blood pressure

    - Nausea

    - Most patients experience an immediate flare-up of joint pain, lasting a few days.

    - Possible infection from the catheter used to remove blood.

    Joint Surgeries

For RA patients who suffer with severe deformities or disabilities there are certain surgical techniques that have been found helpful.

Arthroscopy

This procedure is most commonly performed on the knee but may also be done on the hip. This is where a surgeon uses a device called an arthroscope inserted into the joint to view the joint while he removes bone and cartilage fragments that cause pain and inflammation.

The treatment is most successful when only fragments of cartilage are removed.

Often preformed under local anesthetic as a day surgery where on average a person having this procedure on the knee can expect to resume mild activity within a couple of days, full recovery taking up to three months.

Osteotomy

Knee surgery that involves removing damaged tissue from the knee, then reshaping the bone to remove the deformity.

This procedure is only for patients with a certain section of the knee damaged and is found most beneficial in heavier adults who are under the age of 60.

Unicompartmental Knee Arthroplasty

Unicompartmental Knee Arthroplasty is where the knee is opened via a small incision and small implants are inserted.

This procedure is intended to relieve pain and preserve function of the knee for as long as possible before a total knee replacement is necessary in patients with limited damage in the knee.

Not widely available and considered somewhat controversial since the implants are not considered as reliable as those in total knee replacement.

Synovectomy

With a synovectomy the disease joint lining is removed to reduce symptoms. Most commonly performed on the wrist joint this procedure is used when more conservative measures have failed.

Joint Replacement Surgery

When normal functioning is no longer possible artificial replacement joint implants may be considered for the knees, hips or other joints.

This procedure was generally held off until the later years (60+), however recently younger patients with severe disabilities are finding them useful and the implants are now lasting 20 years and longer.




Complementary or Alternative Treatments for Rheumatoid Arthritis

Healing Foods



The following link is for info on Osteo Arthritis. OsteoArthritis, Joint Pain and Arthritis Relief Arthritis.realage.com offers valuable information regarding osteoarthritis, joint pain, and medically proven steps for arthritis relief.



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This information is not designed as or intended to be used as medical diagnosis or advice. Patients should consult their physicians about diagnosis and treatment





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