Early treatment of rheumatoid arthritis is critical
Q: Why doesn’t rheumatoid arthritis have any medicines to help treat it?
A:
Rheumatoid arthritis is relatively common (as much as 1 percent of the population, with women twice as likely to be affected than men), but it’s a much less common form of arthritis than osteoarthritis, which affects as much as 40 percent to 50 percent of an older population. However, rheumatoid arthritis is much more feared because it can be destructive to the joints. It can also affect other parts of the body besides the joints, especially the heart, lungs, blood vessels and skin.
When I underwent training, I saw many patients with terrible deformities of their hands, but that is much less common now because there are many new and effective treatments for rheumatoid arthritis. It’s important for primary care doctors like me to recognize rheumatoid arthritis early and get our patients to the experts (rheumatologists) as quickly as possible to begin treatment before permanent damage to the joints occurs. Blood testing and X-rays usually confirm the diagnosis.
The typical symptoms of rheumatoid arthritis begin slowly, with joint pain and stiffness, especially in the morning, which might be mistaken for the more-common osteoarthritis. However, the pain from rheumatoid arthritis in the morning, or after a prolonged period of not moving, lasts much longer (usually over an hour) than osteoarthritis (usually under half an hour). The pain and stiffness are usually the same on one side as the other, and there is more likely to be warmth in the joints during an exam. Smaller joints, such as those in the fingers and wrists, are usually the earliest affected. These symptoms shouldn’t be ignored.
Early use of drugs to get RA under control (these are often called DMARDs, disease-modifying antirheumatic drugs) has become the standard of care. Methotrexate is probably the most common drug rheumatologists initially prescribe, but hydroxychloroquine is also frequently used.
Anti-inflammatory drugs, including NSAIDs like ibuprofen as well as steroids like prednisone, are often used at first to get symptoms under control while the DMARDs start working, which may take weeks or months. Once the disease is under control, prednisone-type drugs are stopped entirely or reduced as much as possible to avoid the many
long-term adverse effects of these drugs.
There are a wide range of biological therapies that are used in people who do not respond to this treatment. Many of these drugs, whose generic names end in “-mab,” are monoclonal antibodies working against certain cellular triggers for rheumatoid arthritis, such as tumor necrosis factor, interleukin-6, CD-20 on antibody-producing cells, and many others.
Other synthetic DMARDs work against the Janus kinase enzyme. These drugs end in “-nib.” The treatment of RA is so complex and changes so quickly that an expert who does this every day is by far the best choice when available.
Because RA can affect other organs, other specialists and treatments are sometimes necessary. For primary care doctors, it’s important to recognize
that the chronic inflammation of RA predisposes patients to developing heart disease and stroke at a much greater frequency than expected from their blood pressure and cholesterol levels. Early and aggressive use of treatments to reduce heart attack and stroke risk is appropriate.
Q: You recently had a column on arthritis that recommended more activity. So, what medications can help? You didn’t say in your article. I take a slow-release Tylenol, but I heard of a study that says tart cherry pills help.
A:
Tart cherry juice has been shown to reduce the risk of gout, a type of arthritis caused by uric acid crystals in the joint, by about 35 percent. This is specific to gout, however, and has not been shown to be effective, to my knowledge, in the most common type of
arthritis: osteoarthritis.
When I mentioned exercise treatment for arthritis, I meant specifically for osteoarthritis. Because exercise improves both function and reduces pain, it’s a critically important treatment and one which is often not recommended strongly enough. Many people worry that exercising on their arthritic joints will worsen the problem. We even used to call osteoarthritis wear-and-tear arthritis, leading people to think they will wear out their joints by exercising. However, most people find that the more they exercise, the less pain they feel when exercising.
Unfortunately, some people have such severe arthritis that it is very painful to move the joints, or exercise alone is inadequate for pain relief. For superficial joints, such as the hands and knees, I often recommend topical anti-inflammatories, especially diclofenac (Voltaren) gel, two or three times a day. This medicine gets into the superficial joints (it can’t penetrate into deep joints like the hip) and can relieve pain for many. It is very safe and worth a try.
If topical anti-inflammatories don’t help, I usually prescribe an anti-inflammatory by mouth. The over-the-counter medicines like ibuprofen and naproxen are very good for many people and pretty safe for most. However, they can cause stomach upset and even ulcers, especially in large and sustained doses and especially in older adults (women are a bit more susceptible). They can also cause kidney damage, too, so a discussion with your doctor is wise, even with these relatively safe medicines taken for a prolonged period. The prescription medications offer convenient dosing and work better in some people. It often takes several tries to find the right one.
Tylenol has long been used, but many people get inadequate benefit. And it, too, can cause damage after long-term use, especially to the liver and kidneys. I have had some success with antidepressants, especially duloxetine, as it has some pain benefits.
There are many newer treatments, such as knee injections, TENS units and knee embolization, that may offer some value before considering an aggressive surgery such as joint replacement.
Q: I “toot” a lot. I eat healthy — veggies, beans, grains, etc. — and don’t want to give those up. Can I take an anti-gas over-the-counter medicine after every meal? My spouse is anxious for your reply. Truthfully, my dog would appreciate it, too.
A:
You can take the overthe-counter medicines, but I don’t think they work particularly well. We inevitably pass gas as part of the intestinal bacteria working on undigestible parts of what we eat. The average person passes gas 10-20 times a day. Beans, cabbage, onions, broccoli, Brussels sprouts, wheat and potatoes commonly cause increased gas production, but as you say, these are a part of a healthy diet.
A food diary, combined with keeping track of your gas, might help identify the worst foods for you, but your spouse and dog should know this is also a part of being human.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Drive, Orlando, FL 32803.