Treating Arthritis More than Just Physical Healing

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Patient education as important as drug therapy

The latest and most effective way to treat arthritis, to-date, is through an individualized approach combining drug therapy, diet, exercise, patient education, and as a last resort surgery, according to Lee S. Simon, M.D., Assistant Professor of Medicine at Harvard Medical School in Boston, Mass., and the Education Council Chairman of the American College of Rheumatology. Dr. Simon spoke at a recent AMA media briefing on arthritis.

Treatment Dilemma leads to New Advances

While drug therapy is a very important part of the arthritis treatment program, it also poses a dilemma because of the side effects of some commonly used arthritis medications. Nonsteroidal anti-inflammatory drugs (NSAIDs) decrease the pain and inflammation caused by arthritis, but they can also induce ulcers and other serious gastrointestinal complications in some people.

Dr. Simon is a member of an advisory committee to the Food and Drug Administration which has recently recommended changes in the labeling of NSAIDs. The committee continues to work on other strategies to address the problem.

In addition, researchers are trying to develop new drugs to treat arthritis patients. Several drug companies are working on a new type of arthritis medication that would reduce inflammation by inhibiting an enzyme called cyclooxygenase-2 (COX-2), without inhibiting another form of the enzyme, COX-1, which protects the stomach. Dr. Simon says efforts are also under way focusing on how to reconstitute cartilage damaged by arthritis, but progress on both fronts is still about five years away.

Drug Therapy: The Benefits

The first step toward developing a treatment program for an arthritis patient is identifying which of the 100 types of arthritis the patient has. Osteoarthritis is the most common form of arthritis. It is primarily a disease of the cartilage caused by wear and tear on the joints, and usually affects people later in life. "A person with osteoarthritis will likely be treated with one drug, initially an analgesic like acetaminophen to relieve pain," Dr. Simon explains. "However, a person with rheumatoid arthritis may have to take two, or even three drugs."

Rheumatoid arthritis is one of the most severe forms of arthritis. It is caused by the body's immune system attacking the joints and surrounding tissue. Dr. Simon says "diseases like rheumatoid arthritis would require one or two drugs to decrease pain and inflammation and then perhaps a slow-reacting drug to alter the natural history of the disease."

NSAIDs, which include prescription drugs and over-the-counter products like ibuprofen and naproxen, can help arthritis patients tolerate the disease better, thus improving mobility, but NSAIDs do not alter the natural history of the disease. In addition to an NSAID, a rheumatoid arthritis patient might also take one of a number of slow-reacting drugs called disease-modifying anti-rheumatic drugs (DMARDs). They include chloroquine or hydroxychloroquine (originally used to treat malaria), sulfasalazine (invented specifically to treat rheumatoid arthritis), methotrexate (an anti-cancer drug) or gold therapy (anti-rheumatic class of drugs). "Each DMARD has unique actions, which are unpredictable, and interfere with the cascade of events associated with rheumatoid arthritis," according to Dr. Simon. He adds that a rheumatoid arthritis patient may also be given a third type of drug, a corticosteroid, to reduce inflammation and help stop the body's immune system from attacking the joints and tissues.

Drug Therapy: The Side Effects

"NSAIDs revolutionized patient care because they allow patients who were stiff, sore and unable to work, walk or live a normal life, a chance to get up and get around. But every time you get something good, there seems to be something bad," says David Y. Graham, M.D., Professor of Medicine at Baylor College of Medicine, Houston, Texas, and Chief of Gastroenterology at the Veterans Administration Medical Center in Houston. "These drugs are dangerous. People can die from them. When we prescribe a drug to a patient, we not only have to discuss why the drug is good, but we also need to discuss the side effects and what to do to prevent these effects."

Certain anti-arthritis drugs including NSAIDs, aspirin, and corticosteroids stop the body from making fatty acids called prostaglandins which contain the COX-1 and COX-2 enzymes. Prostaglandins cause inflammation in damaged tissue; however, they are also responsible for protecting the stomach from the acids and other digestive juices that are needed to dissolve food. Without prostaglandins in the stomach, ulcers form.

About 15 percent of arthritis patients have ulcers. That compares to 1-2 percent of the general population, according to Dr. Graham, who says that ulcers in arthritis patients are also more likely to have complications. "They can cause bleeding, they can perforate all the way through the stomach or duodenum and cause a surgical emergency, or they can even cause an obstruction to the outlet of the stomach."

When the typical arthritis patients gets an ulcer, NSAIDs are stopped to allow the stomach to heal. "We then like to prevent the next ulcer from occurring by either switching the patient away from NSAIDs or using replacement therapy of prostaglandins," says Dr. Graham. "We can do the same thing prospectively. If we think a patient is at high risk for developing an ulcer or an ulcer complication, we can co-prescribe a prostaglandin to replace what is missing from the stomach lining."

Synthetic prostaglandins are relatively new in the treatment of arthritis patients. "We are now trying to figure out how to use synthetic-prostaglandin-replacement therapy safely and effectively. Doctors intuitively do not like to use a medicine to protect from the side effects of another medicine, but sometimes it is important to do so," says Dr. Graham. He recently authored a study in the Annals of Internal Medicine on the use of misoprostol, a prostaglandin, in the treatment of older rheumatoid arthritis patients taking NSAIDs. The study found that misoprostol reduced serious upper gastrointestinal complications by 40 percent.

Diet and Exercise Help the Mind as well as the Body

In addition to drug therapy, arthritis patients are also encouraged to exercise and eat right. "Exercise is a very important component to the care of arthritis patients," says Dr. Simon. "It may decrease the deformities caused by arthritis. It helps to maintain muscle strength and the activities of daily living, thereby helping to keep people independent and reduce their isolation." But, Dr. Simon says the exercise has to be judicious. "You don't want to exhaust the patient because that might make the disease worse."

"Diet is really critical, particularly in overweight people with osteoarthritis," say Dr. Simon. "We have learned that if you decrease weight, you decrease the stress across the knee and hip and improve the outcome of treatment."

Patient Education Critical Part of Arthritis Treatment

Patient education is a very important part of treating the arthritis patient, because not only do patients need to understand what drugs they are taking, but they also need to understand how important it is to take these medications properly. "Studies have shown that when a patient is supposed to take a drug four times per day, they really only take it correctly two or three times per day, " says Dr. Simon. "Another study on older patients showed that if they thought NSAIDs were just painkillers, more than 50 percent didn't take them right. If they understood NSAIDs are anti-inflammatory drugs, only about 25 percent didn't take them right."

As a result of patient education programs, Dr. Simon says he is seeing "patients who are feeling more empowered to talk to their doctors, who are interacting better with their doctors, and who are participating more in the decision-making process. That is critical because it allows the physician to be more efficient. It also helps the patient feel less isolated and more willing to participate in self-help programs and educational programs, and thus are more compliant with exercise and nutrition regimens. It is very easy in a chronic inflammatory state like in rheumatoid arthritis to become malnourished because it is so difficult to get out and buy food unless you understand why that is so important."

"Patients also need to be more proactive in dealing with their physicians. By developing an interactive relationship with their physician, patients can let their doctors know what is going on, and at the same time demand more information about their disease," says Dr. Simon. "Doctor means 'teacher' not 'caregiver' in Greek."

"The issue for doctors is that they need to realize there has to be a different kind of interaction with patients with chronic diseases than with patients with an intermittent, acute illness," says Dr. Simon. "Doctors need to enter into a contract with the patient to provide long-term hope and support. If we can't alter the natural history of the disease as sufficiently as we'd like, at least we can be there to help them through the process to keep them as functional as possible."

Surgery: A Last Resort

"There are times when all medical approaches fail. Under these circumstances, the appropriate surgical interventions may be critical," says Dr. Simon.

(Source: American Medical Association, 515 North State Street, Chicago, Illinois 60610, Telephone: 312-464-4443, FAX: 312-464-5839)

For more information on arthritis, go to:

The Arthritis Foundation Page: http://www.arthritis.org/

The Rheumatology Page: http://www.crl.com/~fredt/rheum.html

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