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Monday, May 7, 2018

Suffering from Arthritis

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You are not alone in this endeavor

Have you experienced joint pain or seen someone struggling with arthritis? If you have personally experienced joint symptoms, you are certainly not alone. From 2013-2015, an estimated 54.4 million U.S. adults (22.7%) annually had been told by a doctor that they had some form of arthritis. The most common form of arthritis is osteoarthritis. Other common rheumatic conditions include gout and rheumatoid arthritis. By 2040, an estimated 78 million (26%) U.S. adults age 18 years or older are projected to have doctor-diagnosed arthritis. Arthritis and other rheumatic conditions are a leading cause of work disability among U.S. adults in all states. One in 25 working-age adults (18-64 years old) face work limitations they attribute to arthritis; and among those with arthritis, at least one in four have work limitations. Adults with arthritis are about 2.5 times more likely to have falls and suffer a fall injury compared with adults without arthritis.

The risk of developing various types of arthritis increases with age. Most types of arthritis are more common in women; 52 percent of all adults with arthritis are women. Gout is more common in men. Specific genes are associated with a higher risk of certain types of arthritis, such as rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE).

Common Forms of Arthritis and Treatments

Osteoarthritis (OA) is the most common form of arthritis. As we grow old, many of us will develop some degree of OA in joints. OA usually begins after age 45, and it is more common in people over age 65. It affects knees, hips, lower back, neck, small joints of fingers, the bases of thumb and big toe (bunion formation). OA can lead to pain, stiffness and difficulty using joints. This arthritis develops slowly and can also be called “wear and tear arthritis.” In a normal joint, a firm, rubbery material called cartilage covers the surfaces of gliding bones and acts as a cushion. There is loss of elasticity of cartilage and ultimate cartilage breakdown by constantly using these joints. Apart from hereditary factors, OA is also worsened by weight gain/obesity, muscle weakness, overuse or injury of joints. OA is diagnosed by medical history and physical examination. Your doctor may order X-rays of affected areas and drain fluid from the joint to rule out other forms of arthritis.

OA is managed by medications, weight control and physical therapy. Physical therapy includes stretching exercises, stationary bicycle and water aerobics. Activities like yoga and tai chi may be helpful for people with arthritis. Medications for OA include non-steroidal anti-inflammatory agents (NSAIDs), like Naproxen and Ibuprofen, which can reduce pain, stiffness and inflammation. NSAIDs can cause stomach pain, bleeding and decline in renal function. Narcotic pain medications are also used in advanced OA. Topical pain medications including creams, gels, rubs, sprays and patches can be used for symptomatic relief. These have relatively less side effects if used according to recommended dosing guidelines.

Glucosamine and chondroitin sulfate are nutritional supplements for OA. These are beneficial for some patients, but research does not show clear benefit in all OA patients. Patients also can receive steroid injections in the joints three to four times in a year. Many patients have symptomatic benefits with these injections. Hyaluronan is a naturally occurring lubricant in joints; some patients also receive hyaluronan injections in the knee, leading to some benefit. Patients may need joint replacement surgery in advanced OA, mostly knees and hips; joint surgery is performed to improve a person’s functionality.

Gout affects about 8.3 million Americans. It can occur at any age, but most commonly starts in men after the age of 30. Women can get gout as well, but usually its onset is delayed until after menopause. Gout is caused due to deposition and uptake of uric acid crystals by white cells in the joint. Gout usually starts quickly and leads to a single red, extremely painful and swollen joint. The most common joint that is affected by gout is the large joint of the big toe. Later, knee, ankle, wrist or elbow swelling can happen with gout. Your doctor may drain fluid from the joint to look for uric acid crystals to confirm diagnosis. Gout attack is treated with non-steroidal anti-inflammatory drugs (NSAIDS) as well as steroid injections directly in the joint. Steroid injections in the joint can be the safest method for quick pain relief. If you have side effects due to nonsteroidals like kidney problems and more than one joint is swollen, steroids by mouth can be given with quick taper over two to three weeks.

Not all patients with gout need treatment to control uric acid in the body. Gout can be controlled in certain individuals by changing diet and avoiding excessive alcohol, red meat and purine-rich seafood. Sometimes blood pressure medications like thiazide diuretics should be switched to a different drug, as these can elevate uric acid level in the body. Obesity is linked to high uric acid, and patients with gout improve by losing weight.

If a person has multiple attacks (more than three per year), evidence of damage to joints by gout (erosions on X-rays), or uric acid starts making knots or nodules on the body called tophi, one has to be started on a uric acid-lowering treatment. These medications include Allopurinol and a new medicine called Febuxostat (uloric). Febuxostat can be used in patients with co-existing chronic kidney disease. Probenecid is also used, but it should be given to people with normal kidney function and with no history of uric acid kidney stones; patients need to drink almost a gallon of water every day. Colchicine can be also used to prevent gout flares, as it calms down the white cells.

Rheumatoid arthritis (RA) affects 1.3 million Americans. It usually begins between ages 40 and 60. RA develops over many weeks to months. It usually involves many joints, including small joints on both sides of the body. There is pain and swelling of fingers. One feels fatigued with prolonged stiffness at morning. There is also unexplained weight loss due to ongoing inflammation. Inflammation in the joints makes it challenging to move or use these “gelled” fingers in the morning.

RA is diagnosed with medical history, physical examination and blood testing. Blood testing includes markers of inflammation (Erythrocyte sedimentation rate and C reactive protein) and antibodies (Rheumatoid factor and anti-cyclic citrullinated peptide antibody). X-rays of hands and feet can show weak bones with damage (erosions) in certain areas. One must see a rheumatologist to get RA in good control.

Treatment of RA has improved a lot during the last two decades. Initial treatment of RA includes pain medications which are not dis ease-modifying drugs. RA should be managed by disease-modifying anti-rheumatic drugs (DMARDs) as soon as possible to prevent irreversible damage. Usually, patients are given DMARDs like Methotrexate, Hydroxychloroquine, Sulfasalazine and Arava.

These medications have been used for many years to control RA but have not been successful to achieve full remission (control of disease). A patient has been given steroids by mouth to control inflammation in joints in RA. Steroids are associated with many side effects with long-term use, including weak bones, diabetes, high blood pressure, stomach ulcers, increased risks of stroke and heart disease. Steroids should be only used initially in RA management for rapid response, but it is advisable to taper quickly to the lowest effective dose and stop within a few weeks.

RA treatment has improved significantly with the discovery of biologics. Biologics target certain chemicals or cells in the immune system which are causing damage to joints. These biologics include etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira), golimumab (Simponi), certolizumab pegol (Cimzia), tofacitinib (Xeljanz) and tocilizumab (Actemra). These medications have made remission (full control of disease) possible and have made a great impact on improving quality of life in RA.

One should not receive live vaccine while on biologic therapy. Biologics also make a few patients prone to infections like dormant TB reactivation, shingles, risk of demyelination with family history of multiple sclerosis and Hepatitis B reactivation. Rheumatologists follow their RA patients on biologics for these side effects very carefully.

Physical therapy, occupational therapy, steroid injections in the joints and weight control can also have a beneficial effect on RA. There is significant interest about changing diet in RA to see improvement, and studies have shown improvement with fish oil capsules along with continued medications.

The Center of Excellence of Arthritis and Rheumatology at LSU Health Shreveport has been actively involved in many research projects involving use of biologics in RA. We are participating in many ongoing drug trials to discover more biologics for treatment of this chronic and disabling disease. Because of a lack of availability of good biologic medications in the past, RA patients suffered from chronic deformities and disabilities. With the advent of biologics, the patient has full control of their disease with almost no irreversible damage to their joints. These are fascinating times for patients and rheumatologists to take care of the patient with excellent clinical response. If you or a loved one is experiencing these kind of joint symptoms, you should consult with your doctor as soon as possible, and you may need a rheumatology referral.

Samina Hayat, MD, is the Robert E. Wolf Professor of Medicine and Rheumatology, chief of the Rheumatology Section, and interim director of the Center of Excellence Arthritis and Rheumatology at LSU Health Shreveport. She is also the Rheumatology Fellowship Program Director.

Sarwat Umer, MD, is an associate professor of medicine/pediatrics and associate program director of the Rheumatology Fellowship with the Center of Excellence for Arthritis and Rheumatology at LSU Health Shreveport. She specializes in pediatric rheumatology.

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