Rheumatoid Arthritis.
Last updated Wednesday, September 14, 2005
Management and treatmentTreatment The goals of current RA treatment methods are to relieve pain, reduce inflammation, stop or slow down joint damage, and improve function and patient well-being.
There is no single standard treatment that applies to all people
with RA. The disease may be very different from person to person.
Instead, a treatment program should be designed to best meet each
person's needs, taking into account how severe the arthritis is, other
medical problems, and individual lifestyle and preferences. Often the
use of two or more medications
at a time, each serving a distinct purpose, is necessary. Some of these
medications affect the immune system, making careful monitoring a
requirement for treatment.
Health care team Treating rheumatoid arthritis usually involves a teamwork approach
using health professionals from different disciplines to help an
individual deal with the disease. Treatment most often is directed and
coordinated by an arthritis specialist, who is a physician with special
training in arthritis and other diseases of the bones, muscles, and
joints. Treatment often can be given by a family physician or a
physician specializing in internal medicine but a consultation with an
arthritis specialist is recommended. The arthritis specialist may
continue to act as a consultant or, with the consent of the primary
care provider, may assume primary responsibility for the medical
treatment of the arthritis.
Other health professionals, such as physical therapists,
occupational therapists, nurses, psychologists, orthopedic surgeons,
and social workers, often play other roles in implementing the
treatment plan. Orthpoaedic surgeons can help patients return to function and decrease pain when medications fail. Hand surgeons and spine surgeons help patients whose rheumatoid arthritis has affected those areas; total hip arthroplasty, total knee arthroplasty, and total shoulder arthroplasty also are frequently performaed in patients with rheumatoid arthritis if medications fail to relieve symptoms in those joints.
Diet Some people with RA have discovered that particular foods will
either aggravate or help their arthritis. However, physicians have done
careful studies and currently do not find evidence or proof that change
in the diet
is important in either causing or curing rheumatoid arthritis. It is
very important, however, to maintain a healthy diet that includes
adequate protein and calcium.
During flares of arthritis, people lose their appetite and tend to
lose weight. At these times it is important to make sure to take in
enough calories. When arthritis is less active or when people with RA
are taking corticosteroids, it is important to avoid excessive weight gain. Alcohol intake should be very modest in people who are taking aspirin or NSAIDs,
and people who take methotrexate should avoid alcohol completely. Other
healthy practices, such as not smoking and getting regular medical
checkups, also are very important for individuals with rheumatoid
arthritis. Exercise and therapy People with RA need both rest and exercise, and this naturally is confusing for people with RA and their families.
It's important to realize that rheumatoid arthritis cannot be
controlled by vigorous exercise alone and that fragile joints need
special protection. But rest is good for a joint with active RA, and
exercise is good for the surrounding muscles.
People with RA need to maintain a balance between rest and exercise.
The course of the disease will fluctuate. There will be times when the
joints are more warm, swollen, and painful. There will be other times
when the joints feel better and no longer are warm or swollen. During
these times you'll generally feel better and have less fatigue and
morning stiffness. Exercise and activity need to be adjusted to suit
these two different situations.
Rest
When the joints are warm and swollen, rest will help to settle the
disease down. At times like this it is necessary to rest more, to do
less unnecessary walking, participate in fewer activities, etc. Though
reducing activity, you should still maintain joint mobility by doing
range-of-motion exercises. These are light exercises, done without any
weights and designed to preserve the mobility in the painful joint. The
joint should be taken through a full range of motion each day, paying
special attention to the end of the motion where the mobility is lost.
Ease the joint fully to the limit of range. Aquatic exercise usually
can be continued at these times as the buoyancy of the water protects
the joints from rapid or stressful movement.
Exercise
When the disease settles down and the joints become less warm
and swollen, fatigue diminishes, and morning stiffness reduces, you
should expand your exercise program.
Range-of-motion exercises should be continued on a daily basis to
maintain or restore motion, but strengthening exercises also should be
done. These exercises should be instructed by a therapist. The purpose
is to rebuild the strength of muscles that have weakened during the
acute phase of the disease. Strong muscles are important in providing
support to joints and can be built with exercise. These strengthening
exercises, however, have to be modified for people with damaged joints.
Evidence suggests that people with RA can become aerobically
fit and that this may help improve stamina, reduce fatigue, reduce pain
and even help depression if present! Aerobic exercise has not been
shown to increase the joint inflammation when done properly. An aerobic
program should be developed under the direction of a care provider and
a physical therapist especially for those people with more serious
disease.
Occupational and physical therapy
Therapy treatments are helpful for most individuals with
rheumatoid arthritis. Physical therapists can teach you how to exercise
appropriately for your physical capabilities. They will give you
valuable instruction on how best to use heat and cold treatments to
reduce joint stiffness and swelling and make movement easier. At times
therapists may use special machines to apply deep heat or electrical
stimulation to reduce pain or improve joint mobility.
Occupational therapists construct splints for the hand and
wrist and teach people how to best protect and use their joints when
they are affected by arthritis. They also show people how to better
cope with day-to-day tasks at work
and at home, despite limitations that may be caused by RA. Sometimes
this includes the use of practical tools and items that help
individuals perform their day-to-day activities. It is important to
remember that people with RA can and should be able to do most of the
normal or usual things everyone else can, except that it takes them a
little bit longer to do it.
Medications It should be emphasized that all drugs have side effects, even
over-the-counter medications. However, RA will produce its own
problems, such as joint destruction, if left untreated. Thus treatment
decisions should be as informed as possible, weighing the benefits of
treatment (relieving pain, preventing disability) against the risks and
even the costs of using certain kinds of drugs.
Anti-inflammatories
Aspirin is still an important part of the treatment program for many
people with RA. To be effective, it must be given in doses much higher
than commonly used as an over-the-counter remedy for minor aches and
pains. Compared to other similar nonsteroidal anti-inflammatory drugs
(NSAIDs), aspirin is less expensive, and its blood level can be
precisely measured. However, it can cause stomach problems in many
people. Many providers recommend the use of enteric (coated) forms of
aspirin. These are safer for the stomach, but they cost more.
NSAIDs (nonsteroidal anti-inflammatory drugs)
are a large group of drugs that have mechanisms of action similar to
that of aspirin. This group of drugs does not include corticosteroids
(cortisone and other related substances). Like aspirin, these
medications can relieve some of the signs of inflammation and some of
the pain associated with rheumatoid arthritis. A side effect of these
drugs can be bleeding from the stomach, although this does not occur as
often as with plain aspirin. Sometimes people require additional
medications to prevent the side effects of NSAIDs on the stomach. The
various NSAIDs and aspirin, if taken in full doses, usually have the
same levels of anti-inflammatory effect. However, different individuals
may experience greater relief from one medication than another. Because
aspirin has similar effects and side effects, one should not ordinarily
take aspirin while taking a nonsteroidal anti-inflammatory drug. If you
have any questions, it is best to check with your care provider.
Corticosteroids
The role of corticosteroids
(cortisone, prednisone, and other similar substances) in rheumatoid
arthritis is still debated by physicians. In the short run, cortisone
can make people with RA feel dramatically better. However, if the drug
is used over many months or years, it may not continue to be as
effective, and side effects will begin to appear. These side effects
are serious and can include easy bruising, thinning of the bones (osteoporosis), cataracts, weight gain, a round face, susceptibility to infections, diabetes, and high blood pressure.
Corticosteroids can be given in the form of a pill, injected as a
liquid into a joint directly, or into a muscle. Much of the benefit and
many of the side effects of this drug are directly related to the dose
given. The therapeutic goal is always to find the lowest effective dose
that will avoid as many of the side effects as possible. Most
physicians agree that certain individuals with RA can take daily low
doses of cortisone with minimal risk and important benefit. Usually,
however, cortisone should not be relied upon as the main form of
treatment for the majority of people with RA over the long-term course
of the disease. For anyone who takes cortisone on a regular basis,
careful attention should be directed to proper calcium, vitamin, and
hormone regulation; RA patients should always discuss these issues with
their physician. Taking cortisone over prolonged periods has the effect
of putting the body's own corticosteroid-making function at rest.
Therefore, it will be necessary to supplement or increase the dose at
times of high stress, such as surgery.
CAUTION: It is dangerous to suddenly stop or significantly change
the amount of corticosteriods you are taking. Always consult your
doctor before making changes in your dose of prednisone or other
corticosteroid medication.
Gold
Injectable gold salts
(Myochrysine, Solganal) have been used in rheumatoid arthritis for more
than 60 years. As experience was gained with this type of medication,
physicians were able to establish doses that are both reasonably
effective and acceptably safe. Some physicians have recently questioned
the value of gold salts in rheumatoid arthritis. It is true that this
type of medication does not work for all people with RA and that gold
may lose its effectiveness over time in people who seem to benefit at
first. Furthermore, it often takes three to six months to determine
whether a person is getting benefits from gold salts. For this reason
people who begin gold injections must continue other medications such
as aspirin or NSAIDs. Despite certain drawbacks, most arthritis
specialists still view gold salt injections as an important form of
treatment for rheumatoid arthritis. Carefully done research studies
over the past 35 years have shown that this form of treatment is
effective, and in some people gold treatment may slow down damage to
cartilage and bone. A small group of people with RA experience dramatic
and long-lasting improvement on gold. Gold injections are given weekly
for six months or longer. In those people who have a good response, the
medication usually can be tapered to once every three to four weeks.
You, your physician, and nurse will watch for side effects such as
rashes, protein in the urine, and abnormal blood counts while you are
receiving gold shots. Less frequent tests of blood and urine are
required once injections are administered on a monthly basis.
Methotrexate
Since the mid-1980s methotrexate
(Rheumatrex) has become much more popular as a treatment for rheumatoid
arthritis. It works more quickly than gold and maintains control of the
disease in a larger proportion of people over periods of five years or
longer. Methotrexate is given once a week as pills or as an injection.
Unlike gold, it cannot be taken less frequently after the first six to
12 months but instead must be continued every week.
Methotrexate in much higher doses also is used to treat some forms
of cancer, but it is not believed to cause cancer in the doses used to
treat RA. Methotrexate is a drug that is felt to be reasonably safe in
people without other major medical problems, such as liver disease,
kidney disease, lung problems, or heart failure. Individuals taking
methotrexate should drink little or no alcohol because methotrexate may
produce liver damage in a small number of people. You may be advised to
have a liver biopsy every three to five years while on methotrexate to
verify that no damage has occurred, but the requirement for a liver
biopsy has not been demonstrated with certainty. Your physician will
frequently check your liver function and blood counts while you are
taking methotrexate since the number of white blood cells can be
lowered by this drug. Other side effects include an upset stomach and,
rarely, inflammation of the lungs.
In summary, methotrexate is an effective and important medication
for the management of rheumatoid arthritis. However, individuals who
are particularly vulnerable to its most serious side effects People
with kidney, lung, or liver problems) may not be able to take this drug.
CAUTION: Methotrexate may cause birth defects. Women on methotrexate
must go off their medication during pregnancy. Methotrexate should not
be taken by people who have serious kidney or liver disease or who
drink alcohol.
Other medications
Hydroxychloroquine (Plaquinil) and other antimalarials (drugs
originally developed for treatment of malaria) have been used for many
years to treat rheumatoid arthritis. Serious side effects are uncommon,
but people on these medications must undergo regular eye examinations
once or twice a year because of potential damage to the retina (even
though this event is rare).
Sulfasalazine (Azulfidine) is a drug useful in the treatment
of both rheumatoid arthritis and inflammatory diseases of the bowel. It
is generally taken twice daily ina dose of 2 grams total per day. I
also works more quickly than gold and it is felt by many
rheumatologists to be somewhat less powerful than methotrexate. Side
effects include rashes, upset stomach, and lowered blood counts. Blood
checks are done initially every month and less frequently after 3-6
months.
D-Penicillamine (Depend, Cuprimine) is a slow-acting
medication taken daily as one or more pill(s). It can cause side
effects similar to those seen with gold, and its use requires close
supervision and careful monitoring. It is rarely used due to the
availability of other effective and potentially less toxic medications.
Azathioprine (Imuran) is an immunosuppressive drug used in
rheumatoid arthritis and other rheumatic diseases. It can help
rheumatoid arthritis by suppressing over activity of the immune system
but also can increase susceptibility to certain infections and lower
blood counts.
Cyclophosphamide (Cytoxan) is a very powerful
immunosuppressive drug. Because of its frequent and sometimes life
threatening side effects, cyclophosphamide is only given to individuals
with very severe arthritis unresponsive to other treatments or with
serious complications outside the joint, such as vasculitis (blood
vessel inflammation).
Analgesics (pain medications such as codeine, Darvon, etc.)
are sometimes necessary in combination with other medications. Strong
narcotic pain medications, if taken on a regular basis, often have
undesirable side effects and can produce drug dependency. However,
acetaminophen (Tylenol, Datril), an over-the-counter medicine, often is
useful for pain and generally does not interact with other medications.
New medications
In the last few years, several new and effective agents have been
approved for the treatment of RA. Two of these are know as biologic
agents since they are related to antibodies. Over the next few years,
many more of these types of agents will be evaluated for treatment of
RA and other inflammatory diseases.
Leflunomide (Arava) is a cousin to azathioprine. It is taken
as a pill once a day and affects certain immune cells that cause
inflammation. It has been shown to be as effective as methotrexate and
sulfasalazine in the treatment of RA. Side effects can include,
elevation of liver tests, stomach upset, and mild hair loss.
Etanercept (Enbrel) is one of the new biologic agents. It is
a modified human antibody that "soaks up" a immune system chemical
called TNF alpha. This TNF is responsible for much of the fatigue,
swelling, osteoporosis, and cartilage damage seen in RA. It is given by
injection twice a week and works very quickly. Recent information shows
that it can slow down the disease dramatically in some people. About
70-80% of people have initial benefit. Side effects have included small
rashes at the spot where the etanercept is injected in some people. It
is not recommended that this medication be given to people at risk for
serious infection.
Infliximab (Remicaide) is anopther new biologic agent
approved for use in RA. It is a combination of a human antibody and a
small amount of an antibody from a mouse. It also attaches to and
inactivated TNF alpha. It is given intravenously initially 3 times in
six weeks then every other month. Infliximab should also not be given
to people at risk for serious infection. It is most effective when
given with methotrexate.
Surgery For individuals with rheumatoid arthritis and severe joint damage, surgery
such as total joint replacement of the hips, knees, or shoulders can mean the difference between being
dependent on others and independent life at home or in the community.
Such procedures are performed by orthopedic surgeons with special
training in joint replacement. The damaged parts of the joints
are replaced with metal or plastic components. These parts are attached
to the bone with bone cement or by a careful tight fit of implants that allow the bone to form a biological bond. Some people with RA
will benefit from replacement of other joints and from other types of
surgery for hand and foot problems caused by the disease. People with
early rheumatoid arthritis, however, should be placed on a program of
medications and therapy before surgery is considered as a form of
treatment.Unproven remedies It often is difficult to be patient when suffering from rheumatoid
arthritis. People with rheumatoid arthritis might be tempted to try
unproven treatments. A treatment that promises "a quick cure" or
"miraculous relief" can sound wonderful. But remember, these unproven
treatments usually are expensive and will do nothing. The sensational
successes advertised are usually illusions. They even may be harmful
and often keep people from getting the medical care they really need.
For example, magnet therapy has not been proven to work for rheumatoid
arthritis. Discuss new treatments with a doctor and get his or her
advice.
How useful was this page or article?
|
|