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Rheumatoid Arthritis Treatment The goals in the treatment of RA are to relieve pain, reduce inflammation, maintain function, and prevent joint deformities. Medications are required to control pain and diminish inflammation. Other components of therapy include an appropriate mixture of rest and gentle exercise, as well as physical therapy and protection of the joints. People with RA also must pay special attention to combating fatigue, which can be the most incapacitating feature of the disease. Also, developing strategies to cope with the emotional and psychological factors associated with RA also is a key part of treatment. People with arthritis have especially high rates of depression. About 20 percent of people with RA are depressed, compared with 2 percent to 3 percent of men and 5 percent to 9 percent of women in the general population. This section has more on:
Rest Proper rest when joints are inflamed can help relieve fatigue. Complete bed rest may be necessary during periods of severe inflammation involving multiple joints. Listed below are four general ways to relieve fatigue:
When inflammation is present--but not severe enough to require complete bed rest--joints should be rested properly to avoid flexion contracture. Flexion contracture is a loss of joint motion due to shortening of the surrounding tissues, especially in the hips and knees. Listed below are three tips for proper resting technique:
Braces, Splints, and Assistive Devices Braces and splints are over-the-counter or custom-made supports designed to relieve pain and stabilize and protect joints during periods of inflammation, when joints (especially those in the hands and wrists) are more prone to injury. Splints should be lightweight and easy to remove, allowing for range-of-motion exercises several times daily. Prolonged or improper use of splints can increase stiffness and progressively diminish muscle strength and joint mobility. Splints are most effective for the hands, wrists, or both. The best "splint" for the hip and knee joints is lying in a face-down position on a firm bed for about 15 minutes several times a day. Long-term use of splints for the elbow and shoulder joints poses the risk of rapid loss of mobility in these joints. As a result, judicious use of local treatments such as injections of inflammation-reducing steroids and appropriate use of physical therapy are preferable. Assistive devices (such as faucet turners or jar openers) help decrease the difficulty of everyday tasks. Occupational therapists are experts in fitting braces and splints, recommending assistive devices, and instructing patients in their proper use. Exercise When joints are inflamed, only gentle exercises such as bending and straightening the joint are appropriate. Resistance exercises, which may involve light weights or working against the body's own weight, can be introduced gradually as joint inflammation subsides. Aquatic exercise is an especially good exercise option for people with RA. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) Unless there is some reason not to use aspirin, such as an allergy, this medication is usually the first treatment attempted for RA. Aspirin is effective in reducing inflammation and is less expensive than the other NSAIDs. The dosage depends on a balance between the large amounts of aspirin that may be needed to control symptoms and the development of side effects. Other NSAIDs are employed when aspirin is ineffective or causes serious side effects. These drugs are more expensive than aspirin, but compliance may be better because they are taken fewer times each day. Some (not all) studies suggest that COX-2 inhibitors have fewer gastrointestinal side effects than other NSAIDs. But in light of the recent concerns about COX-2 inhibitors and cardiovascular problems, consult your doctor if you're taking a COX-2 inhibitor. The goal is to use the NSAID that provides the greatest benefit while producing the fewest side effects; some trial and error may be needed because some people respond better to one drug than another. Anti-rheumatic drugs The current trend is to start using potent anti-rheumatic drugs right away if basic anti-inflammatories fail to control symptoms. These potent drugs are usually referred to as disease-modifying anti-rheumatic drugs (DMARDs) but are also called SAARDs (slow-acting anti-rheumatic drugs). Antimalarials. The most commonly used antimalarial is hydroxychloroquine (Plaquenil). Between 30 percent and 40 percent of people with RA respond to this drug, but improvement does not begin for three to six months. The advantage of this drug is its low incidence of side effects. The most serious risk-- vision loss due to damage to the retina--is rare at low dosages, but regular eye exams are required during long-term treatment. Other side effects are gastrointestinal problems and, in rare instances, inflammation of the nervous system and skeletal and heart muscles. Azathioprine. Azathioprine (Imuran) is an antimetabolite (a substance that blocks a normal metabolic process) and is most commonly employed as an immunosuppressant to prevent rejection of transplanted kidneys and hearts. Because it can cause dangerous suppression of the immune system that may lead to serious infection, it is used only when severe symptoms fail to respond to safer drugs. Digestive side effects, such as loss of appetite, nausea, or, rarely, vomiting, may develop. Corticosteroids. The corticosteroid drug prednisone (Deltasone, Meticorten, Prednisone Intensol, Sterapred) usually produces rapid and dramatic symptomatic improvement by reducing inflammation and suppressing the immune system. As a result, physicians and patients alike have been tempted to continue steroid use for long periods, despite many serious side effects including stomach ulcers, diabetes, high blood pressure, muscle wasting, cataracts, increased susceptibility to infections, and psychiatric disturbances. Osteoporosis is also an important side effect of steroid use, occurring in as many as 50 percent of patients. A baseline bone scan should be done before beginning therapy for comparison purposes. Follow-up scans every six months to one year afterward can be used to monitor changes in bone density. Also, people taking steroids should get 1,500 mg of calcium and 400 to 800 IU of vitamin D daily. Low-dose hormone replacement therapy can be used to maintain or improve bone density in postmenopausal women, but this treatment has been associated with a small increase in the risk of breast cancer and cardiovascular disease. For this reason, an osteoporosis treatment such as alendronate (Fosamax), risedronate (Actonel), or calcitonin (Calcimar, Miacalcin) may be a better choice. When corticosteroids are discontinued after being used at high doses or for a long time, the dose must be reduced very slowly to help prevent a flare of arthritis. Cyclophosphamide. The anticancer drug cyclophosphamide (Cytoxan, Neosar) has proved beneficial in studies of people with RA who have not responded adequately to any other therapeutic measure. Serious inflammation of the bladder (hemorrhagic cystitis) is a possible side effect. Also, cyclophosphamide can cause fetal damage if administered to a pregnant woman, an important concern because many RA sufferers are women of childbearing age. Cyclosporine. The drug cyclosporine (Neoral, Sandimmune) is an immunosuppressant that is most commonly used to prevent rejection of transplanted organs. It relieves symptoms of RA by inhibiting the growth and action of immune system cells, including those that cause joint pain and swelling. Because it is highly toxic and can cause high blood pressure and damage to the kidneys, it should be administered in low doses over a period of time, and patients must be monitored closely. Gold salts. Therapy with gold salts (chrysotherapy), which is used in people who do not respond to NSAIDs and are unable to take methotrexate (see below), is beneficial about 60 percent of the time. Gold salts appear to act by suppressing synovial inflammation during active RA. The benefits of treatment are not apparent for about three to six months. Gold is administered either by intramuscular injections or by oral dosages--though injected gold is more effective overall than oral treatment. Side effects, which occur in about a third of people receiving gold injections, include inflammation of the skin and mucous membranes of the mouth, diarrhea, protein in the urine, and a drop in white blood cell levels. Even those who have tolerated gold injections for several years need to watch for adverse reactions, including dizziness, nausea, and pain within an hour of the injection. Regular blood tests are necessary to monitor side effects. Methotrexate. Methotrexate (Rheumatrex), which acts as a mild immunosuppressant, was first used to treat some forms of cancer. It is now recognized as the drug of choice for people with severe RA that does not respond to NSAIDs. It often leads to improvement within a month. The most common side effects are irritation of the stomach and inflammation of the mucous membranes of the mouth. Rarely, the drug produces an extremely dangerous toxic reaction that may include lung inflammation, bone marrow suppression, and severe liver damage. Because methotrexate may harm the liver, experts recommend periodic blood tests to monitor liver function. A biopsy should be performed only if blood tests indicate liver damage. Based on recent studies, low-dose folic acid supplements are recommended as an inexpensive way to reduce methotrexate side effects. The supplements appear to reduce the liver toxicity of the drug. Research on the use of methotrexate to treat RA may in fact result in a major change in the approach rheumatologists take in starting drug therapy. An analysis of results from 11 clinical trials indicates that, contrary to current practice, RA should be treated aggressively in the initial stages of the disease. The analysis found that methotrexate produced major improvements in 44percent of patients during the first year of the disease. The beneficial effect dropped dramatically after five years; just 29percent of people who had RA for more than five years were helped by methotrexate. If these findings are borne out by further research, potent drugs may be prescribed early in the course of the disease to gain better control of symptoms. Additional studies have shown that methotrexate is more effective when combined with other drugs, such as cyclosporine, leflunomide (Arava), etanercept (Enbrel), infliximab (Remicade), or adalimumab (Humira). Minocycline. Minocycline is a tetracycline antibiotic that has been studied for use in RA. It is unclear how it might work but is believed to reduce inflammation. Penicillamine. Penicillamine (Cuprimine, Depen) has proved effective--particularly in studies carried out in the United Kingdom --in people who are unresponsive to all other measures. Its use is limited, however, by adverse reactions that include fever, rash, mouth ulcers, loss of taste, protein in the urine, and low blood levels of white blood cells and platelets. Sulfasalazine. Sulfasalazine (Azulfidine EN-tabs) appears to suppress the immune system response that is activated in RA and also acts as an anti-inflammatory agent. The drug generally does not take effect for at least four weeks. Because of adverse effects--which include skin rash, headache, nausea, vomiting, stomach problems, loss of appetite, and decreased sperm count--patients should be monitored closely for the first three months of therapy. New drugs treatments Etanercept (Enbrel), leflunomide (Arava), anakinra (Kineret), and adalimumab (Humira) are drugs that not only treat the symptoms of RA but also have been shown to slow the associated structural damage in the joint that occurs over time. Etanercept, anakinra, and adalimumab must be injected (leflunomide comes in pill form). At first, a healthcare professional should administer the injections. Only with a physician's approval and after instruction by a healthcare professional should people self-inject the medication. Infliximab (Remicade), another new medication for RA, originally was approved for the treatment of Crohn's disease, a disorder of the gastrointestinal tract. While this medication can treat the symptoms of RA, it is not known to slow the progression of the disease. The drug must be administered intravenously by a doctor or nurse. This section has more on:
Etanercept Etanercept inhibits the action of a protein called tumor necrosis factor, which invades the joints of people with RA. Injections are administered twice weekly. Patients may start to see results two weeks to three months after treatment begins. Etanercept should be used with caution in people with heart failure because the drug has the potential to worsen their condition. The drug can also cause allergic reactions such as hives. Because serious infections have been reported in people using etanercept, it might not be an appropriate treatment for people who are susceptible to infection because of a weakened immune system. Serious neurological problems, including multiple sclerosis, have also been reported, as well as lymphoma and aplastic anemia (anemia caused by reduced production of red blood cells by the bone marrow). People taking the drug also need to be monitored by a doctor for neurological symptoms such as confusion, numbness, changes in vision, and difficulty walking, which may be signs of a rare but serious side effect in which the fatty sheath that coats nerve fibers begins to disintegrate. Common side effects are injection site reactions and headache. Leflunomide The drug leflunomide, which blocks an inflammation-causing enzyme, is taken orally once a day. The drug often begins to work within four weeks but may take more than eight weeks in some people. The most common side effects reported were diarrhea, loss or thinning of hair, and rash. Leflunomide can also elevate liver enzymes (a sign of liver function problems), and people with liver disease should not take the drug. People taking leflunomide should have regular liver tests. Furthermore, the drug should not be used by women who are pregnant or could become pregnant and are not using reliable contraception, because it may cause birth defects or fetal death. People prone to infection are not good candidates for leflunomide. Anakinra Anakinra blocks the activity of a protein called interleukin-1. This protein is produced in excess amounts in people with RA and contributes to the pain, inflammation, and joint damage associated with the disease. The drug, which requires daily injections, is recommended only for adults who have not experienced symptom relief with at least one other DMARD, such as methotrexate, etanercept, or infliximab. On average, symptom relief with anakinra occurred within three months of beginning the treatment. The most common side effects of anakinra in the clinical trials were redness, bruising, inflammation, and pain at the site of injection. These effects, which occurred in about 70 percent of patients, were mild and lasted for two to four weeks. Anakinra also increased the risk of infection. To reduce infection risk, anakinra should not be used while taking etanercept or infliximab--two DMARDs that also increase susceptibility to infection. In addition, anakinra should not be started in people with an active infection or continued if a serious infection develops (for example, one that requires treatment with an antibiotic). In a small percentage of patients, anakinra can cause neutropenia (a decrease in infection-fighting white blood cells called neutrophils). To monitor for this side effect, your doctor should test your blood before beginning treatment with anakinra; after treatment is begun, tests should be done monthly for the first three months and then every three months for up to a year. Anakinra is taken by injection once a day. Infliximab Infliximab is combined with methotrexate in people who do not respond sufficiently to methotrexate alone. As with etanercept, infliximab neutralizes the activity of tumor necrosis factor, thereby reducing some RA symptoms. Infliximab is administered by intravenous infusions, typically in an outpatient setting. A recent phase II trial of infliximab for heart failure found that people taking the drug had an increased rate of mortality and hospitalization for worsening heart failure. In response, the manufacturer notified doctors that people with heart failure should not begin using the drug and that infliximab therapy should be re-evaluated for people with heart failure and some other heart conditions. As with etanercept, people taking infliximab must be monitored by their doctor for neurological symptoms such as confusion, numbness, changes in vision, and difficulty walking. Also, as with etanercept, people taking infliximab may develop serious infections, and people who suffer from chronic infections or take immunosuppressive therapy should consider other RA therapies. Infliximab also has been linked to the blood disorders leukopenia, neutropenia, thrombocytopenia, and pancytopenia, as well as lymphoma. Because infliximab can cause latent tuberculosis to develop into full-blown tuberculosis, patients should receive a tuberculin skin test before beginning therapy. Adalimumab Like etanercept and infliximab, adalimumab works by blocking tumor necrosis factor. It is used in people who have not responded adequately to other medications, such as methotrexate. It can be used alone or in combination with methotrexate or other DMARDs. A dose of the drug is injected once every other week. Common side effects are irritation at the injection site, sinus infections, headache, and nausea. Like etanercept and infliximab, adalimumab may produce rare side effects such as serious infections (including tuberculosis), nervous system diseases, lymphoma, lupuslike symptoms, and allergic reactions. Prosorba Column Similar to kidney dialysis, this unusual type of therapy removes from the blood immune proteins that are believed to cause inflammation. The whole procedure takes approximately two hours and must be performed once a week for 12 weeks to be effective. No clinical studies have yet proved the long-term effectiveness or safety of the Prosorba column. Surgery People with RA may benefit from the following surgical procedures: Joint replacement (arthroplasty). The most common type of arthroplasty is total joint replacement, in which the entire diseased or damaged joint is removed and replaced with a mechanical one to relieve pain and restore function. Resurfacing, also referred to as bone relining, is another type of joint replacement in which the damaged cartilage and bone ends in the hip joint are removed and capped with metal. Arthroscopy. This entails the insertion of a thin, lighted tube with a camera attached to one end into a joint. It may be used diagnostically (to determine the type of arthritis or amount of damage) or therapeutically (to smooth roughened cartilage or flush out the joint to remove debris), Arthrodesis. In this procedure, a surgeon fuses together two bones in a finger, wrist, ankle, or foot joint. While this operation results in a loss of flexibility, it relieves the pain caused by two bones rubbing against each other in a damaged joint. Synovectomy. This procedure--performed mostly in people whose RA has not responded to medication--involves the removal of the inflamed synovial membrane in the elbow, shoulder, hip, or knee. Synovectomy is not as complicated a procedure as joint replacement, and it is not considered a permanent cure because the synovial membrane can grow back within several years. Medication is still required after synovectomy to reduce the chance that synovitis will recur. Resection. In this procedure, all or part of a bone is removed from a joint in the hand, wrist, elbow, toe, or ankle. Resection is most commonly performed to relieve pain in people with RA. Recovery times vary but may be as long as several weeks. Osteotomy. In this procedure a wedge of bone in the knee or spine is cut away and the remaining bones are realigned. Alternative and Complementary Treatments People with RA often turn to therapies that are outside the medical mainstream, especially when conventional medications offer insufficient relief of symptoms or cause troubling side effects. The problem is that few of these nontraditional treatments have been evaluated in well-designed clinical trials. For this reason, people who wish to try complementary therapies should do so with caution. They should be sure to tell their doctor about any complementary therapies they are using or plan to use and should not discontinue their regular medication without discussing it with their doctor. They also should keep an eye on the bottom line: People with arthritis spend an estimated $1 billion each year on unproven remedies. Supplements. People should be skeptical about nutritional supplements that purport to be safe and effective treatments for arthritis. Most of them don't work, and some are dangerous, either on their own or when combined with conventional medications. The Arthritis Foundation warns against using arnica (Arnica montana); aconite (Aconitum napellus); adrenal, spleen, and thymus extracts; autumn crocus (Colchicum autumnale); 5-HTP (5-hydroxytryptophan); GHB (gamma-hydroxybutyrate); GBL (gamma-butyrolactone); L-tryptophan; chaparral; and kombucha tea. Also dangerous are megadoses of vitamins such as A and D, which become toxic at very high doses. However, this is by no means an exhaustive list of unsafe supplements. Chondroitin and glucosamine are two supplements that have shown promising results in people with osteoarthritis). However, there is no evidence for their use in treating RA. Supplements of gamma linolenic acid (GLA) and fish oil for RA have produced slightly more encouraging results, although the few studies conducted have included only a small number of participants. The usual dosage of GLA, which is found in borage oil, evening primrose oil, and black currant oil, is about 1,800 mg a day. The active ingredients in fish oil are the omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA); the usual daily dosage is 3 g. Both GLA and fish oil may cause bleeding in people who are taking warfarin (Coumadin) or NSAIDs. Evening primrose oil can lead to gastrointestinal symptoms such as indigestion, nausea, diarrhea, and abdominal pain. Fish oil can cause indigestion, bad breath, and nosebleeds; nausea and diarrhea can occur at high doses. As mentioned above, contamination and nonstandardization are potential problems in products that are not regulated by the FDA. For example, a recent review of 20 brands of fish oil supplements by ConsumerLab, an independent testing laboratory, found that only 14 contained the amount of omega-3 fatty acids stated on the label. You can reduce these risks by buying supplements that meet U.S. Pharmacopeia standards (look for the USP symbol) or by checking results from ConsumerLab at www.consumerlab.com. Mind-body therapies. Mind-body therapies such as biofeedback, meditation, and relaxation exercises generally are safe and may temporarily reduce pain by promoting relaxation. None of these therapies has been shown to have lasting effects on arthritis, however. Homeopathy. In homeopathy, an agent such as poison ivy or bee venom is greatly diluted and then administered as a remedy. A randomized, controlled trial of homeopathy found that it is no more effective than a placebo for treating RA. Treating Depression While the pain and disability associated with arthritis can trigger depression, evidence also indicates that arthritis pain is worse when accompanied by symptoms of depression. Therefore, treating depression can have far-reaching effects for people with arthritis. Treatment options for depression include medication, psychotherapy, and exercise. Becoming more educated about one's condition also seems to reduce or prevent depression. Are vaccines safe for people with arthritis? People with rheumatoid arthritis or lupus have special considerations when it comes to vaccinations. Keeping your vaccinations up to date is especially important if you have rheumatoid arthritis (RA) or lupus. Not only do the immunosuppressive drugs used to treat these conditions increase your risk of getting an infectious disease such as the flu or pneumonia, they make it harder for your body to recover from these illnesses. Yet only 38 percent of people age 65 and older with RA get vaccinated against pneumonia, and only 32 percent get a yearly flu shot, according to a 2003 study published in the Journal of Rheumatology. Part of this failure to follow standard vaccination recommendations may come from the fear that vaccination could cause problems for people with autoimmune disorders. When a person is vaccinated, the immune system responds by producing antibodies that offer protection against the disease. Because both RA and lupus involve a malfunction of the immune system, some experts have theorized that vaccination could be dangerous or ineffective for people with these conditions. In fact, vaccines have been accused of causing everything from autism to multiple sclerosis to arthritis. Careful studies have found no cause-and-effect relationships, however, and people who are diagnosed with these disorders after vaccination would have developed them anyway. The rubella vaccine can cause a form of arthritis that may last for several weeks, but this type of arthritis goes away on its own and does not progress to RA or lupus. Another concern is that vaccination might worsen RA or lupus. Many studies have looked at the effects of vaccination on lupus and found that getting vaccinated does not worsen the disease. The effects of vaccination on RA have been studied less extensively, but the studies that have been performed have found no link. Some vaccines can cause fever or aches that may be confused with an arthritis flare-up, but these side effects go away on their own in a day or two and do not worsen arthritis. Still, people with these conditions do have some special considerations when it comes to vaccination. Although RA and lupus do not prevent vaccines from working, the medications used to treat them can. According to infectious diseases experts, people who are taking high doses of corticosteroids or other disease-modifying drugs (such as more than 20 mg a day of prednisone) are considered to be immunosuppressed. If the immune system is suppressed, it is less able to produce antibodies in response to vaccination. In order for vaccination to work, people with RA and lupus should have their immunizations during times when their disease is well controlled with only low-dose medication (or no drugs at all). A final concern is that vaccines might be dangerous for people with autoimmune disorders. Although most vaccines are safe for everyone, people who are immunosuppressed should not get vaccines that are made with live viruses or bacteria (see the inset box at right); a suppressed immune system could allow the microbes to spread unchecked through the body. This includes attenuated vaccines, in which the vaccine has been weakened but not killed. Many vaccines are made with killed bacteria or viruses or else employ a protein or a sugar extracted from a virus or bacterium. These types of vaccines are safe for everyone. Safest Vaccines (Protein or Sugar) *Available in two forms: proteinand killed virus. |
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