Arthritis Treatment Update

Symptoms of Rheumatoid Arthritis

Arthritis Treatment Update

WebMD Live Events Transcript

In observance of National Arthritis Month, WebMD arthritis expert Michael Smith, MD joined us to answer your questions and concerns about treatment on May 24, 2005.

MODERATOR:
Welcome to WebMD Live, Dr. Smith. Thank you for joining us today.

SMITH:
Thank you for having me.

MEMBER QUESTION:
I have
rheumatoid arthritis (RA) and my 24-year-old son has been complaining of joint pain and aches. Could he possibly have the beginnings of RA?

SMITH:
It's possible because RA can run in families. However it somewhat depends on where his aches and pains are and the characteristics of the pain. The only way to really know is to have a doctor check out his symptoms to see if they are consistent with RA. There are other possibilities such as osteoarthritis as well.

MEMBER QUESTION:
Can you get arthritis in any joint in your body? I'm just curious.

SMITH:
Yes, it's possible to get arthritis in pretty much any joint. Some joints are more commonly affected such as the hands, knees, spine and hips. However it can even occur in the jaw, the toes, and other joints.

MEMBER QUESTION:
I have been to alternative doctors who claim that early arthritic symptoms can be reversed solely with diet. How much truth is there to this statement?

SMITH:
There is certainly no medical evidence to suggest that is true and I have never seen this happen in any of my patients. Diet can play some role -- how much isn't exactly known. There really is no evidence to say that it can have a really significant impact on arthritis pain.

"Cracking can be a sign of arthritis but usually only if there is also pain. By itself it's nothing to be concerned about."

MODERATOR:
Is joint pain and/or arthritis just inevitable as we age?

SMITH:
It's not inevitable but it's certainly much more common as we age. Some people never get arthritis symptoms although that's probably more rare than common. Most of us will get some form of aches and pains related to arthritis, but this may not happen until we reach our 70s or 80s. Some of us will be affected much earlier but it's unusual until after the age of 40, for osteoarthritis at least.

MODERATOR:
Can arthritis be prevented? What can we do to keep our joints pain free?

SMITH:
It depends on the type of arthritis that we're talking about. For rheumatoid arthritis and other related types we don't know how to prevent them. But for osteoarthritis (OA), the wear-and-tear type, there are things we can do to help prevent it in certain joints. OA in the hips and knees is much more common when we're overweight. This is due to the excess strain we put on those joints. Staying healthy overall does seem to play a role in holding off OA as well. But some forms, such as in the hands, we don't really know what can help prevent it exactly.

MEMBER QUESTION:
Can you update me on the latest recommendations and warnings about prescription pain meds? First some are dangerous, then they're not, then others we thought were OK were pulled off the market. How has this shaken out?

SMITH:
The latest news on this came in a couple of months ago. At this point Vioxx and Bextra are off the market and I doubt that we'll see them come back. A related drug, Celebrex, is on the market. But this drug carries the same label warning as all other prescription anti-inflammatory drugs. This warning says that each of these drugs carries some risk of heart attacks and strokes. We don't really know the exact risk but all of them are thought to be related to some degree.

The warning is a bit different for over-the-counter drugs, such as ibuprofen. For these drugs there is a note on the label to not take them for more than 10 days without your doctor knowing. They don't seem to really cause heart problems at the over-the-counter doses, but with long-term use such problems may be possible. In addition they shouldn't be used long term without your doctor knowing, due to the risk of causing stomach ulcers and bleeding.

MEMBER QUESTION:
With osteoarthritis, would taking Baclofen as a muscle relaxer cause any problems? When I move, my vertebrae have started popping (I can both feel and hear it), until it sounds like "popcorn popping." My husband can hear it also. It's not painful, just annoying. Is this popping a bad sign of anything?

SMITH:
Popping and cracking in a joint without any pain isn't really a suggestion of any problem and it would not be related to the Baclofen. Cracking can be a sign of arthritis but usually only if there is also pain. By itself it's nothing to be concerned about. If you start having pain with it let your doctor know.

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MEMBER QUESTION:
Are Hyalgan injections the same as Synvisc or hylan?

SMITH:
Synvisc is a brand name as is Hyalgan. They are very similar. Synvisc requires three injections while Hyalgan requires five injections. But their safety and effectiveness are the same. There are no particular safety issues with these injections.

Some people have pain after receiving the injections and there is of course the risk of infection. But overall they are well tolerated. How well they work is up for debate. Some doctors feel they certainly have a role while others feel that they don't offer much help. The response definitely seems to differ from one patient to another.

MEMBER QUESTION:
I have osteoarthritis and gout. I have had two surgeries from c4-c7, and the doctor said I have the arthritis of a 65-year-old throughout my spine. I'm only in my 40s and I have a lot of pain. What are the concerns I should look for? What will the long-term effects of both types of arthritis have on my joints and on me? What can I do?

SMITH:
Let's talk about gout first. It depends on the severity of your gout and how well it's controlled with medications. If it's controlled then you won't necessarily have any long-term problems with this. If you have a severe case and the medications only help partially, then it's possible to have more long-term problems. These problems may include growth from the buildup of crystals. These aren't harmful growths particularly, but can cause increased pain. Gout can also lead to kidney stones if not controlled.

As for the OA, it already sounds like that's somewhat severe. It's impossible to really know the long-term outlook because everyone is different. But if you notice any numbness or weakness in your arms you need to let your doctor know. Your arms would be more likely affected with that area of your spine. Otherwise if you notice increased pain let your doctor know.

"Ibuprofen is a tough drug to take because you have to take it several times a day to get full day relief. However there are many other drugs to choose from that you only have to take once or twice a day."

MEMBER QUESTION:
What are some of the most current treatments (besides knee replacements) for advanced knee osteoarthritis in people who are in their early 40s? What types of alternative treatments (such as acupuncture) have been shown to be effective?

SMITH:
Knee replacement is still the best treatment for end-stage severe knee arthritis, but you are a bit young for this. Unfortunately there are no other groundbreaking treatments for knee arthritis. If medications aren't working then you need to talk to your doctor about other options. You may need a different medication or something stronger to take when you're having severe pain.

As for alternative treatments, acupuncture has been shown to help. In addition, supplements such as glucosamine and chondroitin have been shown to help with knee osteoarthritis pain; these supplements have even been shown to help build cartilage but they have to be taken constantly. If you stop them the effects will likely go away.

MEMBER QUESTION:
If I'm taking 100 milligrams of Celebrex per day, could you translate that into an equivalent amount of ibuprofen? Also, isn't ibuprofen OK if you take it with meals?

SMITH:
There is no way to translate a dose of one arthritis drug into an equivalent dose of another arthritis drug.

The 100 milligrams of Celebrex is a very low dose. So if you're concerned about possible side effects on the heart the risk is quite low. That is unless you already have heart problems. There has actually never been shown to be any risk with 200 milligrams of Celebrex a day on the heart and that's twice the dose you're taking.

As for ibuprofen, you can still have side effects even if you take it with meals. Taking it with meals may help with the stomach irritation but using it long-term can still cause stomach problems such as ulcers and bleeding.

MEMBER QUESTION:
What is your opinion of the implantable modalities (either with medicine drip or electrical impulses) to control pain?

SMITH:
The implantable devices for pain are quite effective for people that aren't able to tolerate medications by mouth or who have such severe pain that these other medications aren't working for them. The electrical impulses can also help but these are probably less effective, but this depends on the exact cause of your pain and what area is affected. Your doctor would be able to address this more specifically since he or she knows more about your situation. But both treatments are reasonable when used appropriately.

MEMBER QUESTION:
Given the Celebrex warnings, which would you take: Celebrex or ibuprophen if I'm just taking 100 milligrams per day? If and when I go hiking, I do take 200 milligrams per day.

SMITH:
I can't tell you which one is best for you. However, unless you have had stomach problems, such as an ulcer, there really is no reason for you to need to take Celebrex. Celebrex doesn't relieve pain any better than ibuprofen or the other anti-inflammatory drugs. Recommendations now are that it should only be used when someone has had trouble with the other medications, such as stomach bleeding.

Ibuprofen is a tough drug to take because you have to take it several times a day to get full day relief. However there are many other drugs to choose from that you only have to take once or twice a day.

If you don't have a reason to need Celebrex, talk to your doctor about taking a drug that might be easier to take.

MEMBER QUESTION:
Is Aleve safe to take twice a day for my arthritis? I take 10 milligrams of prednisone, one Plaquenil per day.

SMITH:
Aleve is safe to take but still carries a risk of side effects.

I want to be clear that when we need arthritis drugs they are relatively safe to take. We don't have a lot of other good options so people shouldn't worry excessively about taking the arthritis drugs when they need them.

I'm assuming your doctor knows about the Aleve and that's fine. Your doctor will watch to see if you have any side effects such as stomach irritation and he or she should also follow you to evaluate your heart risks. The risk is low especially if you have no other heart disease risk factors. It sounds like you have RA and you need this arthritis drug or something similar so I wouldn't worry about it. Just take it as directed by your doctor and it should be fine.

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MEMBER QUESTION:
I have nodules on the middle knuckles of my index and pinky fingers. Is this arthritis or are they from gout which I get occasionally? Will they go away? Is there any procedure that will help eliminate them? I think they are referred to as tophi.

SMITH:
Tophi are due to crystal accumulation in the joints related to gout but such nodules can also be caused by other types of arthritis. However, in those middle joints, my guess is that this is due to your gout and not another form of arthritis. Nodules in those joints can sometimes be caused by RA but you don't appear to have any symptoms to rheumatoid arthritis.

Tophi may get smaller with gout treatment but they don't usually go away. Surgery can get rid of them but this is often temporary, therefore we don't usually recommend it.

"There have actually been no studies to show that one arthritis drug works better than another, some people just seem to respond better for whatever reason."

MEMBER QUESTION:
I have been diagnosed with RA and fibromyalgia (FM) for about 12 years. Recently I have had pain on my right side in my rib cage. The urgent care doctor said it was RA in my ribs. Is this possible? It is very painful and hurts throughout the day regardless of what I am doing.

SMITH:
RA can cause pain and inflammation in the joints in the ribs. However it can also cause inflammation in the lining of the lungs; this is called pleuritis and you might want to look it up to see if your symptoms are consistent with this. The pain would occur when you breathe in and out, but the pain with arthritis in the ribs can also occur with breathing so it can be difficult to figure out which one it is.

Pleuritis can show up in a chest X-ray. If you had a chest X-ray in the emergency room the doctor may have ruled this out, but I would let your doctor know as well so he or she can keep an eye on it.

MEMBER QUESTION:
Does osteoarthritis follow from osteoporosis or vice versa?

SMITH:
The two conditions are not really related. Osteoarthritis is inflammation of the joints. Osteoporosis is a thinning of the bones. However, when someone has osteoporosis it can sometimes cause excess strain on a joint that can lead to osteoarthritis, but otherwise the two aren't really related. They do often occur together but that's more due to the fact that they often affect the same group of people. Both are very common in older women but can even occur in men.

MEMBER QUESTION:
I have arthritis in my hip. Vioxx worked wonders until it was pulled off the market. I tried Bextra until it was pulled and Celebrex does not help as much as 400 milligrams of Advil three times a day. I am 54 years old and trying to put off replacement surgery as long as possible. How long can I continue to take the Advil before I risk having stomach problems? If you have any other suggestions, please advise. I have to tell you -- Vioxx worked wonders. I wish it was still available somewhere in the world.

SMITH:
That dose of Advil three times a day is a medium dose. However it can lead to problem over the long term. There is no way to really tell if you'll have stomach problems or when.

There are other medications like Advil that you can take fewer times a day that really should offer you the same degree of relief. There have actually been no studies to show that one arthritis drug works better than another, some people just seem to respond better for whatever reason.

Be sure to let your doctor know how much you're taking. If you start having stomach problems there are ways to protect your stomach with other medications.

MEMBER QUESTION:
Would an orthopaedic surgeon ever consider doing replacements on both a hip and knee at the same time? They are both on the right side. I have been diagnosed since 1987 with OA of the hip. As far as the knee, I can't use it for getting up out of a chair or out of a car. I'm 61 and had the meniscus cartilage completely removed from my right knee when I was 20.

SMITH:
I'm not an orthopaedic surgeon so it's hard for me to answer this one. WebMD actually has a board on joint replacement that's monitored by an orthopedic surgeon and this would be a perfect question for him.

I would think it's unlikely to do both joints at the same time. This would be a lengthy risky surgery and the rehabilitation would be extremely hard. I would recommend asking this question to Dr. Kirschenbaum on the message board because he would be able to help you out much better than I can.

MEMBER QUESTION:
Would pain in the collar bone likely be from arthritis? It starts in the center, but shoots to the right side when holding a book or typing, and it comes and goes.

SMITH:
It does sound like you could possibly have arthritis in the joint that connects the collar bone to the ribs, but it's tough to tell without knowing exactly where the pain is. Your symptoms are consistent with this possibility, so a doctor would need to examine you to be able to tell for sure.

MEMBER QUESTION:
I have RH at 55 and CRP at 20. I also have fibromyalgia (FM). What medicines would help to reduce inflammation? I have a constant feeling like my body is stretching itself inside with nowhere to go and I am tired all the time. What would you recommend for this?

SMITH:
My first concern is that FM doesn't typically cause inflammation. So my question is whether or not you have something more going on like some inflammatory condition. If you haven't seen a rheumatologist I would recommend doing so to be sure that you don't have some other condition that may be causing inflammation.

MEMBER QUESTION:
I have aches and pains in all my joints including my jaw. I exercise regularly and am of normal weight. I do not take medication. Do you have any suggestions? (RA has been ruled out)

SMITH:
It's tough to say that this would be arthritis if it affects your entire body. You can have osteoarthritis in many joints in the body at the same time. However it's unusual for it to be so widespread in the way that you describe.

Fibromyalgia can cause widespread pain but this is more muscle pain than joint pain, although it's often hard for people to tell the difference.

I would recommend that you see a rheumatologist if your primary doctor is not able to pinpoint a cause.

"We recently discovered that being overweight may be the most important cause of gout attacks; there is something about being overweight that seems to trigger gout attacks."

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MEMBER QUESTION:
I have been diagnosed with arthritis in my lower back and in my hip. The doctor also found a cyst in my hip between my ball joint and where it connects, which causes me a lot of pain and immobility. What can they do for this?

SMITH:
A cyst like you describe is not uncommon in someone who has hip arthritis. The cyst can be drained if it's thought to cause such pain, but if the arthritis is so severe that draining the cyst isn't likely to help, you may need to discuss other options with your doctor. This could include joint replacement but it depends on the severity of your arthritis, your age, and your overall medical condition. Draining these cysts isn't particularly common but can be done if necessary.

MEMBER QUESTION:
I had my foot partially amputated about three years ago and I was told my only option was fusion. I have no cartilage in my ankle area. Why fusion and not joint replacement?

SMITH:
Joint replacement for the ankle has not been successful. That's why we often opt for joint fusion for the ankle. This will greatly limit your mobility in the joint but it also will likely eliminate the pain.

Hopefully medical research will bring us to the point where ankle replacements are more successful but right now we just don't have enough success with them.

MEMBER QUESTION:
My husband has gout. What are the best methods to reduce this?

SMITH:
In addition to medication, diet can play a role. A diet rich in meats and high-fat foods can increase gout attacks. We recently discovered that being overweight may be the most important cause of gout attacks; there is something about being overweight that seems to trigger gout attacks. So in addition to medications I would recommend a healthy diet as well as losing any excess weight if necessary.

MEMBER QUESTION:
Have you heard of surgeons not performing a hip replacement because the hip arthritis was just too advanced? I have my first appointment with an orthopaedic surgeon next week.

SMITH:
Severe arthritis would not be a cause of not performing the surgery. However, if the area around the joint is so deformed, for whatever reason, it can make joint replacement impossible. I doubt this is the case with you.

Reasons for not doing surgery can be age as well as overall medical condition. If someone is too young they hesitate to do the joint replacement because they typically only last 15-20 years at the most. And redoing the surgery is quite complicated.

MEMBER QUESTION:
Can osteoarthritis affect multiple joints in the same person? And, if so, what are some possible causes (besides obesity)?

SMITH:
Osteoarthritis can definitely affect multiple joints in the same person.

We don't really know much about the causes of osteoarthritis other than obesity. There is some genetic tendency and we're still learning more about this. We've identified some genes that seem to increase the risk of osteoarthritis, but right now there really is no way to test for these genes.

We just really don't know what causes osteoarthritis in multiple joints in most people. Previous injuries are another possibility.

"Many people with arthritis are afraid of exercise but when done appropriately it can actually be one of the best treatments."

MEMBER QUESTION:
What are effective treatments for osteoarthritis in feet and ankles?

SMITH:
Treatments would be similar to osteoarthritis in other areas of the body. In addition to arthritis drugs, the doctor can consider physical therapy, but this would depend on the symptoms. Physical therapy is best for increasing range of motion and flexibility in the joint.

Exercise is also helpful. Many people with arthritis are afraid of exercise but when done appropriately it can actually be one of the best treatments.

If the arthritis is very severe, ankle fusion is a possibility. But this is done as a last resort because it will eliminate any range of motion in the joint. It does take care of the pain though.

MODERATOR:
Dr. Smith, we are almost out of time. Before we wrap things up for today, do you have any final words for us?

SMITH:
I think the recent developments with the anti-inflammatory drugs have left many people concerned. I want to reiterate that these drugs are very helpful. And while they do carry some risk the benefits for most people will far outweigh the risks. The best thing we can do is to help our hearts by living a healthy lifestyle with diet and exercise. Those of us who need these drugs, myself included since I have ankylosing spondylitis, need to rest assured that medical research is still looking into this.

Do what you can to stay healthy, take your medication as prescribed, but don't worry excessively about this risk. Just be sure to communicate with your doctor.

MODERATOR:
Our thanks to Michael W. Smith, MD, for joining us today.



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Reviewed on 6/9/2005 4:55:10 PM

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