Arthritis Pain Relief Update

WebMD Live Events Transcript

Has the recent news about arthritis pain relievers left you confused and in pain? John H. Klippel, MD, president and CEO of the Arthritis Foundation, joined us on Feb. 23 to answer your questions.

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

MODERATOR:
Welcome to WebMD Live, Dr. Klippel. We've heard so much about arthritis pain relievers in the past few days.

KLIPPEL:
I think the most important thing is to recognize the prompt action by the FDA and industry in addressing the concerns that have been raised with regards to nonsteroidal anti-inflammatory drugs or NSAIDs, and I think the decisions by the FDA advisory board are in the best interests of the consumer in informing the consumer about benefits and risks of this class of drugs.

MEMBER QUESTION:
What do you think the public's perception of the news about all of the Cox-2 inhibitors either being pulled from the shelves, as in the case of Vioxx, or questioned by the FDA? Are arthritis sufferers afraid to take these medications? What does the Arthritis Foundation have to say about these matters?

KLIPPEL:
I think it has heightened the concern that people have with regard to side effects of drugs. I think there are two main issues. All drugs have side effects and an educated consumer should always ask about side effects. On the other hand, we believe that the major concern of people with arthritis is not the side effects of the drugs but the fact that for many, there are inadequate medicines to control their pain. So we hope this results in a better dialogue between the person with arthritis and their doctor about the benefits and risks of these drugs.

MODERATOR:
Has there ever been a study showing the Cox-2 drugs as being more effective at pain relief than NSAIDs?

KLIPPEL:
That's a very good question. These drugs were developed principally to reduce the risk of gastrointestinal, or GI, side effects. The studies have clearly shown they in fact do result in fewer GI side effects. On the other hand, studies have not shown that these drugs actually relieve pain more effectively than traditional agents. Now, having said that, I think any doctor who prescribes these drugs recognizes that patients respond quite differently to these medications and it is our view that there are patients who have on their own discovered that a particular Cox-2 drug relieves their pain more effectively than any drug they have tried. We believe that's an important consideration and it certainly argues for having the maximum number of medications available so patients can try several before identifying the one that is the most effective for them.

MEMBER QUESTION:
Is it true that doses of Celebrex at 200 mg and under are safe, and that the risk is only at higher doses?

KLIPPEL:
That was one of the things that was carefully considered by the FDA Advisory Committee -- the effect of dose. I think the evidence would suggest there is a dose effect for the Cox-2 drugs; that is, the greater the dose the greater the risk of a cardiovascular side effect. We don't find that surprising; that would be predicable based on how these drugs actually work. Certainly one of the recommendations of the Advisory Committee was to use the lowest dose possible that controls arthritis symptoms.

MODERATOR:
Do you think, given the possible cardiac side effects of Cox-2 drugs, that other medications should be tried first?

KLIPPEL:
We believe one of the opportunities this debate creates is to encourage people to really look at all options for the treatment of their arthritis, that pain medications really only represent one approach to arthritis treatment. In particular, for people with osteoarthritis, which is the most common arthritis in the world, we believe not enough attention is paid to diet. The impact that being overweight has on this disease is a risk factor and is also a factor for the progression of the disease. We also believe not enough attention is paid to exercise and fitness.

Now, as for medications -- the recommendations of the American College of Rheumatology suggest for most people that they begin with a pure pain reliever, like acetaminophen or Tylenol, to see what effect that has on the control of pain before they actually try an NSAID.

MODERATOR:
Do you think patients dismiss acetaminophen and other over-the-counter medications because they are available over the counter?

KLIPPEL:
For many people there is a mystique about a prescription drug being more effective than an over-the-counter drug. It's important to recognize that many over-the-counter drugs were at one point prescription medications. So there are three aspects here. One, they are generally more affordable than prescription drugs; second, there's a long history of use of these medications. That means by the time they become over-the-counter drugs they are known to be effective and known to be safe Third, there is little question that over-the-counter drugs as well as prescription drugs play an important role particularly in pain management of arthritis.

MODERATOR:
But at the same time, some people over use over-the-counter drugs and don't follow the directions because they discount their effectiveness.

KLIPPEL:
This in fact relates to the question about the effective dose and side effects and certainly the very same principle applies to over-the-counter medications. When used in higher dosages, there is a greater potential for side effects, so it becomes very important that people follow the directions carefully.

There's actually a second caution with regards to acetaminophen or Tylenol, in that acetaminophen is often used in other over-the-counter preparations. For example, it's a common ingredient in medications for headaches and colds. People need to be very careful to check all their over-the-counter medications to make sure they're not taking more than their recommended dose that's being used for their arthritis. In other words, the problem here is they may be taking acetaminophen for their arthritis but, unknowingly, they are taking acetaminophen for their headaches and cramps. That can lead to overmedication of acetaminophen. There has to be a particular caution about this particular drug.

MODERATOR:
You can always ask your pharmacist about your over-the-counter medications as well as your prescription medications.

MEMBER QUESTION:
Do NSAIDs lose their effectiveness over long-term use to control pain?

KLIPPEL:
That's an excellent question. Studies that have traditionally been done with NSAIDs actually ask the question how well they control pain over a short interval, typically between seven and 30 days. There have been very few, if any, studies that have actually asked the question how effective are they when used chronically, and we would certainly encourage studies to address that question. People with arthritis use these drugs for months or years, and we do not have good information from studies that address if they continue to have an important effect on pain, and is that lost over time.

MEMBER QUESTION:
I have heard that taking Tylenol over a long period of time for pain relief can cause problems with your liver and kidneys. I have been taking Tylenol 3 for five years. Is there any truth to this concern and are their any alternatives that will not place my health at risk?

KLIPPEL:
There are two considerations with Tylenol. One is the use of Tylenol in excess dosage, and the second is that alcohol use, particularly overuse, can also lead to side effects from Tylenol. However, people who use the standard recommended dose of this drug and who use social or conservative amounts of alcohol can be assured this is a safe medication with minimal risks of side effects.

MEMBER QUESTION:
I really feel that Celebrex greatly helps the quality of my life. However, I also take a low-dose aspirin regimen. I have been experiencing excessive bleeding when I had a minor cut or oral surgery. I take the aspirin regimen to inhibit the possibility of cardiac problems. Do you have any suggestions to resolve the bleeding problems? And does the aspirin regimen really help prevent cardiac problems with Cox-2 inhibitors?

KLIPPEL:
This is an interesting problem, because the reason Celebrex or any Cox-2 inhibitor is used is to reduce the risk of GI side effects. If one adds aspirin in any dose, even low doses to protect your heart, a person will increase his risk of GI side effects. One needs to be particularly cautious about combining NSAIDs, including aspirin, and remind people to make sure their doctors are aware of all medications, including over-the-counter meds that are being taken.

MEMBER QUESTION:
Will Vioxx be making a return to the market or will it disappear forever?

KLIPPEL:
We're actually encouraged by the consideration of Merck to put Vioxx back on the market, for two reasons. One is there are many people who very much relied on Vioxx for pain relief and for those people in particular they would be benefited by this decision. The second opportunity this presents is to have Merck take a leadership role in helping to educate the consumer about the benefits and risks of this classification of medicines. We look upon this decision with interest and certainly it would be in patients' best interests if a decision was made to return the medication to the marketplace.

MEMBER QUESTION:
Dr. Klippel, I currently still take Celebrex and without it, after seven calendar days, I am completely bedridden. I feel that its benefits of enhancing my life far outweigh the risk. Do you know if they are seriously considering how this medication greatly affects others' overall well-being either way?

KLIPPEL:
I think we should applaud the decision of Pfizer when the controversy began to keep Celebrex on the market and it was done specifically for people like this questioner, who were benefiting from this drug. We would applaud the decision of the FDA Advisory Committee who has made a decision to the FDA to keep both Celebrex and Bextra on the market.

MEMBER QUESTION:
Thank you for your time doctor. A lot has been made not only of Celebrex and fellow Cox-2 inhibitors, but also Naproxen. I am a 27-year-old and suffer from PA and have been on Naproxen 500mg tabs for over 10 years. What are you thoughts about the future of Naproxen?

MEMBER QUESTION:
Were the concerns about Aleve put to rest, or do we need to be concerned?

MODERATOR:
(Naproxen = Aleve)

KLIPPEL:
Naproxen would be an example of an over-the-counter medication in which we have known about the efficacy of this drug for more than a decade. In our opinion, this continues to be a very effective and safe choice of NSAIDs. We believe the public was unduly alarmed by expressing a concern that the FDA Advisory Committee considered and we, again, applaud the FDA's Advisory Committee's decision that this is a safe an effective form of NSAID.

MEMBER QUESTION:
Do you think the pharmaceutical companies have handled the release of this information in the proper way or could they be doing a better job for the consumer?

KLIPPEL:
I think it's incumbent on all of us, the drug companies, federal regulatory agencies, as well as the Arthritis Foundation to learn from the recent experience with Cox-2s, so that we all do a better job of informing the consumer in a responsible manner and not creating either confusion or panic.

What we believe is that there's very little attention paid to why people use drugs in the first place, which is benefits, and I think we're fortunate in this country to have pharmaceutical and biotechnology companies that each year produce more effective and safer medications for the person with arthritis. These are responsible companies that are contributing to improving the lives of people with arthritis.

MODERATOR:
So the best way to protect yourself is to be an informed consumer -- ask your doctor all of the questions you have. Be a partner in your own care.

MODERATOR:
Let's move away from the drugs for a moment and go back to two things you mentioned earlier -- diet and fitness. Do you have specific recommendations for exercise to help arthritis sufferers?

KLIPPEL:
The exercise needs to be individualized, based on the joint or joints affected by arthritis. For example, a person with arthritis affecting the knee would be doing a different set of exercises than a person with arthritis of the lower back. There are certainly many good resources for advice on exercise. In particular, the Arthritis Foundation web site, arthritis.org or brochures or books from the Arthritis Foundation can be very helpful in recommending exercises.

For most people, walking would be a great form of exercise which not only is good for joints, but it is good for their general fitness and for their heart. The Arthritis Foundation in April and May has an Arthritis Walk across the country that we would encourage everyone to participate in.

MODERATOR:
What about swimming? Yoga? Are they particularly helpful?

KLIPPEL:
Swimming or even exercising in a pool are great forms of exercise for a person with arthritis. Most chapters of the Arthritis Foundation have aquatic programs and information can be found at arthritis.org. Yoga would be an example of a form of exercise that involves joint flexibility, muscle strengthening and mental discipline that many people with arthritis find beneficial. That would be an example of a joint-safe form of exercise that people with arthritis might want to consider.

MODERATOR:
Who should you see to be evaluated and treated for arthritis?

KLIPPEL:
For most people, seeing their primary care or family doctor would be who they would see first. It's important to recognize there are two specialists who deal mostly with arthritis, and those would be a rheumatologist, or in the instance of a child, a pediatric rheumatologist. For many people, a specialist like a rheumatologist is very important to make a diagnosis -- there are more than 100 forms of arthritis -- and outline and begin a plan of treatment. The other specialist that plays an important role in arthritis and musculoskeletal disorders is an orthopaedic surgeon. In particular for people who have advanced disease or are limited by their arthritis, orthopedic surgeons play an important role in performing surgery on knees or hips, which can make a dramatic difference in improving the lives of people affected by arthritis.

MEMBER QUESTION:
I am very active, and arthritis limits my mobility at times. Can one overdo exercise? I play tennis, swim, walk and jog.

KLIPPEL:
A person with arthritis has to use common sense and listen to his or her body. If one overexercises, typically one pays a price -- often that night. The biggest challenge that we face though is to get people with arthritis to start an exercise program, simply because their joints hurt. It's very important that people understand the importance of exercise in the management of their arthritis and get involved in a daily exercise regimen.

MEMBER QUESTION:
Can you tell me the side effects of using Plaquenil with methotrexate for a period of two years for rheumatoid arthritis (RA)?

KLIPPEL:
Plaquenil is an example of an antimalarial drug, which is used in rheumatoid arthritis and other (inflammatory) forms of arthritis. When used in low dosages, typically 200 mg a day, Plaquenil is extremely safe, including when combined with methotrexate. Often physicians will have a person, after taking Plaquenil for a year, see an ophthalmologist for an eye exam to check for a very, very rare complication of Plaquenil that affects the eye.

MODERATOR:
Have there been any serious concerns about the medications used to treat RA or psoriatic arthritis?

KLIPPEL:
The important thing for anyone who has rheumatoid arthritis, psoriatic arthritis or related diseases has been the tremendous advances in drug therapy for these conditions, particularly over the past decade. Like all drugs, these drugs have side effects and a person considering or using these drugs should be familiar with the side effects. But, every person I have ever met who has benefited from these drugs would admit the benefits far outweigh any potential side effect which might be associated with these drugs.

MEMBER QUESTION:
Are there any supplements that help with arthritis? Aside from losing weight, are there any diet changes that help?

KLIPPEL:
There has been a lot of interest in two particular dietary supplements for the management of osteoarthritis, particularly arthritis affecting the knees. The supplements are glucosamine and condoitin sulfate. There have now been a number of studies which indicate that these supplements relieve pain, improve the person's ability to use the joint without pain, and intriguingly, several studies have suggested that these supplements may prevent joint damage.

I think that we would encourage people, based on studies we know of, the most important thing besides attention to calories is making sure the diet is balanced. There is a lot of interest in the role of vitamins in protecting people in the development of arthritis. We certainly think that taking a multivitamin each day would be good health maintenance for arthritis, and people have focused on the role of vitamin C and the various antioxidants in protecting people from developing osteoarthritis. In addition, it's important that people continue to take daily doses of vitamin D, along with calcium, to protect from the development of osteoporosis, a common complication seen in people with arthritis.

MEMBER QUESTION:
I am 57 and have had RA for over 12 years. I am currently on no meds and exercise regularly. Can you mention any solutions to the ever-present fatigue?

KLIPPEL:
That's a very interesting question, particularly in RA. Fatigue, or simply being exhausted or running out of energy early, is a common complaint with this disease. In general, the fatigue is a marker of the activity of the arthritis, and one often finds that better drug treatment of the arthritis results in improvement of the fatigue. I think it's also important, particularly for someone with progressive fatigue to make certain that there is not another explanation for the fatigue. Typical examples might include hypothyroidism (low thyroid hormone) or anemia or low blood count, both of which can be seen in people with rheumatoid arthritis.

MODERATOR:
How effective are NSAID creams?

KLIPPEL:
There continues to be controversy about the use of NSAID creams in arthritis. These are available in other countries, particularly European countries. However they are not available in this country.

MODERATOR:
On the Arthritis Foundation web site, do you have a listing of scams people should watch out for or avoid?

KLIPPEL:
We actually, on the web site, attempt to provide people with information that will make them better consumers of health care. We've been particularly proactive in the role of informing people about drugs, so annually we offer an updated drug guide. The 2005 drug guide was just produced last month. We are also very active in educating the consumer about alternative therapies, so people can find what we hope is useful information on the web site as well as publications from the Arthritis Foundation.

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

KLIPPEL:
We very much appreciate the interest and the Arthritis Foundation is here to help and better serve every man, woman and child in this country with arthritis. Thanks for the interesting questions and I hope everyone has benefited from the questions. Thank you.

MODERATOR:
Our thanks to John H. Klippel, MD, for joining us today. And thanks to you, members, for your great questions. I'm sorry we couldn't get to all of them.

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