Living with Ol' Arthur
By Susan Jacobi, M.D.
By Susan Jacobi, M.D.
First a clarification: Ol’ Arthur isn’t just for old folks. Although the image of your grandma or grandpa may spring to mind when someone mentions arthritis, joint pain and damage from inflammation can occur in any age group, even children. Fortunately, exciting new treatments are now available that have dramatically improved the course of many types of arthritis.
Arthritis is a catchall term that encompasses a range of diseases and conditions. The most common category of arthritis falls under the heading of osteoarthritis. This is a degenerative process that may be caused by previous injury, wear-and-tear, aging, and genetics. The cartilage will deteriorate and allow damage to the joint surface, resulting in pain, restricted movement, and deformity. This would be the arthritis of old age—ol’ Arthur.
Exercise and weight loss can be important components of management, particularly when dealing with the knees and hips. Treatment also typically includes pain relievers (such as acetaminophen) and anti-inflammatories (such as ibuprofen). There is some evidence that the glucosamine sulfate found in over-the-counter supplements may be of some benefit. Sometimes a cortisone injection directly into the painful joint is helpful. Other preparations containing hyaluronic acid derivatives (a component of cartilage) are available for injection into the arthritic knee and may provide longer-term relief. Advanced joint damage that limits activity may ultimately be best addressed with joint replacement surgery.
Whereas osteoarthritis is characterized by wear and tear in the cartilage and joints, many other types of arthritis produce joint damage as a result of inflammation. The inflammation occurs for various reasons and at various ages (including children), depending on the type of arthritis. For example, an infection within the joint will cause acute inflammation, and requires treatment with antibiotics. By a different mechanism, an infection in another part of the body can trigger an inflammatory reaction within the joints, producing a reactive arthritis.
Gout is an acutely inflammatory arthritis. A metabolic problem results in elevated levels of uric acid in the blood, and a flare-up is caused by the deposition of uric acid crystals within the joint space. It is characterized by intense pain and swelling in a joint, classically the big toe joint.
Since purine compounds produce uric acid crystals, following a low-purine diet is often recommended. This means avoiding alcoholic beverages, certain seafood and shellfish, and some meat, including turkey, veal and liver.
In reality it can be very difficult to completely control gout via diet modification. Fortunately, there are several medications available that can lower the serum uric acid level by either increasing elimination through the kidneys, or increasing its metabolism in the body. Non-steroidal anti-inflammatory drugs (NSAIDs) and steroids are useful in an acute flare.
The immune system normally produces inflammation as part of its response to infection. The body recognizes the bacteria as foreign, and tries to “attack” and clear it. In some diseases, the immune system is misdirected and attacks its own cells. This results in an autoimmune inflammatory process. In the case of rheumatoid arthritis (RA), the inflammatory response involves the joint lining, or synovium.
The persistent inflammation eventually can lead to permanent joint damage and deformity. The goals of treatment therefore include reducing the pain and inflammation, and hopefully preventing loss of function. The ideal would be to achieve long-term remission.
For many years the mainstays of treatment for RA included high dose aspirin, NSAIDs, glucocorticoids (steroids), and a few stronger medicines, including gold (yes, that gold) which was given in the form of injections. The introduction of immunosuppressant medications (such as methotrexate) brought new options and expectations for improved disease control.
Basic science research into the biologic mechanism of the inflammatory response has brought dramatic advances in treatment of autoimmune diseases such as RA. A new class of compounds called biologic response modifiers offers control of disease that was not possible 15 years ago. These medications provide excellent control of the arthritis, but unfortunately do not provide a cure. In most cases, RA still requires long-term management.
The spectrum of arthritis reaches into childhood. Several types of inflammatory processes can affect the joints in youngsters, including autoimmune diseases. Many of the classes of drugs used in adults have also been studied and found effective for the treatment of juvenile arthritis.
Because the treatment of joint pain varies with the type of arthritis, accurate diagnosis is important. This is not always a straightforward process. History, physical exam, blood work, and x-rays are all pieces to the puzzle. Even with extensive testing, however, the diagnosis may not be obvious. Sometimes the disease process itself needs to evolve a bit before it can be labeled. Therefore an initial treatment program may need to be adjusted and modified as new issues arise.
There are many other facets to the diagnosis and treatment of arthritis. The Arthritis Foundation website (www.arthritis.org) provides comprehensive up-to-date information. The website for the American College of Rheumatology (www.rheumatology.org) is also an excellent resource.
Today there is much to be optimistic about in the management and treatment of ol’ Arthur. Although he is still with us, perhaps his future visits will bring less discomfort.
Susan Jacobi, M.D. is a Rheumatologist with Mercy Arthritis & Osteoporosis Center in Des Moines, Iowa