Frequently Asked Questions
General Arthritis Questions
| Q. What are NSAID's? |
|
A. The term NSAID stands for Non-Steroidal Anti-Inflammatory Drugs. These are non-aspirin compounds that are used to treat arthritis symptoms. The term non-steroidal refers to the fact that these are not corticosteroids. They work by decreasing inflammation in the joints. |
| Q. I understand there are some risks to taking nonsteroidal anti-inflammatory drugs, particularly with regard to the stomach? |
|
A. Yes. This is true. The traditional non-steroidal anti-inflammatory drugs that we have been using over the last twenty years have had a particular risk regarding gastrointestinal side effects including stomach ulcers as well as stomach inflammation (gastritis). There have been episodes of gastrointestinal bleeding secondary to these medications. A large number of these medications act similarly to aspirin in that they interfere with platelet function, which is important in clotting in the body. Thus patients have had some increased bruising on the skin. These medicines also may interfere with kidney function particularly in those patients who already have underlying kidney problems to start with. Sometimes liver function may be affected with some elevation of liver blood tests. In the majority of patients these are reversible once the medication is discontinued. The important point here is that when patients take these medications they need to be monitored closely for these various side effects. In individuals over age 65, laboratory tests should probably be done at a minimum of every six months to ensure that no changes in the blood count, liver functions or kidney tests are occurring. |
| Q. What is all this stuff I am hearing about COX-1 versus COX-2 inhibition? Is this important for me in deciding which medications I should take for my arthritis? |
| A. Within the last ten years it was discovered that there are two different enzymes involved in the production of prostaglandins in the body. Cyclo-oxygenase 1 (COX-1) is an enzyme that is important for the normal physiology of the stomach, platelets, and other organs. COX-1 helps protect the lining of the stomach against ulceration and thus maintains the integrity of the lining tissue. Any medicines which would block COX-1, therefore, would predispose the patient to stomach ulcers and the potential for perforations and bleeding. This enzyme is present all of the time and therefore it is called "constitutive." A second enzyme called cyclo-oxygenase 2 (COX-2) only arises when there are abnormal states of inflammation present such as in the joint with arthritis. In these situations, inflammation induces this enzyme and therefore it is called "inducible." Much work has been done since 1990 to develop medications that selectively act to block cyclo-oxygenase 2 so as to prevent inflammation in the joint without significant interference with cyclo-oxygenase 1. This avoids disturbing the normal physiology of the stomach and affecting the integrity of the tissue that lines the stomach. The first medicine released that is COX-2 selective was Celebrex (celecoxib). It was followed soon thereafter by Vioxx (refocoxib). Other companies are currently in the developmental stage with other COX-2 selective medications which decrease the incidence of gastrointestinal side-effects. These gastro-intestinal problems have been the major drawback of older traditional NSAIDS. |
| Q. I seem to have most of my symptoms in my muscles rather than in my joints. Can this still be a form of arthritis? |
| A. Arthritis by definition involves the joints where bones meet and thus if your symptoms are only in your muscles, this is not truly arthritis. There are, however, many diseases that rheumatologists treat that do involve muscles. These include polymyalgia rheumatica, which is seen more in individuals over age 65 and mainly involves the upper arm muscles and thigh muscles. It may also include polymyositis where there is an actual significant inflammation in the muscles with associated weakness. Many patients have muscular pain with a condition called fibromyalgia syndrome, with multiple tender points in the muscles. It is sometimes associated with various degrees of depression and anxiety or worsened by weather changes. There are some situations where forms of arthritis such as rheumatoid arthritis may have muscle aching (myalgias) associated with the joint involvement, but the arthritis symptoms are also fairly apparent as well. |
| Q. What are DMARDs? |
|
A. The term DMARD comes from the first letters of the words, Disease Modifying Anti-Rheumatic Drug. This is a common term used for specialized medications that are used to treat rheumatoid arthritis. In past years medications which came under the heading of DMARDS included gold given by injection or by mouth, Plaquenil (hydroxychloroquine) which is an anti-malarial medication, penicillamine (which is not used with any great frequency now), Imuran (azathioprine), and Azulfidine (sulfasalazine). In the 1980s methotrexate became the most popular DMARD for rheumatoid arthritis and has continued to occupy this place. In the last couple of years, however, we now have additional choices as DMARDS, including Arava (leflunomide) and also the incorporation of biologic agents. Enbrel (etanercept) was the first of these approved and now Remicade (infliximab), an intravenous therapy, has been approved as an additional DMARD. Thus, the patient and rheumatologist now have a multitude of choices, many of which may be used singly or in combination with other DMARDS to rapidly control the underlying activity of the disease in rheumatoid arthritis. Incidentally, a number of these medications are used as disease modifying therapies in other rheumatic illnesses as well, such as Plaquenil and methotrexate which are used, for example, in the treatment of systemic lupus erythematosus. |
| Q. Can a blood test tell whether I have arthritis or not? |
| A. In some situations an abnormal blood test will indicate the possibility of arthritis such as a positive rheumatoid factor antibody in rheumatoid arthritis or a positive antinuclear antibody that may be seen in association with one of the connective tissue diseases such as systemic lupus erythematosus. In osteoarthritis, there is no particular blood test that is abnormal and yet an individual can still have degenerative arthritis in the joints. In inflammatory forms of arthritis, there are two tests that may be elevated which correlate with inflammation and these are the erythrocyte sedimentation rate (ESR) and the C-reactive protein (CRP). A group of disorders called seronegative spondyloarthropathies which includes ankylosing spondylitis and psoriatic arthritis, Reiter's syndrome and arthritis in association with inflammatory bowel disease, may have a genetic test in common which is a positive HLA-B27 antigen. However there are many individuals who have this same antigen on genetic testing and yet do not have any form of arthritis. Thus it is important that a patient have a history and physical examination performed by a rheumatologist who can then correlate any of these laboratory test abnormalities with the patient's complaints and other findings to determine if the patient truly has one of these diseases or not. |
| Q. How does the taking of x-rays help in the diagnosis of arthritis? |
|
A. There are a number of different types of x-ray abnormalities in arthritic conditions. First of all, rheumatologists look for any joint space narrowing where two bones meet at the joint space. Although you cannot actually see cartilage on a plain x-ray, the fact that the joint space has narrowed implies a loss of the cartilage that covers the ends of each bone. In the case of a patient with rheumatoid arthritis, we are also looking for any small erosions of bone, which may occur generally at the margins (sides of the joint). One can see evidence of bone cysts as well on the x-rays. In the case of osteoarthritis, we are looking for joint space narrowing, but also for the evidence of spurs or osteophytes at the corners of the joints. There also may be some "whitening" of the ends of bones called sclerosis. In ankylosing spondylitis, x-rays of the spine may reveal evidence of calcium depositing in the ligaments that join the vertebrae together. Also there may be changes found at the sacroiliac joints in the pelvis including narrowing of the joint or even total fusion (joining together) of the sacroiliac joint. Thus there are many different x-ray findings which help to confirm a specific diagnosis of one of the many types of arthritis. |