Arthritis

Arthritis is a condition associated with swelling and inflammation of the joints, which often results in pain and restriction of movement. The most common forms of arthritis are osteoarthritis, which is a breakdown of the cartilage in the joints, and rheumatoid arthritis, which is an inflammation of the tissue lining the joints and in severe cases inflammation of other body tissues. In the joints, sustained inflammation leads to hypertrophy of the synovium and the formation of a "pannus", which spreads over the joint causing erosive destruction of the bone and cartilage. Rheumatoid arthritis occurs when the body's immune system starts attacking it's own organs (joints, bones, internal organs).

What causes Arthritis and who is at risk?

Arthritis is a result of a breakdown in cartilage or inflammation.

Cartilage protects joints and enables smooth movement by absorbing shock when pressure is placed on a joint. Without the usual amount of cartilage, the bones rub together and this causes pain, swelling (inflammation), and stiffness.

Joint inflammation can occur for a variety of reasons, including:

  • Broken bones
  • Infections (usually caused by bacteria or viruses)
  • An autoimmune disease (where the body attacks itself because the immune system believes a body part is foreign)
  • General "wear and tear" on joints

Often, the inflammation goes away once the injury has healed, the disease is treated, or once the infection has been cleared. However, with some injuries and diseases, the inflammation does not go away or the cartilage is destroyed and long-term pain and deformity results. When this happens, the disease is called chronic arthritis.

Osteoarthritis is the most common type of arthritis and is more likely to occur with increasing age. It can occur in any of the joints but is most common in the hips, knees or fingers.

Risk factors for osteoarthritis include:

  • Being overweight
  • Having previously injured the affected joint
  • Using the affected joint in a repetitive action that puts stress on the joint (baseball players, ballet dancers, and construction workers are all at risk)

Arthritis can occur in both men and women and in individuals of all ages. Some forms of arthritis also affect children.

Types of Arthritis

As mentioned earlier, the most common forms of arthritis are Osteoarthritis and Rheumatoid arthritis. However, there are numerous forms of arthritis, including:

Symptoms of Arthritis

A person suffering from arthritis may experience any of the following:

  • Joint pain
  • Joint swelling
  • Stiffness, especially in the morning
  • Warmth around a joint
  • Redness of the skin around a joint
  • Reduced ability to move the joint

Diagnosis

A doctor will first note your symptoms and will then look at your medical history in detail to see if arthritis or another musculoskeletal problem is the likely cause of those symptoms.

Your doctor will then perform a thorough physical examination to see if there is any fluid collecting around the joint (an abnormal build up of fluid around a joint is called "joint effusion."). The joint may be tender when gently pressed, and it may also be warm and red (especially if you have infectious arthritis or autoimmune arthritis). You may also find it painful or difficult to rotate the joints in some directions (this is known as "limited range-of-motion").

After this initial physical examination, your doctor may then ask you to undertake a number of different tests, depending on what they suspect to be the cause of your symptoms. Often, you will need to have a blood test and joint x-rays. You may also need to have a test where joint fluid is removed from the joint with a needle; the fluid will then be examined under a microscope to check for infection and for other causes of arthritis, such as crystals, which cause gout.

If arthritis is diagnosed and treated early, you can prevent joint damage. Find out if you have a family history of arthritis and share this information with your doctor, even if you have no joint symptoms. In some autoimmune forms of arthritis, the joints may become deformed if the disease is not treated. Osteoarthritis may be more likely to develop if you over-use your joints. Take care not to overwork a damaged or sore joint. Similarly, avoid excessive repetitive motions. Excess weight also increases the risk for developing osteoarthritis in the knees, and possibly in the hips and hands.

See your doctor if:

  • Your joint pain persists beyond 3 days.
  • You have severe unexplained joint pain.
  • The affected joint is significantly swollen.
  • You have a hard time moving the joint.
  • Your skin around the joint is red or hot to the touch.
  • You have a fever or have lost weight unintentionally.

Treatment Options

The treatment of arthritis depends on the particular cause of the disease, on the joints that are affected, on the severity of the disorder and on the effect it has on your daily activities. Your age and occupation will also be taken into consideration when your doctor works with you to create a treatment plan.

If possible, treatment will focus on eliminating the underlying cause of the arthritis. However, sometimes the cause is NOT curable, as with osteoarthritis and rheumatoid arthritis. In this case, the aim of treatment will be to reduce pain and discomfort and prevent further disability. Symptoms of osteoarthritis and other long-term types of arthritis can often be improved without medications. Making lifestyle changes without medications is preferable for osteoarthritis and other forms of joint inflammation. If needed, medications should be used in addition to lifestyle changes.

Arthritis Medications

Your doctor will select the most appropriate medication for your form of arthritis.

Acetaminophen and Combination Medicines

Most people can take acetaminophen without any problems so long as they do not exceed the recommended dose of 4 grams in 24 hours (taken in 4 divided doses every 4 to 6 hours). It reduces mild pain but does not help with inflammation or swelling. Acetaminophen is available as a combination with other mild pain relief medicines for mild osteoarthritic pain, and with narcotics for severe pain. Acetaminophen with aspirin and or caffeine are over-the-counter medicines. Acetaminophen with codeine, propoxyphene or narcotics are prescription medicines.

Brand Name Generic Name
Anexsia (different strengths with varying amounts of hydrocodone), Co-gesic, Lortab, Norco, Vicodin, Vicodin ES, Vicodin HP, Zydone acetaminophen and hydrocodone
Darvocet A500, Darvocet-N 100, Darvocet-N 50 acetaminophen and propoxyphene
Darvon propoxyphene


Excedrin Back and Body acetaminophen and aspirin
Excedrin Tension Headache acetaminophen and caffeine
Excedrin, Vanquish acetaminophen, aspirin and caffeine
Oxycet, Percocet, Roxicet, Roxilox, Tylox acetaminophen and oxycodone
Tylenol acetaminophen
Tylenol with Codeine acetaminophen and codeine
Ultracet acetaminophen and tramadol

Non Steroidal Anti-Inflammatory Drugs

Although NSAIDs work well, long-term use of these medicines can cause gastrointestinal problems, such as stomach ulcers and bleeding. In April 2005, the FDA asked manufacturers of NSAIDs to include a warning label on their products that alerts users of an increased risk of cardiovascular events (heart attacks and strokes) and gastrointestinal bleeding.

Taking a combination of NSAIDs or NSAIDs and aspirin together increases the incidence of stomach ulcers or bleeding.

Brand Name Generic Name
Advil, Cap-profen, IBU-Tab, Ibuprohm, Medipren, Motrin ibuprofen
Aleve, Anaprox, Naprosyn, Naprelan naproxen
Ansaid flurbiprofen
Cataflam, Voltaren, Voltaren XR diclofenac
Clinoril sulindac
Daypro oxaprozin
Lodine, Lodine XL (brand discontinued) etodolac
Feldene piroxicam
Indocin, Indocin SR indomethacin
Orudis, Orudis KT (brand discontinued) ketoprofen
Mobic meloxicam
Relafen (brand discontinued) nabumetone
Nalfon
fenoprofen
Tolectin tolmetin

Combination Drug Products

These contain a non steroidal anti-inflammatory drug and a stomach protecting agent, to prevent or treat the gastrointestinal side effects which may be caused by NSAIDs.

Brand Name Generic Name
Arthrotec diclofenac/misoprostol
Prevacid NapraPAC 500 naproxen/lansoprazole
Vimovo naproxen/esomeprazole

Cycloxygenase 2 Inhibitor (COX-2 inhibitors or Coxibs)

COX-2 inhibitors block an inflammation-promoting enzyme called COX-2. This class of drugs was initially believed to work as well as traditional NSAIDs, but with fewer stomach problems. However, numerous reports of heart attacks and strokes have prompted the FDA to re-evaluate the risks and benefits of the COX-2 inhibitors. Rofecoxib (Vioxx) and valdecoxib (Bextra) have been withdrawn from the U.S. market following reports of heart attacks in some patients taking the drugs. The available medicines in this class have been labeled with strong warnings and a recommendation that these be prescribed at the lowest possible dose and for the shortest duration possible.

Brand Name Generic Name
Bextra - withdrawn April 7, 2005 valdecoxib
Celebrex celecoxib
Vioxx - voluntarily withdrawn from market on September 28, 2004. rofecoxib

Salicylates

Brand Name Generic Name
Amigesic, Disalcid, Salflex, Salsitab salsalate
Bayer Aspirin (many other brands are available) aspirin
Dolobid (brand discontinued, generic version available) diflunisal
Tricosal, Trilisate choline salicylate/magnesium salicylate

Corticosteroids have been used to reduce inflammation in rheumatoid arthritis for more than 40 years but it is not known whether they can slow down the progression of disease. It can be used in conjunction with other rheumatoid arthritis medicine.

Potential long-term side effects of corticosteroids limit the use of oral corticosteroids to short courses and low doses where possible. Side effects may include bruising, psychosis, cataracts, weight gain, susceptibility to infections and diabetes, high blood pressure and thinning of the bones (osteoporosis). A number of medications can be administered with steroids to minimize the risk of osteoporosis.

Intra-articular steroid injections can effectively relieve pain, reduce inflammation, increase mobility and reduce deformity in one or a few joints. If repeated injections are required then the dose of DMARDs should be increased.

Brand Name Generic Name
Aristospan, Kenalog-10, Kenalog-40, Triesence, Trivaris (injection) triamcinolone
Celestone Soluspan (injection) betamethasone
A-methapred, Depo-Medrol, Solu-Medrol (injection) methylprednisolone
Cortisone (oral) cortisone
Prednisone (oral) prednisone

Corticosteroids

Corticosteroids suppress the immune system and also reduce pain and inflammation. They are commonly used in severe cases of osteoarthritis and they can be given orally or by injection. Steroid injections are given directly into the joint (intra-articular). Steroids are used to treat autoimmune forms of arthritis but they should be avoided if you have infectious arthritis. Steroids have multiple side effects, including upset stomach and gastrointestinal bleeding, high blood pressure, thinning of bones, cataracts, and increased infections. The risks are most pronounced when steroids are taken for long periods of time or at high doses. Close supervision by a physician is essential.

Brand Name Generic Name
Aristospan, Kenalog-10, Kenalog-40 triamcinolone injection
Celestone Soluspan betamethasone injection
A-methapred, Depo-Medrol, Solu-Medrol methylprednisolone injection
Cortisone cortisone
Prednisone prednisone

Disease Modifying Anti-Rheumatic Drugs (DMARDs)

DMARDs are the most effective agents available for controlling rheumatoid arthritis, but they all have a slow onset of action. Mechanisms of action for most of these agents are not known and they all are different but they all appear to slow or stop the changes in the joints. They can alter laboratory characteristics of disease activity and delay the progression of bone damage.

Patients taking DMARDs generally show some response within 8 to 10 weeks. However, this is variable depending on the patient and drug. Dose of DMARDs is titrated up as far as side effects allow. An additional DMARD is added when the maximum dose is reached, or the initial DMARD is stopped and switched to another.

Most DMARDs require monitoring (such as full blood count, liver function test, urea and electrolyte level test) to ensure drug safety, as the majority can cause bone marrow toxicity and some can cause liver toxicity as well. Regular blood or urine tests should also be done to determine how well medications are working.

DMARDs (Oral Form)

Brand Name Generic Name
Arava leflunomide
Azasan, Imuran azathioprine
Azulfidine sulfasalazine
Cuprimine, Depen penicillamine
Gengraf, Neoral, Sandimmune cyclosporine
Plaquenil hydroxychloroquine
Ridaura auranofin
Trexall methotrexate

DMARDs (Subcutaneous Injection)

Brand Name Generic Name
Actemra tocilizumab
Cimzia certolizumab
Enbrel etanercept
Humira adalimumab
Kineret anakinra

DMARDs (Intravenous Infusion and Intramuscular Injection)

Brand Name Generic Name
Myochrysine gold sodium thiomalte (intramuscular injection)
Orencia abatacept
Remicade infliximab
Rituxan rituximab
Solganal aurothioglucose (gold)

Methotrexate is probably the most commonly used DMARD. It is effective in reducing signs and symptoms of rheumatoid arthritis and slows down damage to the joint. Results can be seen in 6 to 8 weeks. Other DMARDs such as hydroxychloroquine and sulfasalazine can used in conjunction with methotrexate.

Hydroxychloroquine, an antimalarial drug, is effective in the treatment of rheumatoid arthritis. It is usually used in combination with methotrexate and sulfasalazine for added benefits.

Sulfasalazine is also an effective DMARD. It can reduce symptoms and slow down the joint damage.

Leflunomide shows similar effectiveness to methotrexate and can be used in patients who cannot take methotrexate.

Tumor necrosis factor (TNF) inhibitors are a relatively new class of medications used to treat autoimmune disease. They include etanercept, infliximab, adalimumab, tocilizumab, certolizumab and golimumab. TNF Inhibitors are also called "Biologics" biological response modifiers.

Tumor necrosis factor alpha is produced by macrophages and lymphocytes, and acts on many cells in the joints and in other organs and body systems. It is a pro-inflammatory cytokine known to mediate most of the joint damage. In rheumatoid arthritis it is produced by the synovial macrophages and lymphocytes. By inhibiting TNF alpha the inflammation process, which attacks or damages the joint tissue, is halted or slowed.

Methotrexate can be used with TNF inhibitors to increase the effectiveness of therapy.

Gold is also effective in the treatment of rheumatoid arthiritis, particularly when given intramuscularly. It isn't used as often now due to its side effects and slow onset of action. Oral gold preparation is available but is less efficacious compared to the intramuscular preparation.

Abatacept decreases T cell proliferation and inhibits the production of the cytokines tumor necrosis factor (TNF) alpha, interferon-?, and interleukin-2.

Rituximab depletes the B cells, which have several functions in the immune response. Rituximab has reduced signs and symptoms of rheumatoid arthritis, and manages to slow down the joint destruction.

The Interleukin-1 Inhibitor, Anakinra, is a new synthetic protein that blocks the inflammatory protein interleukin-1. Anakinra is used to slow progression of moderate to severe active rheumatoid arthritis in patients who have not responded to one or more of the DMARDs.

Alkylating Agents

Alkylating agents, such as cyclophosphamide, are drugs that suppress the immune system and are sometimes used in people who have failed other therapies. These medications are associated with toxic side effects and usually reserved for severe cases of rheumatoid arthritis.

Brand Name Generic Name
Lyophilized Cytoxan (injection) cyclophosphamide (injection and oral)

Supplements

Nutraceuticals

Many people find that over-the-counter nutraceuticals and vitamins, such as glucosamine and chondroitin sulfate help relieve the symptoms of osteoarthritis. There is some evidence that these supplements are helpful in controlling pain, although they do not appear to grow new cartilage.

Brand Name Generic Name
Cosamin DS, Osteo Bi-Flex, Pryflex, Relamine, Schiff Move Free chondroitin/glucosamine
SAMe s-adenosylmethionine

Vitamins

Bioflavonoids are found in the rind of green citrus fruits and in rose hips and black currants. They have been used historically in a variety of disease states including rheumatic fever, habitual abortion, poliomyelitis, prevention of bleeding, rheumatoid arthritis, periodontal disease, diabetic retinitis, and others.

Brand Name Generic Name
Amino-Opti-C, Limbrel, P-1000, Pan C 500, Peridin-C, Span C bioflavonoids

Topical Pain Relief Agents

Diclofenac topical is a non-steroidal anti-inflammatory drug. Although it is applied topically it is still absorbed systemically and may cause systemic effects such as gastrointestinal side effects.

Trolamine salicylate is a topical salicylate pain reliever, used for minor pain and inflammation. It works by reducing swelling and inflammation in the muscle and joints.

Brand Name Generic Name
Flector Patch, Voltaren Gel diclofenac
Myoflex Cream, Aspercreme Cream trolamine salicylate

Capsaicin is extracted from chillies (genus Capsicum). Capsaicin topical causes a decrease in a substance (substance P) in the body that causes pain. It is used to relieve minor aches and pains of muscle and joints associated with arthritis, simple backache, strains and sprains.

Brand Name Generic Name
Capsin, Trixaicin, Zostrix capsaicin

Artificial Joint Fluid

Hyaluronic acid is normally present in joint fluid, and in osteoarthritis sufferers this gets thin. Hyaluronic acid can be injected into the joint to help protect it. This may relieve pain for up to six months.

Brand Name Generic Name
Synvisc hylan g-f 20
Orthovisc hyaluronan
Euflexxa, Hyalgan, Supartz sodium hyaluronate

Non-Drug Treatment

Non-drug treatment is also important. It is important to make lifestyle changes. Exercise helps maintain joint and overall mobility. Ask your health care provider to recommend an appropriate home exercise routine. Water exercises, such as swimming, are especially helpful. You also need to balance rest with activity. Non-drug pain relief techniques may help to control pain. Heat and cold treatments, protection of the joints and the use of self-help devices are recommended. Good nutrition and careful weight control are important. Weight loss for overweight individuals will reduce the strain placed on the knee and ankle joints.

Physical Therapy

Physical therapy can be useful for improving muscle strength and motion at stiff joints. Therapists have many techniques for treating osteoarthritis. If therapy does not make you feel better after 3-6 weeks, then it is likely that it will not work at all.

Braces

Splints and braces can sometimes support weakened joints. Some prevent the joint from moving, while others allow some movement. You should use a brace only when your doctor or therapist recommends one. The incorrect use of a brace can cause joint damage, stiffness and pain.

Surgery

Surgery to replace or repair damaged joints may be needed in severe, debilitating cases.

Surgical options include:

Arthroplasty - total or partial replacement of the deteriorated joint with an artificial joint e.g. knee arthroplasty, hip arthroplasty.

Arthroscopic - surgery to trim torn and damaged cartilage and wash out the joint.

Cartilage Restoration - For some younger patents with arthritis, cartilage restoration is a surgical option to replace the damaged or missing cartilage.

Osteotomy - change in the alignment of a bone to relieve stress on the bone or joint.

Arthrodesis - surgical fusion of bones, usually in the spine.

See Also:

Last updated: 2012-10-23

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