Rheumatoid Arthritis (RA)
treatment, prevention and pain relief
Rheumatoid arthritis (RA) is an autoimmune disorder of unknown etiology. Rheumatoid arthritis (RA) is characterized by symmetric, erosive synovitis and, in some cases, extraarticular involvement. Most patients with Rheumatoid arthritis (RA) experience a chronic, fluctuating course of disease that, despite therapeutic measures, may result in progressive joint destruction, deformity, disability, and premature death.
The inflammation associated with Rheumatoid arthritis (RA) damages the synovial joints of the wrists, shoulders, knees, ankles and feet. Since RA is systemic, it can attack other parts of the body besides the joints. This may result in general fatigue with no specific complaints. The patient may also present with pathology of the nervous system, with accompanying sensory changes or sensory loss. Eye lesions may occur, and some patients may develop dry eye.
Rheumatoid nodules that form close to the joints and other skin problems may be present in approximately 25 percent of Rheumatoid arthritis (RA) patients, and usually signal the most rapidly progressive form of the disease. Rheumatoid nodules usually develop in areas of the body where pressure is applied, including the sacrum and elbows. The patient's skin may also bruise easily. Some patients experience the effects of Rheumatoid arthritis (RA) in places other than the joints. Many develop anemia. Very rarely, patients may experience vasculitis, pleuritis, or pericarditis.
In most cases of Rheumatoid arthritis (RA), the patient experiences remissions and exacerbations of symptoms. There will be times when the patient feels good and times when he or she complains of feeling worse. A patient with Rheumatoid arthritis (RA) may sometimes feel that he/she has been "cured." In fact, very few patients ever enjoy a complete remission of the disease and it is therefore imperative that the appropriate program of Rheumatoid arthritis (RA) treatment continues.
Rheumatoid arthritis (RA) affects approximately 1% of the adult population. The ultimate goals in managing the condition are to prevent or control joint damage, prevent loss of function, and decrease pain.
CONTRIBUTING FACTORS
The etiology of Rheumatoid arthritis (RA) remains unknown in spite of extensive research into metabolic and nutritional factors, the endocrine system, geographic, psychologic, and occupational data. The most accepted theory as to Rheumatoid arthritis (RA)'s cause is that an unknown antigen initiates the autoimmune response. This suggests strongly that Rheumatoid arthritis (RA) is caused by a bacterial or viral infection.
Researchers are now focusing on the concept that Rheumatoid arthritis (RA) is a T-cell-mediated disease precipitated by both genetic and environmental factors.
TREATMENT MODALITIES
There is no known cure for Rheumatoid arthritis (RA). Treatment designed for the individual patient can, however, reduce pain, maintain and/or improve joint mobility, and limit functional impairment. While some contributory factors cannot be modified (genetic predisposition, environmental), there are many ways in which the progression of Rheumatoid arthritis (RA) can be addressed. These include physical and psychosocial coping mechanisms, and use of medications.
Physical and psychosocial coping mechanisms:
These include exercises for strengthening the joints, diet and other lifestyle factors, all of which are helpful in relieving the physical and emotional aspects of osteoarthritis. Rheumatoid arthritis patients should be encouraged to participate in self-management programs since individuals who participate in these programs report decreases in joint pain and frequency of arthritis-related physician visits, increases in physical activity, and overall improvement in quality of life.
Click here to view rheumatoid arthritis risk factors, prevention & wellness tips for your patients.
Click here to view general wellness tips for your patients.
Medications
Medications to treat Rheumatoid arthritis (RA) fall into two categories...those that control symptoms (analgesics, anti-inflammatories), and those that affect the progression of Rheumatoid arthritis (RA) (DMARDs). The biostructural medicine, Recovery‡ is also proposed to slow progression of the disease.
Analgesics and Anti-inflammatories
NSAIDs
Nonsteroidal anti-inflammatory drugs (NSAIDs) are a group of drugs commonly used to treat Rheumatoid arthritis (RA) because of their analgesic, anti-inflammatory, and antipyretic properties. NSAIDs inhibit the enzymes Cox-1 and Cox-2 (cyclooxygenase), which catalyze arachidonic acid to prostaglandins and leukotrienes. Arachidonic acid is released from membrane phospholipids as a response to inflammatory stimuli. The efficacy of NSAIDs differs from patient to patient. This is likely due to the pharmacokinetic differences among the various NSAIDs.
By inhibiting Cox-1 enzyme, NSAIDs can cause stomach irritation, bleeding, fluid retention, and decreased kidney function. Since NSAIDs bind to plasma proteins they may be displaced by or may displace other plasma-bound drugs such as coumadin, methotrexate, digoxin, cyclosporine, oral antidiabetic agents, and sulfa drugs. This interaction can enhance the therapeutic or toxic effects of either drug.
NSAIDs (particularly indomethacin) can interfere with the pharmacologic control of hypertension and cardiac failure in patients who take beta-adrenergic antagonists, angiotensin-converting enzyme inhibitors, or diuretics.
The long-term use of NSAIDs may have a damaging effect on chondrocyte function.
Adverse effects of NSAIDs (which can occur at any time), include renal failure, hepatic dysfunction, bleeding, and gastric ulceration.
Cox-2 Inhibitors
A relatively new sub-class of NSAID, known as Cox-2 inhibitors, work by blocking cyclooxygenase 2 enzyme which is involved in the inflammation pathway. By sparing cyclooxygenase 1 (Cox-1) enzyme, gastrointestinal toxicity is purportedly reduced. Due to their proclaimed reduction of gastro-intestinal side effects, Cox-2 inhibitors have claimed a large share of the osteoarthritis medications market.
Unfortunately, recent studies have indicated that Cox-2 inhibitors can increase the risk of cardiovascular problems including angina, myocardial and cerebral infarction, thrombosis and sudden death, to four times that of traditional NSAIDs. A review of more than 48,000 patients taking rofecoxib revealed that 0.52% of patients taking an inactive placebo pill had a heart attack each year. The annual rate of heart attack was 0.74% for patients taking rofecoxib. One theory for this holds that Cox-1 enzyme plays a role in preventing the clot formation that leads to cardiovascular problems.
The assertion that Cox-2 inhibitors (rofecoxib, celecoxib) do not induce haemorrhage in the upper gastro-intestinal tract, is also under dispute. While studies confirm that Cox-2 inhibitors cause fewer gastro-intestinal events than traditional NSAIDs in the short-term, it is not yet known what the long-term effects of these drugs will have on the gastric mucosa.
*Important News Release September 2004
Vioxx®, the cox-2 inhibitor made by Merck, has been pulled from the market because of severe lethal side effects due to heart attack and stroke.
Acetaminophen
Acetaminophen is often prescribed to relieve mild to moderate arthritis pain. The drug possesses analgesic and antipyretic properties, but is not an anti-inflammatory. For this reason, it may usually be safely combined with an anti-inflammatory medication to relieve pain.
Overdosing can cause liver damage that may be severe enough to cause liver failure and death. This damage occurs in a dose-related manner and is the leading cause of rapid onset liver failure in the US, Canada and the UK.
For the average healthy adult, the recommended maximum dose of acetaminophen over a 24-hour period is four grams (4000 mg) or eight extra-strength pills. (Each extra-strength pill contains 500 mg and each regular strength pill contains 325 mg.) A patient who drinks more than two alcoholic beverages per day, however, should not take more than two grams of acetaminophen over 24 hours. For children, the dose is based on weight and age.
A single dose of 7 to 10 grams of acetaminophen (14 to 20 extra-strength tablets) can cause liver injury in the average healthy adult. (This amount is about twice the recommended maximum dose for a 24-hour period.) In children, a single dose of 140 mg/kg body weight of acetaminophen can result in liver injury. However, amounts of acetaminophen as low as 3 to 4 grams in a single dose or 4 to 6 grams over 24 hours, have been reported to cause severe liver injury, sometimes resulting in death. Certain individuals, for example, those who regularly drink alcohol or those with hepatitis C, are more prone than others to developing acetaminophen-induced liver damage.
Cortisone
Cortisone may be injected directly into the joint to relieve severe inflammation and swelling. A cortisone injection can provide almost immediate relief for a tender, swollen or inflamed joint. However, since corticosteroids can degrade cartilage and demineralize the bone, they should only be used rarely. Chronic use of corticosteroids may result in weight gain, hypertension, susceptibility to infection, capillary fragility, acne, excess hair growth, cataracts, glaucoma, diabetes, muscular atrophy, accelerated atherosclerosis, menstrual irregularities, irritability, insomnia and psychosis. Since steroids appear to cause premature death of osteoblasts and slow their replacement; osteoporosis and bone damage are of particular concern. Long-term use may also affect brain cells, causing memory loss. Certain side effects such as hypoglycemia, edema and hypertension can be minimized by treatment.
Substances that may help modify the disease process
DMARDs
This group of medications share the common characteristics of relieving symptoms and helping to control Rheumatoid arthritis (RA) by modifying the actual disease process.
These drugs may take up to six months to take effect. They are normally only prescribed when inflammation continues for more than six weeks or when the disease strikes many joints at the same time. While DMARDs reduce inflammation, they cannot reverse permanent joint damage.
Methotrexate is one of the most widely prescribed DMARDs. Due to this drug's potential to cause serious side effects, patients on methotrexate should be carefully monitored. Methotrexate also has the potential to produce abnormalities of bone marrow and liver function. Certain individuals who are at an increased risk for serious side effects should not be prescribed these drugs, including pregnant and nursing women, people using alchohol, and people with AIDS. Additional side effects of methotrexate may include fatigue, flu-like symptoms, headaches, upset stomach and mouth sores. (The daily use of folate may reduce the severity of some of these effects.)
Side effects from using other DMARDs (leflunomide, sulfasalazine, azathioprine, cyclosporine, hydroxychloroquine), may include diarrhea, nausea and mouth sores. More serious side effects, which are normally monitored through regular blood and urine tests, include liver damage and excessive lowering of white blood cell count and platelet count.
DMARDs are normally prescribed in addition to an NSAID or prednisone.
BIOLOGICAL RESPONSE MODIFIERS (BRMs)
These drugs are usually prescribed for people with Rheumatoid arthritis (RA) who fail to respond to conventional treatment. Biological response modifiers (also known as BRMs or biologic agents) target specific chemicals in the immune system that contribute to the Rheumatoid arthritis (RA) disease process.
BRMs can provide fast relief - usually within a couple of weeks. Medications that are administered by injection may cause mild skin reactions and infections at injection sites including itchiness and redness. Other side effects may include headaches, upper respiratory infection, pain, swelling, or on rare occasions, damage to bone marrow.
Some BRMs negatively affect the immune system and patients should not receive live vaccinations such as oral polio, chicken pox, or the measles/mumps/rubella vaccine during treatment with a biologic agent.
Nutricol®
Nutricol®has been developed to improve circulation to tissues, speed repair and slow or halt tissue damage. Available as the OTC supplement Recovery® in many pharmacies, Nutricol® is proposed to reduce the inflammation that accompanies Rheumatoid arthritis (RA). This may reduce the likelihood of progression and diminish accompanying pain. Nutricol® (Recovery®) is an anti-catabolic agent that works at cellular level to help stabilize joint structures. Biomedica Labs also believes that this proprietary blending of plant nutrients naturally increases the cells' receptivity to hormones such as insulin which are required to speed the repair of joint tissues.
Recovery® contains the active ingredient Nutricol®, a disease modifying anti-catabolic agent (DMAC), which Biomedica Labs is proud to introduce to health care professionals.
Nutricol® (Recovery®) may be safely combined with other arthritis medications or taken on its own to help counter pain and inflammation. It does not produce unpleasant side effects. Since this product works to modify the body's responses, it may take up to six weeks for your patients to experience relief, with most people noticing benefits within a month.
Biostructural® Medicine goes beyond simply addressing symptoms and focuses on the degenerative process and optimal healing.
Nutricol® (Recovery®) may be safely combined with other medications or taken on its own to help counter inflammation and improve the quality and rate of healing.
Information for Doctors: Print an 6-page detailed information package that provides the following:
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Click here to view feedback from health professionals and users about the results noted from Recovery® with Nutricol®.