Although an accurate diagnosis is important in treating arthritis, often the symptoms can be treated even if the exact nature of the condition remains unclear. Initial treatment options for most forms of arthritis include medications to reduce pain and swelling, exercise, as well as other lifestyle modifications and supportive procedures.
Many times, a comprehensive treatment plan will involve different health care professionals. In addition to your primary care physician, you may work with a doctor who specializes in treating people with arthritis — called a rheumatologist. You may also consult a physical therapist and an occupational therapist, who will help you develop ways of moving and perhaps an exercise routine to maintain and improve joint functioning. They will also help with the proper use of assistive devices.
If there is significant damage to the joints that occurs despite medical therapy, you might be referred to an orthopedic surgeon. This type of doctor can offer surgical treatment of disorders of the joints, skeleton, muscles and other supporting structures, such as the ligaments, tendons and cartilage.
Until recently, conventional medical treatment for arthritic conditions relied on two major categories of medications:
- Those that reduce symptoms of inflammation, such as nonsteroidal anti-inflammatory drugs (NSAIDs)
- Disease-modifying drugs (also called remittive agents, immunosuppressive or immunomodulatory medications), which work to slow the underlying autoimmune disease process, such as rheumatoid arthritis or lupus
In most cases, more than one type of medication is needed to control the symptoms over time.
Anti-Inflammatory Drugs (NSAIDs And Corticosteroids)
NSAIDs are a class of drugs that relieves the symptoms associated with many forms of arthritis by slowing the body’s production of prostaglandins. Prostaglandins are responsible for the characteristics of inflammation — swelling, pain, stiffness, redness and warmth. NSAIDs are also analgesics, or pain relievers, separate of their anti-inflammatory effect; the anti-inflammatory effect is generally experienced only with moderate or high doses. In the United States, there are more than 20 different NSAIDs approved by the Food and Drug Administration, each with slightly different characteristics, but more alike than different. Aspirin is the most well-known anti-inflammatory agent. Other NSAIDs include ibuprofen (Motrin, Nuprin or Advil, for example), naproxen (Naprosyn, Aleve) and indomethacin (Indocin).
The most common side effect associated with NSAIDs is stomach upset. Sometimes, stomach problems can be minimized if the medications are taken with meals, milk or antacids. Even so, stomach irritation remains a common problem. In a small number of patients (2 percent to 4 percent per year of those taking NSAIDs in moderate or high doses on a regular basis), an ulcer develops that may bleed, cause obstruction or perforation requiring surgery.
Newer NSAIDs, such as celecoxib (Celebrex), are as effective as the older NSAIDs but cause fewer ulcers. (These newer drugs are called “Cox-II selective” because they primarily inhibit one enzyme called Cox-II, rather than inhibiting both Cox-I and Cox-II, as the older drugs do.) However, one study showed that for people at highest risk (those with recent bleeding ulcer), up to 10 percent of those treated with celecoxib developed a new ulcer; in addition, the risk was similar for these high-risk patients when taking an older drug (diclofenac) combined with a drug to protect the stomach (omeprazole). Just how safe these drugs are for the stomach in persons at lower risk of ulcers remains an area of some controversy and active research; current recommendations suggest reserving the Cox-II inhibitors for people at higher risk of ulcer disease (such as those who are also taking corticosteroids or who have had an ulcer in the past).
Because aspirin has an anticoagulant effect — that is, because it inhibits the blood’s ability to clot — people who take a lot of aspirin (or any of the older “nonselective” NSAIDs) may bleed or bruise easily. Other important side effects include kidney injury, allergic reactions, fluid retention and elevation of blood pressure. The cost of the different NSAIDs varies dramatically, from pennies per day to $2 per day or more; whether the differences in their side effect profiles are worth the added cost is often unclear.
For persons taking low-dose aspirin (for example, about 80 milligrams) for heart protection and another NSAID for pain, the aspirin should be taken first, at least an hour before the other NSAID so that the benefits to the heart will not be lost.
The most powerful anti-inflammatory agents are corticosteroids. These are synthetic versions of the body’s hormone, cortisone, that are produced in small quantities by the adrenal gland. Synthetically produced corticosteroids are used to reduce inflammation and suppress activity of the immune system. The most commonly prescribed are prednisone and dexamethasone.
Corticosteroids can produce dramatic improvement within a day or two. However, they tend to have little lasting benefit. Too many corticosteroid injections into a joint may damage it. Long-term use of oral corticosteroids often produces troubling side effects, such as weight gain, rounding of the face, high blood pressure, acne, easy bruising, cataracts, thinning of the skin and bone and an increased risk of diabetes and infection. When taken along with NSAIDs, there is a markedly increased risk of stomach ulcers.
Doctors prefer to prescribe a short course of corticosteroids to relieve acute symptoms and then gradually decrease the dosage. In all cases, the possible benefits are weighed against the possible side effects. And because side effects occur more frequently when corticosteroids are taken over long periods of time at high doses, these drugs are typically prescribed at the lowest effective dosage with ongoing efforts to reduce it further.
Disease-Modifying Antirheumatic Drugs
When a person’s arthritis is due to rheumatoid arthritis or systemic lupus erythematosus, disease-modifying antirheumatic drugs may be recommended. Many of these medications are actually borrowed from other diseases, such as cancer and malaria. Antimalarials include chloroquine (Aralen) and hydroxychloroquine (Plaquenil). Drugs considered to be even more powerful in these diseases include methotrexate (Rheumatrex), sulfasalazine and azathioprine (Imuran). All of these agents act to suppress inflammation, presumably through their effects on the immune system, and also have a risk of more serious side effects.
It may take weeks or even months before these drugs produce any beneficial effect. During the time it takes for these drugs to work, your doctor may recommend that you take an NSAID or a corticosteroid as well.
As with any medication, the disease-modifying antirheumatic drugs can have problematic side effects. Various drugs in this category can cause diarrhea, rashes, anemia (decrease in red blood cells), leukopenia (low white blood cell count) and increased risk of infection. In general, when a drug works by suppressing the immune system, there is an increased risk of infection. In addition, methotrexate can cause serious liver and lung problems. Some antimalarial drugs can affect the eyes. It is therefore necessary that use of these drugs be carefully monitored.
Gold salts, another disease-modifying antirheumatic drug, have been used to treat arthritis for more than half a century; however, the way in which they work is not entirely clear. It is rare now for physicians to prescribe gold. Recent advances in research and technology have yielded promising new anti-arthritis therapies, including leflunomide (Arava) and drugs that suppress the action of tumor necrosis factor (TNF).
Leflunomide reduces the action of immune cells by impairing a protein required for DNA synthesis, whereas anti-TNF drugs seem to slow the destruction of the joints by disrupting the activity of TNF, a substance that promotes inflammation and joint damage. Examples of drugs that block the effects of TNF include:
- adalimumab (or Humira, injected under the skin once every two weeks)
- certolizumab (or Cimzia, injected under the skin every 2 to 4 weeks)
- etanercept (or Enbrel, injected under the skin once or twice a week)
- golimumab (or Simponi, injected under the skin every month
- infliximab (or Remicade, injected intravenously every four to eight weeks).
Anakinra (Kineret) inhibits a different chemical mediator of inflammation called interleukin-1 (IL-1) while tocilizumab (Actemra) inhibits interleukin-6 (IL-6). Other injectable medications for rheumatoid arthritis include abatacept (Orencia), which prevents certain immune cells from causing inflammation, and rituximab (Rituxan), which acts against certain antibody-producing immune cells (called B-cells). Belimumab (Benlysta) also inhibits the activity of B-cells and is the first new drug approved for systemic lupus erythematosus in decades.
Medical research is also looking into ways of restraining the body’s autoimmune response before it is triggered, including efforts to develop a vaccine against arthritis. Loss of excess weight can also be helpful.
Although much of conventional anti-arthritis medications are palliative, that is, they treat the symptoms, much of the newer research, and the therapies that hopefully will emerge, may provide much more substantial relief and perhaps even cure.
Pain Relievers That Don’t Treat Inflammation
In the most common form of arthritis, osteoarthritis, there is typically little or no inflammation. As a result, managing pain may be the primary focus of medical therapy. Pain relievers such as acetaminophen (Tylenol) may then be sufficient to control the pain. Other medications that may reduce symptoms of osteoarthritis include NSAIDs, other pain relievers, injected corticosteroids, or an injectable medication called hyaluronate (although its effects are modest).
For the vast majority of people who suffer with arthritis, surgery is seldom necessary. But when all else fails, orthopedic surgery can reduce pain and increase mobility significantly. For some, surgery can spell the difference between living a life that is severely restricted and being able to continue with a full, independent, active life.
There are a number of operations offered for arthritic conditions. The most commonly used procedures are osteotomy, synovectomy, tendon reconstruction and joint replacement. The surgeon may use an arthroscope (a thin tube, with a light and magnifying lens on the end that is inserted into the joint) or an open procedure, in which the surgeon makes an incision allowing him or her to see the joint directly. In general, arthroscopy is considered a minor procedure, whereas an open operation is considered major surgery with a longer recovery period.
An orthopedic surgeon can realign the joint in a procedure called an osteotomy, in which a section of bone is removed, allowing the joint surface or the joint angle to change. For example, a less damaged portion of the joint may be realigned so that weight is placed on it rather than on a more damaged portion.
When the lining of the joint (synovium) is damaged or chronically inflamed, a surgeon may remove the tissue in an operation called a synovectomy. However, because it is difficult to remove all of the tissue, synovectomy is seldom performed by itself. Rather, this procedure is more often done as part of reconstructive surgery, especially tendon reconstruction. Synovectomy may be performed through an arthroscope or during a more extensive surgery, in which the joint is opened. Often the procedure is performed to prevent tendon rupture or to reduce pain when other treatments have failed.
When a tendon (the tissues that attach muscle to bone) is damaged or ruptured, a procedure called tendon reconstruction rebuilds the tissue by attaching an intact tendon to it. This procedure is most successful in restoring function to a hand or ankle, for example, if it is done before the tendon is completely ruptured.
Joint replacement is the most commonly performed surgery for arthritis. In this type of operation, a seriously damaged joint — most often, a hip or knee — is replaced with an artificial joint. This type of surgery can dramatically reduce pain and improve function. Although, in many cases, the results can be dramatic, surgery is not for everyone. The decision should be made only after considering the person’s overall health, function, quality of life, and the condition of the affected joint or supporting structures. If it appears that this major surgery will improve function and quality of life at an acceptable risk, joint replacement surgery should be seriously considered.
Rehabilitation after surgery lasts months and is carefully planned before the operation.
Arthritis Specialists And Support Services
In addition to your primary care physician or your general practitioner, you may have occasion to consult with specialists. A rheumatologist is specially trained in the diagnosis and treatment of arthritis and related disorders. An orthopedic surgeon specializes in the surgical treatment of bones, joints and soft tissues (ligaments, tendons and muscles).
Other professionals can make living with arthritis an easier proposition. From time to time, you may want to talk with a dietitian about ways to lose weight, because excess pounds means more stress on the weight-bearing joints. A personal athletic trainer can help design an exercise program that allows you to remain active despite arthritis. A physical therapist who is knowledgeable about arthritis will be able to design an appropriate home exercise program and teach you about pain management. An occupational therapist will help you find ways to manage ordinary tasks around your home and work and provide special devices to help with activities of daily living. With the help of these professionals, you can learn about joint protection, energy conservation and proper body mechanics — how to place your body for a given task, such as carrying a grocery bag, sitting at your computer, getting in and out of a car or combing your hair. Podiatrists have expertise in arthritis involving the foot and ankle and may suggest a treatment plan that includes shoe inserts (orthotics), exercises, adjustments in the type of shoes you wear, cortisone injections or even surgery.
Arthritis brings, in addition to its physical implications, emotional and social stress as well. Consequently, a mental health professional — a psychiatrist, psychologist or social worker — may be able to help you sort out the feelings and complications that inevitably arise from living with a chronic disease.
In most communities, there is a range of support services for people who suffer with various forms of arthritis. Many are offered through hospitals, medical clinics or local Arthritis Foundation chapters. These services frequently include educational classes, home study courses, video tapes, libraries and other informational assistance to help people learn to listen to and cope with their disease.
In addition, support groups can provide the opportunity to learn practical ways of dealing with your condition, including how to protect joints, how to sleep comfortably, how to take a bath, how to get up after falling and how to cope with the emotional and physical pain of this chronic illness. For more information on support services, contact your local chapter of the Arthritis Foundation or call the national headquarters at (800) 568-4045.