ARTHRITIS: Understanding the Disease
Learning the causes—as well as what’s being done to find a cure—is key to easing the agony
BY:ERIC FEIL
Arthritis is a multifaceted disease, attacking the body on numerous levels. It affects some 66 million Americans—nearly one in every three adults. The most prevalent chronic condition in the U.S., arthritis is also the nation’s leading cause of disability among people over age 15, second only to heart disease as a cause of work disability. It accounts for more than 39 million doctor visits each year, and costs the U.S. economy a whopping $86.2 billion annually. Though it typically strikes as we get older, no age group is immune.
Incredibly, more than 100 types of conditions fall under the massive arthritis umbrella, from gout to lupus to fibromyalgia. “Arthritis really means an inflammation in the joint,” says Patience White, MD, MA, chief public health officer for the Arthritis Foundation. “When we’re talking about arthritis, most people are talking about rheumatoid arthritis and osteoarthritis.”
That’s because we’re talking about nearly 25 million people with one or both of these ailments. And we’re talking about pain.
Inside the Pain
“One of the most important things people need to understand is that arthritis is a serious disease,” says Hayes Wilson, MD, chief of rheumatology at Piedmont Hospital in Atlanta and national medical advisor for the Arthritis Foundation. “It can be extremely painful and debilitating. It is much more than ‘Take two aspirin and call me in the morning.’”
Osteoarthritis (OA) is the most common form of arthritis, affecting nearly 21 million Americans. It is a “wear-and-tear” disease, developing over time as the cartilage that covers the ends of bones in a joint deteriorates. The loss of cushioning causes bone to rub against bone—mostly in fingers, knees and hips—leading to pain, stiffness, mobility loss and, if unresolved, severe disability. Most people develop the condition to some degree in at least one joint by age 60.
Rheumatoid arthritis (RA), by comparison, is an autoimmune disease in which a malfunctioning immune system attacks the body’s own joints and inflames the membrane lining the joint, causing pain, stiffness, a burning sensation and swelling for some 2.1 million Americans. The inflamed membrane can then invade and damage bone and cartilage, leading to joint deformities, loss of joint movement and limitations of activities requiring use of the joint. Without effective therapy, approximately 15 percent of RA patients will end up crippled. “Research has indicated that having severe rheumatoid arthritis can take ten to fifteen years off your life,” adds Dr. Wilson.
There is no cure for OA or RA. But there is hope.
Drug Wars
It was not long ago that Vioxx seemed like a blessing for arthritis sufferers. At its core was a cox-2 inhibitor, a drug that blocks pain but doesn’t interfere with the stomach and intestinal linings. When Vioxx was pulled off the market in 2004 after being tied to heart attacks, however, people began wondering not only if new treatments were safe (Celebrex remains the only cox-2 inhibitor on the market in the U.S.), but what course of action they should take.
As with any illness, the key to successful treatment is timing. With RA, in particular, “one has to be fairly aggressive early in the game because much of the damage occurs in the first two or three years,” says Hugo Jasin, MD, a Little Rock-based rheumatologist and director of the division of rheumatology at the University of Arkansas for Medical Sciences Program. “Before, we didn’t have much to stop it. Now I would say in 80 percent of patients, rheumatoid arthritis can be controlled.”
Dr. Wilson agrees on the importance of early action. “RA is a chronic inflammatory condition and it throws off your immune system,” he says, “so there’s an increased rate of infection and an increased rate of cancer. We know that if you treat the RA aggressively with biologic medications, you decrease somewhat the chances for cancer and serious infection.”
In both OA and RA, the first goal is to reduce pain. Steroids may help, but more common are non-steroidal anti-inflammatory drugs (NSAIDs)—prescription drugs like diclofenac (Cataflam, Voltaren), piroxicam (Feldene), indomethacin (Indocin) and over-the-counter drugs like acetaminophen (Tylenol), ibuprofen (Advil), naproxen (Aleve) and ketoprofen (Actron). As with aspirin, they can reduce pain and inflammation, yet they can also have decidedly negative gastrointestinal effects and aren’t for everybody. In other cases, they are not strong enough to combat the illness.
For RA patients who do not respond to frontline treatments, the most effective weapons, says Dr. Jasin, are usually disease-modifying anti-rheumatic drugs (DMARDs). They don’t directly reduce pain, and take several months to act in most cases, but they modify the course of inflammatory conditions, slowing the progression of the disease. “These have been the biggest development for the disease,” adds Dr. Jasin.
A relatively mild first step is the anti-malarial Plaquenil. Sulfasalazine may also be taken, but methotrexate—long used to treat psoriasis and cancer—is “the gold standard,” says Dr. Wilson. Although it only works in roughly one-third of patients, it works faster than other DMARDs, taking weeks instead of months.
Ultimately, mixing DMARDs is proving most effective of all. “There are trials,” explains Dr. Jasin, “showing that if you have that cocktail of at least three of these, about 70 percent of patients are well-controlled.”
Biology Lessons
In order to effectively fight arthritis in the long run, and perhaps one day find a cure, medicine must be able to target the causes. “In RA, the exciting advances are in biologic drugs, which are showing tremendous ability to decrease the destruction of rheumatoid arthritis and improve patients’ lives,” says the Arthritis Foundation’s Dr. White. “Some of the old therapies were like bombing the whole town, while these are like going only for the electrical system. These are very smart drugs. They go to just the proteins that begin a cascade of inflammatory response that causes the disease.”
By hitting specific targets, not healthy parts of the body, a number of these biologic drugs are showing great promise. For example, Enebrel (etanercept), Remicade (infliximab) and Humira (adalimumab) have been developed to neutralize the protein tumor necrosis factor (TNF). Meanwhile, doctors have had success battling B-cells, which manufacture the renegade antibodies in autoimmune diseases like RA, with Rituxan (rituximab).
For RA sufferers, the biggest news may be abatacept, the first of a new variety of drugs that prevents the activation of T-cells, which are inflammatory agents within the body. In a recent trial of this drug that received FDA approval in December 2005, patients who used abatacept (Orencia) were more than twice as likely as those using standard therapy to show significant improvement over a six-month period. “For many of these patients, it means a significant increase in their ability to function,” says Mark Genovese, MD, an associate professor of immunology and rheumatology at Stanford School of Medicine. “That means turning on the shower, opening a car door, using the toilet—little actions that make a huge change in their quality of life.”
Joint Ventures
For all their boons, drugs are not the only option in fighting arthritis, says David E. Krebs, PhD, professor at and director of Massachusetts General Hospital Biomotion Laboratory in Boston. Krebs and others have been studying the impact of muscle-strength exercise and functional training—exercises that focus on practicing routine activities of daily living—on seniors with knee OA.
“We’re working on improving gait and mobility directly,” says Dr. Krebs. “Teaching people how to get out of a chair and do their daily activities more efficiently, specifically by improving their posture, improving their ankles and hips, so any habits they’ve formed won’t hurt their knee.” Such physical alterations can alleviate pain. They have proven so successful that Dr. Krebs is looking to apply the techniques to other forms of arthritis.
A growing number of doctors also are embracing the concept of “integrative medicine,” a mix of traditional approaches and a range of therapies such as acupuncture, meditation, massage, yoga, herbal remedies and some dietary supplements.
Supplements have provided the biggest news to hit the OA front thanks to the recent National Institutes of Health study on the impact of glucosamine and chondroitin. Naturally produced by the body, glucosamine and chondroitin in turn produce cushioning between joints. In the largest placebo-controlled, double-blind clinical trial ever staged for the supplements, they also produced results, demonstrating that a combination of the two not only effectively treated moderate to severe knee pain caused by OA, but also outperformed Celebrex.
If neither drugs nor alternative approaches are successful, there is the option of joint-replacement surgery. But, Dr. Krebs asserts, “the basic goal is to put that off as long as you possibly can. Joint replacements are not only expensive and inconvenient, but they fail. Unless you plan to die within the next ten years, you’re going to outlive your joint, in which case you’re going to have to have it replaced again.”
Dr. White concurs. Even though advances are being made in materials and surgical techniques that will improve joint replacements, she says, “it’s better to do some prevention work up front.”
Pounds of Prevention
Although OA and RA can strike without warning—and researchers are investigating how everything from youth sports injuries to labor-intensive jobs to smoking to hormonal imbalances may influence one’s likelihood of contracting them—it is already a certainty that weight and RA and OA are closely tied. Unlike other links, though, this one can be controlled, particularly in OA.
“There’s very exciting news in the linkage we’re finding between weight and the risk for OA and improvement in progression of OA,” says Dr. White. “For example, if you’re overweight and you lose 10 percent of your weight and you have OA of the knee, you’ll reduce the pain by 50 percent! Little changes can mean a lot.” Indeed. Conversely, however, Dr. White indicates that “people who are at the high end of normal or are overweight increase their risk [of developing OA] by ten percent if they gain two pounds.”
Physical activity is also important, and not just for weight maintenance, says White. “Being physically active—ideally walking three times a week, just 10 minutes at a time, getting those muscles around the knee stronger—gives you much less pain and less progression of OA.”
The Fight Goes On
Every day, researchers are making headway in the fight against arthritis. Doctors increasingly are finding better ways to treat the pain, slow the progression and increase the quality of life for those with the disease. Yet, more that 23 million Americans report living with symptoms of arthritis but not getting diagnosed by a doctor. Whether it’s believing the pain is nothing more than a little ache—or the fear of hearing bad news—countless victims are not getting the attention they need. “The longer one goes without treatment,” notes Dr. Jasin, “the worse the problem will get.”
Today, unfortunately, half of those stricken with arthritis still don’t think anything can be done to help them. Fortunately, day by day, more of them are wrong. Advocacy efforts and public awareness are on the rise, and Dr. White believes that the Baby Boomer generation can make arthritis a much larger focus of the government and the medical community. “So far, it hasn’t gotten the same attention as other diseases—and this isn’t to say those are not important,” explains Dr. White. “But with the Baby Boomers aging and arthritis numbers growing, it’s going to be hard to ignore.”