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Arthritis: Life after Vioxx
Edward Rubin M.D.
Select Pain Consultants
516-492-3100
Arthritis: A Brief Overview
Inflammation of a joint(s) causing pain,
swelling and stiffness.
Is all arthritis the same?
No, arthritis comes in several varieties
OSTEOARTHRITIS
– Most common. 20 million affected adults.
– Progressive wearing on opposing joint
surfaces
– Occurs over time due to repetitive motion
– Hence, increases with age
Osteoarthritis
Rheumatoid Arthritis
A major form of the disease in which the
body’s immune system attacks joints,
causing hot, painful, swollen and
deformed joints.
Rare compared to osteoarthritis.
1% of population affected.
Rheumatoid Arthritis
Other forms of arthritis
Spinal Arthritis
Lupus
Gout
Psoriasis
Scleroderma
Ankylosing Spondylitis
Symptoms
l
Each type of arthritis has different
symptoms and patterns. Each requires
different treatments. Common
symptoms include:
– Pain or tenderness
– Swelling in one or more joints
– Warmth and redness
– Stiffness or difficulty using or moving the
joint
Diagnosis
l
To find out whether
you have arthritis, a
doctor will take your
medical history and do
a physical
examination. He or she
may also have X-rays
or other imaging
procedures done along
with blood and lab
tests.
Conservative Treatment
Rest. Being tired and feeling pain are
signs of arthritis and show that it may
be time to rest joints and muscles
l Exercise, when balanced with rest, can
help reduce pain and stiffness, making
muscles stronger and joints more
flexible. Consult your doctor first,
however, before beginning an exercise
program.
l
l
l
l
More Conservative Treatment
Maintaining proper body weight and eating a
well-balanced diet. Extra weight increases
pressure on the joints and can make some
types of arthritis worse.
Using devices such as splints, braces, canes
or shoe inserts to protect joints from the
stresses of daily activities and relieve
symptoms.
Heat and cold therapies. Heat therapy
(ultrasound or moist heat) increases blood
flow and flexibility in the joint. Cold therapy
(cold packs, cold-water soaks, over-thecounter sprays and ointments) numbs the
nerves and relieves inflammation.
What if conservative treatment
fails?
Medical Management
What medications are available?
– Anti-inflammatory meds
Ibuprofen (Motrin, Advil)
Naproxen (Aleve)
Celebrex
Vioxx – back on the market?
– Topical – Lidoderm Patches, Capsaicin Cream
– Narcotics – more in a minute
Drug Interactions
What is safe to take with my other meds?
Check out Drugs.com
– Learn details about any drug
– Check interactions with other drugs
– Check details about foods that interact with
your meds
Many other sites as well (Walmart.com,
Discovery Health online)
Anti-inflammatory Drugs
How do they work?
– Block inflammation throughout the body by
blocking an enzyme named COX.
– Most anti-inflammatory drugs block both
COX-1 and COX-2.
– COX-1 helps protect your stomach lining and
therefore may lead to ulcers when blocked.
– This is why the COX-2 drugs were created
(Celebrex, Vioxx and Bextra)
Ibuprofen
aka Motrin, Advil
Typically use 300-800mg 3-4 times/d
Max 3200mg/day ($15/mo)
Take with food
Can cause stomach ulcers, increased blood
pressure, kidney damage, fluid retention
Naproxen
aka Alleve, Naprosyn
250–500mg 2 times/day
Max 1500mg/d ($20/mo)
Avoid taking with Probenecid (gout med)
Can cause stomach ulcers, increased blood
pressure, kidney damage, fluid retention
Diclofenac
Voltaren
50mg 2-3 times/d ($55-100/mo)
Max 150mg
Take w/ food
Same side effects as the rest
Diclofenac/Misoprostol
Arthrotec
Misoprostol to protect the stomach lining
1 tablet 2-3 times/d ($115/mo)
Better choice in patients with stomach
ulcers. Still not risk free.
Can cause fluid retention and increased
blood pressure. Flatulence common.
Celebrex
Only COX-2 selective on the market
200mg once a day or 100mg twice a day
$90-100 per mo.
Less stomach irritation
Appears to have lower cardiac risk than
most NSAIDs.
Cardiac Risk with NSAIDs
Mobic: The big ?
Meloxicam
7.5mg or 15mg a day
$90-130 per mo
Has not been studied as rigorously
Risk probably same as the rest of the class
of drugs
Vioxx
Pulled from the market due to increased
incidence of cardiac events
Earlier study looking at stomach effects
(VIGOR trial) found 5x increase in heart
attacks.
Early studies were compared to Naproxen
but not to placebo.
Why is Vioxx worse than the
rest?
No one knows for sure.
Several Theories
– Sticky platelets (not likely).
– Fluid retention and high blood pressure.
– Studies show that borderline high BP can
increase risk of heart attack by 32%. True HTN
can double the risk (ie BP >140/90).
– Actively treating high blood pressure in one
trial resulted in a 36% decrease in both fatal
and nonfatal strokes and heart attacks.
Take Home
Non-steroidals can be used, but with great
caution in those with high blood pressure
and history of heart problems.
Discontinue treatment if blood pressure
rises or treat BP more aggressively.
Discontinue if symptoms of heart failure
arise.
Other Alternatives: Lidoderm
• Lidoderm is a new stick-on
patch containing lidocaine that
can reduce the pain of arthritis
and shingles.
• Designed to deliver a painkilling drug to the nerves, rather
than via the blood, easing pain
levels quickly. As it is not taken
orally this reduces side-effects.
• The patch can be cut to the
exact size required for the painful
area.
• In the arthritis trial it was found
to reduce pain and stiffness and
improve the working of joints.
Other Alternatives
Capsaicin
Made from chili peppers
Depletes pain receptors
Burns before it numbs
Efficacy of topical
capsaicin is moderate at
best
Narcotics
Ultram
Vicodin
Percocet
Morphine
Dilaudid
Fentanyl Patches
Methadone
Narcotics: Pros & Cons
Pros
Temporary Relief
Cons
Does not treat the
cause, only the
symptoms
Tolerance
Sedation
Constipation
Habit forming
Expensive
Supplements & Diet
Memorial Sloan-Kettering Web Site
MSKCC.org
Serach: Herbs
Detailed information from reasonable
physicians regarding herbal remedies
What are Glucosamine and
Chondroitin Sulfate?
Glucosamine and chondroitin sulfate are substances
found naturally in the body. Glucosamine is a form of
sugar that is believed to play a role in cartilage
formation and repair. Chondroitin sulfate is part of a
large protein molecule (proteoglycan) that gives
cartilage elasticity.
Both glucosamine and chondroitin sulfate are sold as
dietary or nutritional supplements. They are extracted
from animal tissue: glucosamine from crab, lobster or
shrimp shells; and chondroitin sulfate from animal
cartilage, such as tracheas or shark cartilage.
1,200 - 1,500 mg per day
Diet
There are three golden rules
1. Eat a balanced diet which gives you all the
vitamins and minerals you need and which
also keeps your weight down
2. Eat more fruit and vegetables
3. Take regular exercise.
Diets for Healthy Healing by
Linda Page PhD
Drink lots of water
Low sulfur linked to arthritis
– Eat broccoli, onions, cabbage, garlic
Increase Bioflavanoids in diet
PhD in holistic
– Cranberries, grapes, papaya
nutrition from
Clayton College of
Omega 3 (good fatty acids)
Natural Health
– Cold water fish like salmon
Multivitamin supplements
Supposed Triggers to Avoid
Corn
Wheat
Rye
Bacon/Pork
Beef
Eggs
Coffee
Oranges
Milk
Pepper
Eggplant
Tomatoes
Potatoes
Mustard
Sodas
Chocolate
Review of Good Foods
Green tea
Artichokes
Cabbage
Brown Rice
Shitake Mushrooms
Cold water fish
Seaweed
Fresh fruits
Leafy greens
Ginger
In summary: Stay away from the deli and diner and order
Japanese food
Quackwatch.org
Stephen Barrett, M.D
Many nonaccredited correspondence schools issue
"degrees" and certificates which suggest that the recipient
is a qualified expert who can provide rational advice about
nutrition or health care. These documents are promoted as
though they are equivalent in meaning to established
credentials—which they are not. One of the most prolific is
the Clayton College of Natural Health, of Birmingham,
Alabama, which offers home-study courses leading to
"degrees" and "certificates" in "natural health," traditional
naturopathy, "holistic nutrition" and related subjects.
The application form in the packets from 1983 through
1991 was a single page that asked nothing about previous
education. The only apparent requirements for admission
were a name, an address, and payment of tuition.
There are no cures that “they”
don’t want you to know about!
In a latest case, the FTC has
slapped a fine of two million
dollars on Kevin Trudeau for
making fraudulent and
misleading claims about a
health product. Besides the
fine, the FTC has also banned
him from appearing on TV to
promote his products.
Injections
Cortisone injections into the joint may
decrease inflammation and provide weeks
to months of relief.
Can only do 3-4 times per year (limited by
total dose of steroids).
Too much steroid can increase blood
pressure, exacerbate diabetes, cause weight
gain, lead to osteoporosis.
Surgery
Total joint replacements available for hips, knees,
and shoulders.
Choose a surgeon that believes in trying
conservative therapy first.
Go to a center that specializes in joint
replacement.
US News and World Report rankings
– Hospital for Special Surgery #2 in the country.
– Lowest Mortality Rate in the country.