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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.