On call: Arthritis Rx: 'Old gold' to innovative advances

[Guest guest]

On call: Arthritis Rx: 'Old gold' to innovative advances

WILLIAM W. O'CONNOR, MD, The Saratogian October 14, 2002

Recent advances offer new hope for the millions of Americans who suffer from

arthritis. But before we discuss these new treatments, it's worth noting

some ''old gold'' standards that still belong at the heart of arthritis

care.

Motion is lotion. Weight loss and a low-impact exercise program -- 20

minutes a day, five times a week -- should be the foundation of any

arthritis management approach. Examples of low-impact exercise include

bicycling, swimming, cross country skiing, use of a Nordic Trac or

elliptical rider and, my personal favorite, walking. It requires the least

amount of preparation, is most adaptable to any environment and, in winter

months, can be moved indoors to a mall to avoid slips and falls.

Tylenol vs. NSAIDs (nonsteroidal anti-inflammatory drugs). The safest drug

for pain relief is Tylenol or acetaminophen. NSAIDs, including aspirin,

Naprosyn, Ibuprofen and cox-2 inhibitors are more likely to irritate the

stomach and intestinal linings, resulting in peptic ulcers. Long-term use

can lead to kidney damage or nephritic syndrome. In doses above 4,000 mg.

per day, even Tylenol can cause liver injury. The old adage, ''everything in

moderation,'' probably best sums up the approach to living with arthritis.

Assistive devices, such as jar openers, large handle utensils, sock helpers,

seat boosters. If you want more information, your local occupational

therapist is the expert.

New frontiers

Advances in arthritis treatment typically fall into one of the following

categories: nutritional supplementation, injection therapy, bracing,

surgical treatments, and genetic manipulation.

Nutritional supplementation with glucosamine and chondroitin sulfate.

Studies published in the Journal of the American Medical Association and

Journal of Bone and Joint Surgery show relief of arthritis pain symptoms and

increased mobility after daily dosing of these amino acids. I want to

emphasize that we do not yet know the long-term effects of high-dose amino

acid oral supplementation. In addition, these amino acids are ingested and

then processed in the liver, where the body then decides where and how to

use them. This differs from direct injection into the joint.

Injection therapy. About three years ago, the FDA approved a third amino

acid, hyaluronic acid, for injection into the knees. This therapy improves

symptoms in 77 percent of patients; 7 percent have adverse reactions

including redness, swelling, or allergic reactions. These results mimic

those of steroid injection therapy but address relubrication rather than

anti-inflammation. The number of injections varies depending on the

patient's age, health, and other factors. Both steroid and hyaluronic acid

injections are administered in a doctor's office. Although these therapies

are not curative, they have provided many patients with profound, temporary

relief (less than six months).

Bracing. This can provide temporary relief, particularly for knee, ankle and

foot arthritis, by stabilizing or unloading a part of the joint that's

arthritic. I find bracing most helpful when it's used for only part of the

day or for a specific activity. For example, an avid golfer with knee

arthritis would wear a brace for several hours two to three times a week

while golfing. In my experience, the longer patients wear braces, the more

they tire of them. I think it's like my necktie. It feels good at first, but

as the day goes on, I can't wait to get rid of it.

Surgical treatments. These range from cartilage and meniscal replacement to

partial and total joint replacement. The Swedes pioneered growing your own

cartilage in a laboratory, culturing it for six weeks, and then reseeding a

divot or pothole in your joint. This biological breakthrough requires

several surgeries and bigger incisions. More recent efforts in Italy and

California have focused on using scaffolds in which cartilage cells have

been implanted. The goal is to reduce the scaffolds to the size of small

tablets and then implant them through minimally invasive surgery.

A popular, minimally invasive surgery for arthritis in the knee is

unicompartmental or partial joint replacement, in which we resurface only

the portion of the knee that's arthritic. A good option for younger patients

(ages 45-65) with debilitating knee arthritis, this procedure relieves pain

and improves activity with minimal bone removal. Benefits last five to nine

years, and it's fairly simple to revise this to total knee joint

replacement.

Other advances focus on improving the bearing or surface of the joint.

Options include metal on plastic, ceramic on plastic, ceramic on ceramic,

and metal on metal. We're even seeing some preliminary work with industrial

diamond in California. (Keep in mind that this diamond option has not

received FDA approval and that clinical trials are a long way off - if

ever.)

Genetic manipulation. A group from the University of Pittsburgh has been

experimenting with altering the joint lining cells of the hand knuckle

joints as an approach to treating rheumatoid arthritis of the hand -- with

promising results. Early data shows significant arrest of arthritic

progression.

Minimally invasive surgery and computer assisted surgery. I believe these

will become the norm within 5 to 7 years. Trials are underway, but many

glitches still need to be worked out. Don't sacrifice a long, lasting

pain-free artificial joint for a day or two shorter hospital stay. Stick to

sound, biomechanical principles of joint replacement.

W. O'Connor, MD, is an orthopaedist on the medical staff of Saratoga

Hospital, a member of Saratoga Care. On Call is written by guest columnists

affiliated with Saratoga Care. It appears on the first Monday of the month.

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