Arthritis sufferers weigh choices for battling debilitating disease in light of drug risks

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Arthritis sufferers weigh choices for battling debilitating disease in light of drug risks

By Janice Gaston

JOURNAL REPORTER

Although he's just 3, Henrietta Little's grandson, Cobbs, understands why his nana can't pick him up and carry him around the house. Little has suffered the effects of rheumatoid arthritis for all of 's life. When she can walk, she limps on swollen knees that throb with pain. Some days, she leans on a cane. Other days, she requires a walker or crutches. Sometimes, she has to get around in a wheelchair.

When she reaches for , it's with arms that she hasn't been able to straighten in nine years. On days when the pain imprisons her and she can't rise from her bed, reassures her:

"I'm going to take care of you," he says. "It's going to be all right."

Little, 42, developed rheumatoid arthritis nine years ago. Her daughter, Sheneka Gaddy, was 14. Her son, DeA'ndre, was 2. The disease robbed her of her job as a nurse assistant and some of the joys of parenthood.

"I couldn't lift a pencil, much less a child," she said. The disease affects much of her body, including her knees, her elbows and joints in her hands. Her knees swell with fluid that sometimes needs to be drained with a needle by her doctor at Wake Forest University Baptist Medical Center. The process hurts.

"All of Baptist hears me when they do that," she said.

Now, Little and millions of other arthritis sufferers must weigh the benefits of taking drugs that blunt the effects of their arthritis against other risks that the drugs could pose to their health.

In recent months, the safety of several widely used arthritis drugs has been called into question. Merck & Co. pulled Vioxx from the market last September. Celebrex, Bextra and naproxen, marketed under the brand names of Naprosyn and Aleve, are also under scrutiny. Studies have linked the drugs to increased risk of heart attack and strokes.

Vioxx, Celebrex and Bextra are -2 inhibitors, drugs that help relieve the pain of arthritis by blocking messengers produced by the body that cause pain and inflammation of the joints. The drugs have brought relief to many arthritis patients who can't take an older group of arthritis drugs, called nonsteroidal anti-inflammatory drugs, or NSAIDs. Those drugs include ibuprofen and naproxen. The drugs can pose problems for people who are at high risk for gastrointestinal side effects, said Dr. O'Rourke. O'Rourke is an associate professor of rheumatology and the head of the section on rheumatology at Wake Forest University School of Medicine.

People who shouldn't take NSAIDs include the elderly, people who have had ulcers or other gastrointestinal problems, people who take steroids and those who take drugs to keep their blood from clotting.

NSAIDs can cause internal bleeding and can interfere with kidney function, O'Rourke said.

Both sets of drugs have been used to treat the two broad categories of arthritis: rheumatoid and osteoarthritis. Rheumatoid arthritis is marked by inflammation of the joints for no apparent reason and can occur at any age. It causes pain, stiffness and loss of motion and can also produce swelling, fever and fatigue.

Osteoarthritis affects the cartilage that keeps bones from rubbing together within the joints. It occurs more as people age and is related to injuries and overuse of a joint. It also can stiffen joints and inflict pain ranging from mild to severe.

Both forms of arthritis can affect people to the point that they can't work and can't even perform simple routines of daily living, such as walking up and down stairs or grasping a toothbrush. It is the No. 1 cause of disability in older patients, O'Rourke said.

Arthritis is a disease that can be managed but not cured.

Doctors across the country have been flooded with calls from patients worried about how to handle their arthritis pain, now that the drugs they depended on are no longer considered safe.

"You have to approach them as individuals," O'Rourke said. "For patients who require some form of anti-inflammatory therapy, one has to choose the drug that has the least potential for long-term side effects." He tries to avoid prescribing the -2 drugs for patients who have a known history of heart disease, stroke or vascular disease.

Some patients can get by on pain relievers alone, he said. Others need more. Some people have found that a -2 inhibitor is the only drug that seems to provide substantial relief from their arthritis.

"If they make an intelligent, informed decision to stay on the medicine, the best we can do is monitor them carefully while they stay on it," he said.

Little, who also suffers from lupus, fibromyalgia and aneurysms, takes 13 medicines each day. She had been on Celebrex, but when warnings came out about the drug, she stopped taking it. She suffered a minor stroke after stopping Celebrex, but doctors don't link the stroke to the drug, she said. Her high blood pressure and high stress levels were the more likely culprits, they said. She switched to Naprosyn. She also takes Vicodin, a powerful pain reliever, and methotextrate, a chemotherapy drug sometimes prescribed to treat rheumatoid arthritis.

She carefully studies the side effects of every drug she takes so that she knows the risks and can make an informed decision. She keeps a drug reference manual close by.

"You know your own body more than anybody," she said. "If it's going to bother me, I'll stop taking it."

Drugs are just one facet of arthritis treatment, O'Rourke said. "It's very uncommon in my practice, taking care of chronic arthritis, that I rely on medication alone," he said.

Patients fight arthritis with physical therapy and occupational therapy. Little has undergone physical therapy in the past, but her swollen joints prevent her from exercising now.

Some patients need surgery to replace affected joints. And being overweight can put more strain on arthritic joints, particularly such weight-bearing joints as knees, hips and ankles, O'Rourke said, so diet and exercise are also important weapons against arthritis.

"Even a modest weight loss, 10 or 15 pounds, can have a tremendous benefit toward arresting or slowing the development of osteoarthritis of the knees," he said. "One needs to think of weight loss as a significant component of their treatment."

Floyd "Ski" Chilton, a professor of physiology and pharmacology at Wake Forest University School of Medicine, has studied the effects of diet on people who have arthritis and other inflammatory diseases, such as asthma and eczema.

In addition to weight loss, Chilton says, certain foods may help ease the pain of these diseases.

In his new book Inflammation Nation, Chilton says that arachidonic acid, a fatty acid that is present in many foods that have been presumed to be good dietary choices, inflames the immune system.

Such healthy food choices as turkey and many types of fish contain high concentrations of the acid, Chilton writes. He has spent 20 years studying fatty acids and the role that they play in inflammation. Much of his work was inspired by his sister, Tammy Chilton Lee, who developed juvenile rheumatoid arthritis in her teens.

Although doctors recommend diets high in fish for heart health, "not all fish are created equal," Chilton said. He recommends eating as much "good" fish, including European anchovies, Greenland halibut, shrimp, smelt, oysters, mussels and sea bass, as possible. He tells people to avoid "bad" fish, such as grouper, halibut, pompano, farmed and wild channel catfish, and farmed Atlantic salmon.

His diet plan also advises steering clear of egg yolks (egg whites are OK) and choosing lean beef or lean pork over turkey. But turkey, he said, "is a minor problem compared to the wrong type of fish or compared to eggs. Make no mistake about it, pork fat still is very bad for you and contains large amounts of this harmful fatty acid. Lean pork is a different animal."

Chilton describes arthritis as an agonizing disease. Little agrees. The disease has taken a toll on her and her family.

"There are days I can't even get out of bed," she said. "I've learned to stay prayed up."

NEW YORK (Reuters Health) - Many elderly people with rheumatoid arthritis may go about their daily activities with no more problem than others their age, a new study suggests. In the study of older men and women, those who had rheumatoid arthritis were, on average, able to walk, climb stairs and take care of themselves as well as the others, researchers in Finland found. Rheumatoid arthritis (RA) is a chronic disease in which the immune system mistakenly attacks the joints, leading to inflammation, pain and stiffness -- and, over time, joint destruction and disability. The lack of difference between RA patients and other elderly folk in this study was something of a surprise, noted lead researcher Dr. Markku Kauppi of the Rheumatism Foundation Hospital in Heinola. The finding, Kauppi told Reuters Health, likely reflects the success of various RA treatments, such as disease-modifying medications that slow RA progression, physical therapy and prosthetic replacements for seriously damaged joints. For their study, the researchers analyzed health data on 600 men and women older than 75 from one Finnish town. Sixteen, or just under 3 percent, had been diagnosed with RA. Of the RA patients, half received the best possible score on a standard scale that measures independence in daily activities like walking, stair climbing, dressing and bathing. That compared with 40 percent of the rest of the study group. Still, three RA patients, or 19 percent, were judged to be severely disabled, versus only 4 percent of men and women without the condition. Serious disability was "strongly associated with the presence of dementia," the team reports in the ls of the Rheumatic Diseases. Older adults with RA are not at increased risk of dementia, Kauppi said, as there is evidence that they may even have a lower risk of Alzheimer's disease, the most common form of dementia. However, when a person with RA develops dementia, it's likely to speed functional decline, according to Kauppi. People with significant arthritic joint damage, the researcher noted, need to have the skills to compensate for their difficulties performing daily activities -- by, for instance, using assistive devices to get around. "Dementia," Kauppi said, "may make it impossible for an RA patient to find solutions to daily problems and to compensate (for) joint destruction." SOURCE: ls of the Rheumatic Diseases, January 2005.

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