Pain management for arthritisThe primary aims of arthritis treatment are: • Pain management Frequent short breaks may be necessary to reduce arthritis symptoms such as inflammation, pain, and fatigue. Exercise should be interspersed with rest periods in order to stretch and relax. However, too much rest can also be a problem - resting in bed for long periods of time weakens the heart, irritates the skin, and erodes the muscle strength needed to protect joints. When joints flare up and are extra painful and inflamed, longer and more frequent rest periods may allow you to continue exercising. If pain is increasing or sharp, or if you feel new pain, rest the affected joint immediately. Temporary rest for a specific joint can be provided by a splint, brace, or cane. Doctors or physical therapists can recommend the appropriate fit and use of these supports for arthritis symptoms. Each device supports a particular joint, lessening inflammation. In addition to allowing rest, a splint may be used to hold an unstable or deformed joint in position. Splints are most often applied to wrists and hands, but also can relieve pain and swelling in ankles and feet. Splints should be removed periodically to prevent skin irritation and to move the joint through its normal range of motion. Maintaining a healthy weight may help with aches and pains, since additional weight can strain joints throughout your body. If joint surgery is needed, it is easier and less risky to conduct surgery on a patient that has less excess weight. Physical therapists often work with patients who have rheumatoid arthritis symptoms to improve joint function and reduce pain. One Canadian study involving 117 people found that education, exercise, and other forms of physiotherapy led to lasting improvements in morning stiffness and other rheumatoid arthritis symptoms. Heat applied to the aching joint often eases the pain and muscle tension of rheumatoid arthritis. Choose heat sources that gently warm your muscles, such as a hot shower or bath, hot water bottles, electric heating pads, or heat lamps. To prevent burns, check your skin periodically and be careful not to fall asleep while applying heat. Cold can be applied to help reduce inflammation or relax muscle spasms. Wrap an ice bag in a towel, rather than applying ice directly to the skin. Neither heat nor cold should be applied if you have poor circulation or numbness. Capsaicin or counterirritant ointments that increase the blood flow in the skin can have soothing effects similar to applying heat. Capsaicin ointments contain extract of red chili peppers from the jalapeno pepper plant. These extracts are rich in capsaicin, a substance that makes peppers burning hot. Capsaicin increases the release of, and then depletes, a messenger substance that transmits pain signals to the brain. Although it is quite difficult to conduct double-blind trials because of the burning sensation that capsaicin initially causes, applying capsaicin ointments to painful joints appears to ease pain. And, unlike counterirritant ointments, capsaicin preparations do not cause redness. Capsaicin ointments, such as Zostrix®, are typically applied to the skin directly over the painful joints two to four times per day. Maximal pain relief may require several weeks. For the first few days of use, capsaicin ointment will cause a burning sensation where it is applied. The burning sensation may increase when using warm water (i.e., in a bath or shower), when the cream is applied less than three or four times per day, when there is perspiration, or when a bandage is used over the cream. It is extremely important to handle capsaicin ointments carefully and to wash your hands thoroughly-especially your fingertips-after each application to avoid spreading the cream onto sensitive areas. If capsaicin comes into contact with wounds, the mouth, the nose, or other mucosal surfaces-especially the eyes-it causes very severe pain but does not cause damage. Counter-irritation is the pain-relieving effect achieved by causing less severe pain to counter more intense pain. Counterirritant ointments are applied to the skin over painful joints to produce a mild local inflammatory reaction and sensations of heat or cold. This may relieve the deeper-seated joint pain. Active ingredients may include aromatic oils such as menthol, peppermint, clove, and camphor oils. There is little evidence on the effectiveness of counterirritant preparations. Counterirritant ointments are available over the counter. An example is Tiger Balm. Counterirritants should not be used with other topical ointments or creams or on open wounds. Some people may be hypersensitive to one or more of the ingredients. Drug treatments for rheumatoid arthritis can be divided into two categories, those that treat the symptoms of pain and inflammation and the more aggressive drugs that slow the progression of rheumatoid arthritis. Your medical treatment may start with either kind of drug, or a combination of both, depending on how severe your condition is. Medications that treat acute rheumatoid arthritis symptoms but are not used for long-term care include corticosteroids (also known as steroids), and non-steroidal anti-inflammatory drugs (NSAIDs). Medications that slow rheumatoid arthritis are called disease modifying anti-rheumatic drugs (DMARDs). This category includes a wide range of unrelated drugs that affect the body's immune system. They are effective against rheumatoid arthritis, but also cause many serious side effects because they weaken the body's defenses. Nonsteroidal Anti-inflammatory Drugs (NSAIDs) When lifestyle and self-help measures, topical ointments, and acetaminophen are not able to control pain, NSAIDs are typically used as the next line of defense against rheumatoid arthritis. For people who suffer from rheumatoid arthritis pain and do need NSAIDs, it is important to understand the side effects involved and the ways in which the risk of these side effects can be reduced. There are some reports that NSAIDs vary in their ability to combat pain and inflammation caused by rheumatoid arthritis, but these differences may be due to the various doses that are used in investigations. There is no evidence that one drug is consistently better than another. Because no differences in efficacy between NSAIDs are evident, specific NSAID medications should be selected based on safety, how well they are tolerated, and cost.
In many people, NSAIDs increase the risk of ulcers and bleeding in the stomach and upper small intestine (duodenum). The higher the dose, the greater the risk that the drugs will cause a hole in the walls of the stomach or small intestine-a condition that is a serious medical emergency and can be fatal. Some estimates put the number of hospital admissions due to gastrointestinal side effects of NSAIDs at more than 100,000 per year.
Long-term treatment with NSAIDs can raise blood pressure. This may be troublesome for people with already elevated blood pressure or other risk factors for coronary heart disease. A review of several studies (Johnson et al 1994) concluded that the typical increase is 5 mmHg, which can make arteries age faster and your real age significantly older.
Long-term use of NSAIDs can lead to retention of salt and water in the body. In people who are at risk of congestive heart failure, this can become troublesome. NSAIDs can cause impairment of blood flow in the kidneys, especially in older people. This problem will go away once the drug is no longer taken.
Because NSAIDs interfere with the clotting function of blood platelets, their use can prolong bleeding time and make it more difficult to stop bleeding. This may be a problem for people who take blood thinners. Fortunately, there are nonacetylated NSAIDs, such as salsalate, which do not interfere with blood clotting.
Short-term use of an NSAID-for one to two weeks-is generally safe. The risk of side effects increases with age, dose, and duration of use. Depending on interpretation of the numbers, the risk can appear high or low. Some estimates put the number of hospitalizations due to gastrointestinal side effects of NSAIDs at more than 100,000 per year and deaths due to NSAID gastrointestinal side effects at more than 16,000 per year. These figures are high because many people are taking NSAIDs. So, what is the risk per person? Serious gastrointestinal complications can occur in people who do not take NSAIDs. Such complications occur at a rate of about 0.1% to 0.3% per year. Regardless of what risk factors for gastrointestinal side effects may be present, the Food and Drug Administration predicted that 2% to 4% of patients who take NSAIDs on a daily basis for 1 year will have a symptomatic GI perforation, an ulcer, or bleeding. In rheumatoid arthritis patients with no risk factors for NSAID-related ulcers, the risk of developing ulcer complications was 4 out of every 1,000 patients (0.4%) per year. Generally, the most serious side effects-namely bleeding and ulcers in the stomach and small intestine-are most common in people who: take high doses of NSAIDs In a large study of people whose average age was 68 years, about 14 out of 1,000 people (1.4%) developed ulcers or bleeding in the stomach and upper small intestine over the course of 6 months. The longer they took NSAIDs, the more likely they were to develop complications. The risk factors for developing the side effects related to NSAIDs were being over the age of 75, having a history of ulcers of the stomach or upper small intestine, having a history of bleeding from the stomach or small intestine, and having a history of heart disease. Of people with none of these risk factors, fewer than 1% can expect to develop bleeding or ulcers from taking NSAIDs for one year. For people with any single risk factor, about 2% per year can expect to develop this complication. People with a combination of any three of the risk factors have an 8% to 10% per year chance of developing bleeding and ulcers. For people with all four risk factors, the risk is 18% per year. When NSAIDs are needed, they must be used carefully. The use of NSAIDs has been associated with about 20% to 30% of all hospital admissions and deaths due to stomach ulcers in patients aged 65 and older. Some research suggests that the long-term use of some NSAIDs, especially indomethacin, may lead to more severe changes in joints affected by rheumatoid arthritis than would be expected in untreated joints. These studies suggest that NSAIDs may inhibit processes involved in cartilage repair and may accelerate cartilage destruction. Researchers hope that COX-2 inhibiting NSAIDs will not have this effect. There are several ways in which the risk of NSAID side effects can be reduced. For example, use: lower-risk NSAIDs, such as ibuprofen, at doses of less than 1,600 mg per day (4 doses of 400 mg per day), if possible enteric-coated aspirin, which is more expensive than simple aspirin but has a lower risk of side effects misoprostol (Cytotec®), which has been shown to protect the stomach lining when taken in addition to NSAIDs) omeprazole (Prilosec®) and similar drugs such as ranitidine (Zantac®), cimetidine (Tagamet), famotidine (Pepcid®), and nizatidine (Axid), which can reduce the risk of gastrointestinal side effects when taken in addition to NSAIDs COX-2 inhibitors, a new class of drugs that promises to be about as effective as traditional NSAIDs but with fewer side effects so-called intermediate selective inhibitors or COX-2 preferential inhibitors, which are NSAIDs that inhibit COX-2 as much as other NSAIDs and COX-1, but less than traditional NSAIDs and more than COX-2 inhibitors (An example is meloxicam (Mobic), which inhibits COX-1 less than COX-2. At doses that are effective in fighting pain, it has a lower risk of causing gastrointestinal side effects
But misoprostol has side effects of its own, including diarrhea, cramps, and gas. While potentially unpleasant, these side effects should be weighed against the more serious side effects from NSAIDs. Corticosteroids Corticosteroids are available in different forms. Oral steroids often are combined with DMARDs and have sometimes been used for people who experience severe side effects from NSAIDs. Injections can relieve acute flare-ups of particular joints, but only three to four injections per year are considered safe. Injections also are used for rheumatoid arthritis in children in place of oral medications. Finally, intravenous steroids may be applied as an alternative to DMARDs.
Long-term use of corticosteroids can cause severe side effects and make withdrawal difficult. Side effects may include high blood pressure, infections, cataracts, glaucoma, diabetes, psychosis, and osteoporosis. Additional side effects that may cause concern include weight gain and fluid retention, irregular menstruation, acne, excess hair, bruising easily, irritability, and insomnia. Corticosteroids replace hormones that are usually produced by your adrenal glands. Once acclimated to artificial steroids for an extended period of time, the adrenal glands will not immediately resume hormone production if you stop corticosteroid use. This withdrawal is risky and steroids should only be discontinued under a doctor's supervision. Medications that slow the progression of rheumatoid arthritis are called disease modifying antirheumatic drugs (DMARDs). These drugs are used to prevent damage to joints and limit development of rheumatoid arthritis. DMARDs have a delayed effect and may be used in combination with drugs that address immediate pain and inflammation such as NSAIDs or corticosteroids. Early, aggressive treatment with DMARDs has sometimes been effective in slowing the progress of rheumatoid arthritis, and also might prevent damage to the heart and other tissue. Over time (usually two years), the effectiveness of these drugs decreases while the risk of serious side effects increases. DMARDs are a broad category that includes a wide range of different drugs that also have been used for other conditions. Different kinds of DMARDs include tumor necrosis factor (TNF) blockers, other biologic response modifiers, and immunosuppressants. Depending on what kind of rheumatoid arthritis you have and whether it is expected to progress, your treatment may begin with either DMARDs or NSAIDs. When compared to NSAIDs, DMARDs are stronger but have more side effects. Most DMARDs are deleterious to the stomach and intestine. Serious complications are comparable to those for long-term use of NSAIDs but are rare. Examples of the most commonly used DMARDs include methotrexate (Rheumatrex, Trexall), hydroxychloroquine (Plaquenil), leflunomide (Arava), the auranofin (Ridaura) and other compounds containing gold, sulfasalazine (Azulfidine, Azulfidine EN-Tabs) and minocycline (Dynacin, Minocin). Biologic response modifiers are DMARDs that have been engineered to modify the body's inflammatory response. They work by targeting specific proteins that contribute to inflammation during rheumatoid arthritis. This specificity means that they are less harmful than immunosuppressants that weaken the entire immune system and leave the body vulnerable to ordinary infections. Several tumor necrosis factor (TNF) blockers and one interleukin-1 blocker are approved for use in moderate and severe stages of rheumatoid arthritis. These kinds of drugs are named for the inflammatory proteins they target. Additional drugs that block different inflammation-causing proteins are currently under development. Tumor necrosis factor (TNF) blockers are biologic response modifiers used to treat moderate to severe rheumatoid arthritis. Two TNF blockers are currently in use, infliximab (Remicade) and etanercept (Enbrel), but many insurance plans do not cover them because of their high cost. Long-term side effects are not well known for TNF blockers because they are relatively new, but there is concern that they may damage nerves or increase infections. For this reason, TNF blockers may not be recommended for people with multiple sclerosis or people who carry tuberculosis. One review of current studies on TNF blockers emphasized the need to consider possible side effects (Furst et al. 2001). Only one biologic response modifier that targets the protein interleukin-1 has been approved. This protein contributes to joint inflammation and blocking it may reduce pain. Anakinra (Kineret) is delivered intravenously and it has worked for some patients who do not respond to standard DMARDs. Some side effects have been reported, including greater susceptibility to respiratory and other infections, and headaches. Immunosuppressants are used only when other treatments are no longer effective. They have many negative side effects. Leflunomide (Arava) has fewer side effects because it acts on the immune system in a targeted way. However, most of these drugs weaken the immune system and also may increase the risk of stomach and intestinal distress, anemia, blood problems, and some kinds of cancer. Examples of immunosuppressants include azathioprine (Imuran) and cyclosporine (Neoral, Sandimmune). The most common kinds of surgery used to repair deformity or disability in rheumatoid arthritis are joint replacement, tendon reconstruction, and synovectomy. Other surgical procedures that may be considered include arthroscopic removal of damaged tissue, arthrodesis, osteotomy, and tenosynovectomy. Non-medicine approaches:
|
