Pain management for rheumatoid arthritis sufferers

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit

The treatment of rheumatoid arthritis consists of the folloowing:

Patient education
Assistive devices

Patients education is critical since arthritis is a poorly understood topic.

Simple things to start with include:

Rest periods interspersed with exercise.

Temporary rest for a specific joint can be provided by a splint, brace, or cane. Doctors or physical therapists can recommend the appropriate type.

Maintaining a healthy weight may help with aches and pains, since additional weight can put excess strain on joints. Also, there is evidence that fat cells produce leptins, proteins that aggravate inflammation.

Physical therapy is important. 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 (Lineker et al. 2001).

Heat often eases the pain and muscle tension of rheumatoid arthritis. Use moist heat and be careful.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.

Drug treatments for rheumatoid arthritis can be divided into two categories, those that treat the symptoms of pain and inflammation and more aggressive drugs that slow the progression of rheumatoid arthritis.

Medications that treat acute rheumatoid arthritis symptoms include corticosteroids (also known as steroids), and nonsteroidal anti-inflammatory drugs (NSAIDs).

Medications that slow rheumatoid arthritis are called disease modifying antirheumatic drugs (DMARDs). This category includes a wide range of drugs that affect the body's immune system. They are effective against rheumatoid arthritis, but also can cause many serious side effects because they weaken the body's defenses.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in relieving pain in rheumatoid arthritis (Towheed and Hochberg 1997).

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 (Langman et al 1994; Fries et al 1993). 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 RealAge 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 (Brooks and Day 1993).

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.

NSAIDS interfere with the anti-platelet action of aspirin used by patients for stroke and heart prophylaxis.

NSAIDS are associated with an increased risk for cardiovascular events such as heart attack and stroke.

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.

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 (Paulus 1988). 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 (Silverstein et al 1995).

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
are 65 years or older
have a history of stomach or intestinal ulcers
are using anticoagulants such as Coumadin
are using corticosteroids
smoke tobacco
drink alcohol

Corticosteroids are used often for acute pain and inflammation because they provide quick relief.

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. 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.

Corticosteroid withdrawal is risky and steroids should only be discontinued under a doctor's supervision.

Disease Modifying Antirheumatic Drugs (DMARDs) are medications that slow the progression of rheumatoid arthritis. These drugs are used to prevent damage to joints and limit development of rheumatoid arthritis. DMARDs have a slow onset 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.

Different kinds of DMARDs include tumor necrosis factor (TNF) blockers, other biologic response modifiers, and immunosuppressants.

Examples of the most commonly used DMARDs include methotrexate (Rheumatrex, Trexall), hydroxychloroquine (Plaquenil), leflunomide (Arava), 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. These drugs, while having many potential side effects, have revolutionized our approach to the treatment of rheumatoid arthritis. Today, most patients with rheumatoid arthritis, when diagnosed early and treated aggressively, will go into remission.

Surgery may be considered when damage to a joint impedes daily activity.

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.

Get more information about pain management for rheumatoid arthritis sufferers and related topics as well as...

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Click here Second Opinion Arthritis Treatment Kit

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