Therapy

Sock's Rheumatoid Arthritis Page 1:

Therapy

| | | | | | | | | | | | | | | | | | | | | | | | |

There are a number of non-pharmacologic approaches. One is that people first have to acknowledge that medications alone cannot work and that they need to modify their activity. They need to learn to find how to offload inflamed joints and modify the way they do tasks to protect those joints.

A good example of that would be that if fingers are really sore, to find a way maybe to grasp which is different than just grasping or if someone has a problem with their wrist, perhaps use a splint which is a way of supporting that when they're doing a task that might irritate it, like vacuuming.

There are a number of other types of approaches, like using adaptive footwear, like shoe orthotics or adaptive shoes. And of course,there are a number of exercise-directed therapies which can really reduce muscle tension, improve sense of well-being and general conditioning.

There are lots of different ways that people cope with pain which are kind of interesting. Some of these are sort of short-term interventions, and some are longer-term, but certainly distraction, and changing what you're doing, and changing your physical activity you're doing at a time is a good technique.

Sometimes people will meditate or pray. There's some pretty interesting research written about reflective writing, where people who are experiencing pain will write essays, and this activity often brings insight into the experiences people have but also reduce pain because it distracts the brain from really focusing on the pain itself.

Then the whole other question is how do we safely apply heat and cold? And there are many ways. You could use radiant heat from a heat lamp. You could use a moist heating pad. One can could use paraffin baths using paraffin wax that's heated. There are a lot of different ways to do this, and it's just a matter of what people find works for them.

The other thing is that often people have fatigue. And so if you control the disease process and you have less pain but also less fatigue, you'd be more likely to live a full life.

Another important marker is sleeping. Often because people feel poorly, they have impaired sleep and, if you're tired and have pain and you don't sleep well at night, it's pretty tough to enjoy what you're doing

NSAIDs can be troublesome drugs for particular individuals, particularly elderly people or people with a past history of ulcers, and although the lower the dose that you use, the safer they are, the problem seems to be that sometimes people think if a little is good, then more is better. And so people adjust the doses up and take three tablets instead of two tablets like they're supposed to.

There can be a lot of problems with high blood pressure or edema, ulcers, kidney problems. These are difficult drugs to use, particularly if you push to higher doses.

There's a subset or a group of patients who need to be worried. Those are the patients with edema or swelling, congestive heart failure, renal or kidney problems, people with stomach problems such as ulcer disease, and people who happen to be older. One of the problems is too often these are the same people that we take care of who have rheumatoid arthritis.

The other problem with the non-steroidals is that some patients and even sometimes their physicians will see a response and will think this is a sufficient therapy, and not realizing that the progression of the disease and the cartilage and bone wear continues despite these medications.

It's really a great idea from the beginning to help people understand what our goals are is to control symptoms and signs, and to try to prevent joint damage. To use the disease-modifying drugs is a continuous process that's necessary.

Cortisone is such an important drug that we have, but it needs to be used very carefully because it can cause a lot of problems. Using intermittent injections of cortisone into the joints can be a real godsend and can really improve people's function.

For example, if someone's shoulder is limited in its ability to move, an injection of cortisone in the shoulder can provide rapid relief that can really provide benefits while you're waiting for the disease modifying drugs to take effect.

Gold is an old treatment, and in some ways that's really nice because physicians know a lot about it. They know what's good about it, and the bad about it. It is an effective treatment in about 55 percent of people who use gold. Gold suppresses the disease partially, but it's very slow. You need to use it with weekly injections for 20 weeks often to see clinical benefit.

And sometimes people can have problems with rash or low blood counts. Others can have oral sores or even problems with protein or blood leaking from the kidneys. So, while gold can be used safely and there may be particular patients that's a really good drug to use, it is something that is sometimes a troublesome drug, too.

One of the problems with gold is that patients and doctors do have to wait often the 20 weeks or more to make a decision whether this is an appropriate therapy, and also,may have lost six months of ability to treat the patients.

Gold is probably not a very good first choice of a second-line agent or of a disease modifying drug unless there's some reason that the physician didn't want to use methotrexate. Patients has to get a urine test and a blood test once a week to be sure that they don't have the kidney and bone marrow troubles that some patients have.

Methotrexate is actually a therapy that's been around for a very long time. It was used for cancer patients, and it's been used in rheumatoid arthritis for well over 20 years now.

The way it actually works is still not perfectly clear. Physicians know it works by decreasing inflammation, but it also works by decreasing immune cells.

A very large study that was published in 1999 showed that, finally, that it is not only a medicine that makes the patients' signs and symptoms or their joint pain and swelling better, but it slows the x-ray progression down, so it truly is one of our medicines that modifies the disease.

With reference to side effects,it's important also to understand that there are risks with not treating rheumatoid arthritis,that's the perspective or the frame in which you've got to look at the possible risks of methotrexate. Methotrexate is very well tolerated by most people, and even in relatively high doses, more than 85 percent of people will be able to continue it for at least a year.

The other signs of its safety is that at five years, more people tend to stay on methotrexate than any other drug. It's important to note that generally it is very well tolerated by most people.

There are two types of side effects. One is the relatively common kind of minor side effects. Occasionally people are a little tired or may have a little bit of nauseousness or loose stools after they take their weekly dose.

And then there are probably the less common or more sporadic type of problems which can be more serious, which are methotrexate-associated serious liver scarring, which occurs approximately in one in 1000 people who take it for five years, or serious lung scarring which can occur in around one and a half or two percent of people.

Methotrexate can be administered either by pill, which is the most common way that it's used in the United States, but it also can be administered by injection. The injections offer possibly a little more safety, a little more regulation of the dose, and in higher doses doctor's are able to have to switch their patients to injectable methotrexate.

Leflunomide is a drug which is similar in some ways to methotrexate in that it impairs the ability of inflammatory cells to reproduce rapidly. It is a bit expensive, about 280 dollars a month, and so that's actually somewhat of a barrier to people who don't have health insurance, but it is generally well tolerated by people.

The side effect seen most commonly is loose stools associated with it, but for most people that's not too much of a problem. It has some benefits in that it does seem to have some benefit within the first six to eight weeks of use, and it appears that its ability to suppress swelling and pain and to prevent joint damage is perhaps close to or similar to methotrexate. It would be an alternative to patients who either did not respond or could not take methotrexate.

Plaquenil has been used for a long time, and there are some really nice features about it which doctors include that it really doesn't need frequent blood monitoring, and it does not have a significant toxicity to liver.

However, at least in patients with recent-onset rheumatoid arthritis, there has never been a published study that has shown that it slows or prevents joint damage.

Therfore,for someone who has significant and functionally limiting rheumatoid arthritis, Plaquenil is not a good first choice. And also,the fact that it does take many months to see a response, we may lose our window of opportunity.

In Europe and outside of the United States, sulfasalazine is very commonly used. It's less commonly used in the United States. Sulfasalazine can be a very helpful drug. It is relatively inexpensive. The mode of onset is not as fast as methotrexate, but certainly faster than gold. The side effect profile, unless it causes stomach upset, is generally pretty good.

In the research studied, it may not be as effective as methotrexate or leflunomide, but it is certainly an effective treatment. For some people, it is a very useful drug. In people with the most severe arthritis, though, again that a faster-acting and more potent drug would be a choice of physicians.

D-Penicillamine, is rarely used now,especially with the newer drugs available. With the advent of the biologics, doctors don't need to use it because it is a troublesome medicine.

Now that we have a number of better-tolerated, faster and more effective treatments, these are clearly treatments physicians don't use as often. Azathioprine is a drug that is effective to some degree in reducing joint swelling and pain. The data supporting the idea that it prevents joint damage is really not as robust, and it's really quite slow. It's largely been supplanted in its place by Arava.

Treatment with cyclophosphamide was tested in the '60s, late '60s, early '70s, and it's certainly a very potent agent, but unfortunately it does carry with it a substantial risk of developing leukemia in the ten years after being treated with it. Cyclophosphamide really is not,or rarily used for rheumatoid arthritis.

Summary: In someone who has either very mild rheumatoid arthritis or maybe you're not sure it's rheumatoid,rheumatologists might consider Plaquenil early, but choices such as sulfasalazine, Arava or methotrexate would be their first choices.

Important Factors in Therapy:

Biologics: Enbrel, which is etanercept, and infliximab, the trade name is Remicade. They both are targeted towards the inflammatory messenger called TNF or tumor necrosis factor, and these are similar in many ways.

Enbrel is actually the receptor that TNF binds to on the inflammatory cell, and research-scietists figured out how to make that little receptor and how to help it circulate in the blood, and so what it acts as a sponge to take this out of circulation.

Infliximab or Remicade is a little different in that instead of just a receptor floating around, infliximab is an antibody, and that is it binds specifically to TNF and "kills" or eliminates it out of the blood.

With Enbrel individuals can administer that to themselves, and so that gives them a measure of control and independence. It's also not really associated with a meaningful immune response, so it can be taken all by itself.

Remicade is a little different in that it needs to be given as an intravenous treatment, and because one third of Remicade comes from a mouse, they have to take a drug like methotrexate with it to suppress making anti-mouse antibodies.

Currently,these drugs are limited because of cost and the requirements are that patients if they fail on an initial agent such as methotrexate need to be considered for a biologic,unless one has private health coverage and most plans have the same limitations.

Infliximab or Remicade, because of the mouse protein in it, one has to continue the methotrexate whereas with Enbrel or etanercept, it can be used as a single agent with very good success.

The other important point is that not all of these medicines work for every patient, and rheumatologists have to make decisions which are go, no-go decisions whether this is the right medicine and the right dose of medicine for the patient. Being on one of these medications is not enough.

The rheumatologist and the physician taking care of the patient has to make a decision whether it's really doing the job that it needs to be done. Therefore,rheumatologists will look at the patient's joints and they'll do a joint count so they find out how many of the joints are tender and how many are swollen, and they will follow x-rays on a periodic basis to be sure that there is no damage that's progressing to make decisions whether or not this is an effective medicine, whether it be a biologic such as Enbrel or a synthetic such as methotrexate.

One of the things that we as a society have to come to grips with is that the cost of biologics is much more than methotrexate is. And so, while there are individuals that without any question should be started on the biologics first, like people with significant liver disease or someone who has moderately severe kidney disease, in most individuals who do not have those processes, probably an initial trial of a potent disease-modifying pharmaceutical like methotrexate is probably from a financial standpoint the most sensible thing, and probably from a social society view.

The actual cost of the biologics is higher than methotrexate. Also, many of the patients with rheumatoid arthritis often come already on methotrexate. Many internal medicine doctors have already started them on methotrexate, and a decision needs to be made is that the right medicine and if so, is it the right dose, and often it's too low, and one pushes the dose.

A comparative study has been shown that higher doses of methotrexate work better. This is a very individual decision with the patient and the physician.

But what doctors would focus the most on isn't necessary what is the first drug that is used but that these biologics are not something that should be saved until there are no other options. These are drugs that should be used easily in the first six months to a year of disease if traditional therapies don't very effectively suppress the arthritis.

People should not wait because, the pace and the progression of joint damage is a continuous and rapid process, and if we can in a rapid fashion suppress people's disease,and over many years will reduce the amount of joint damage which should translate into better work, better health, and better social function.

We're all self-managers, and there are two ways of looking at that. If you choose to be a self-manager and you make a deliberate choice and create a mindset that you will take control of the management of your disease, you will likely turn into being a good manager.

Most individuals use one to three coping skills, and sometimes denial is that coping skill, but if you deny that you have disease, that is a rather poor thing because you are still a self-manager, you're just a poor self-manager, and you're not making interventions that can help you and your health over time.

Overcoming the grief and the feelings of loss, and accept that "Yes, I have this probably incurable disease," but quickly coming around to the idea that, "Well, I'm going to do whatever it takes so I can live as full life as I can and that this is more of an inconvenience to me rather than a life-changing illness."

The European Medicines Evaluation Agency has warned of an increased risk of serious infection and neutropenia in patients treated concurrently with the arthritis drugs anakinra (Kineret; Amgen) and etanercept (Enbrel; Wyeth and Amgen).

In a statement, it said results of a clinical trial sponsored by Amgen showed that 7% of rheumatoid arthritis patients who received both medications at the same time had developed serious infections. Two percent of patients also developed neutropenia.

A special warning has now been added to the label of both drugs saying that concurrent administration is not recommended because of the increased risk.

The purpose of the trial, which involved 242 patients, was to compare the efficacy and safety of Enbrel 25 mg biweekly alone with Enbrel plus Kineret 100 mg daily.

The incidence of infection and of neutropenia was higher in the combination arm and there was no therapeutic advantage, the EMEA said.

Last month, the EMEA advised physicians to "use caution" when prescribing Enbrel in patients with congestive heart failure because of the possibility that the therapy might worsen their condition.

You don't have to be an expert to appreciate how arthritis can cause depression, and how feeling down can also make you feel tired. Indeed, pain, depression and fatigue often combine to create a vicious cycle that can be very tricky to escape.

Then there's the opposite side of the equation, when your symptoms seem to fade away, and you feel good. The natural temptation to expand your regular activities is seductive, but beware: You may be courting a flare of symptoms (including fatigue) if you over-extend yourself and ignore the signals your body sends you when you've reached your limit.

For personal or social reasons, or as a result of peer pressure, some people with arthritis try to hide their condition. That's not a good idea. If your family, friends or colleagues don't know you have arthritis (or don't know you're hurting especially badly today), they could easily set a pace that will over-tax your limited physical resources. Better you should tell them how you feel and explain what you are capable of doing.

That way you won't have any embarrassing explanations or excuses to make afterward - and you won't pay for your silence with a flare-up of symptoms. A little misplaced pride could cost you dearly.

Fatigue may result from the disease process itself. This is especially true if you have rheumatoid arthritis, lupus or another type of inflammatory arthritis that affects the whole body. Chronic joint inflammation, a flare in symptoms, or anemia - a drop in the number of red blood cells normally found in the bloodstream - frequently contribute to fatigue. Sleep disturbance and non-refreshing sleep, along with generalized muscular pain, are hallmarks of fibromyalgia.

The constant physical and emotional effort you make to manage your pain can drain you of energy. When you compensate for arthritis pain by 'favoring' a joint - thus placing additional stress on other healthy joints, you can tire very quickly, since the muscles and tendons of those joints are unaccustomed to the extra work. And if you're exhausted and in pain, you're likely to be less physically active, which leads to disuse syndrome and more pain and fatigue.

List all your activities for a typical week, and don't forget to include leisure activities and pastimes. If you work, include the different work-related tasks you do on a given day. Now rearrange the list by placing all your activities in order of importance. You may want to make several headings - say, 'Work,' 'Home,' 'Play' - and set priorities of your activities by category. Next, pencil in on a calendar when you normally do your top-priority and daily activities.

Are your activities spread out over the week, or are they all bunched into a few days? Do you schedule your top priorities for when you're feeling the least joint pain and stiffness?

Is there a balance between activities you have to do and those you like to do? If you work, are you trying to cram in too many activities after-hours or on weekends? Do you have any flexibility in scheduling rest breaks at home or at work? Do any patterns emerge from your weekly schedule? Do periods of increased pain and fatigue coincide with certain activities?

Realistically - given the way you currently feel - are you trying to do too much? As you analyze your priorities and scheduling further, you'll no doubt find other questions specific to your situation. Keep at it until you're satisfied you've got the 'big picture' and have identified any problem areas.

To prevent exhaustion, develop a schedule that allows alternating periods of activity and rest. If you've come to the conclusion that you need to rearrange your schedule, then it's time to consider the 'economics' of spending your energy wisely:

A 10-minute break each hour, for example, may prevent fatigue, whereas it may take you much longer to recover if you over-extend yourself. Try to anticipate fatigue and rest before you get tired. It helps to learn your tolerance levels for sitting, standing, walking and other activities. Try completing the following statements, then develop a few more for the priority activities you've identified:

I can sit for ? minutes before I have to change positions. I can stand for ? minutes before I feel uncomfortable. I can walk for ? minutes (or # of blocks) before I need to sit down.

Another approach is to take a task and break it into units of work and rest. Take vacuuming, for example: Can you do one room in the morning and another in the afternoon? What about vacuuming one part of a room, then taking a 10-minute break before starting another? For that matter, could you do one room every other day?

If you think about it, most tasks have a set sequence of movements. When you perform at a steady rate and develop a rhythm to your movements, you use less energy. The trick is to avoid being rushed. You can usually avoid that pitfall by organizing and planning your activities beforehand.

A final tip about pacing: Use your morning range-of-motion and stretching exercises to gauge your energy levels and what you feel up to doing on a particular day. Also, observe the 'Two-Hour Pain Rule': If after an activity you feel pain for more than two hours, you did too much too fast.

Planning: Now you're ready to develop a weekly schedule that balances your top priorities with rest periods, one that sets a pace you can live with. Then try it for eight weeks or so. At the end of the trial period, ask yourself whether you feel as fatigued as you did before. If you do, have another look at your schedule to see where you can do a little fine-tuning.

If you discover that your expectations for your weekly schedule far exceed what you're truly able to do, it's time to start asking some hard questions:

Are there any activities you can do less often or drop entirely? Are there activities you can break down into smaller units? Are there activities you do for others that they could do for themselves? Is there someone to whom you can delegate certain tasks? Can you say 'no' when someone's expectations of you are unrealistic? Can you say 'no' to yourself when your own expectations are too high?

Can your doctor schedule your pain medication differently so that it's at peak levels when you're called on to perform? Are there other pain management techniques that would help you save more energy? Are you getting enough exercise? Are you eating properly?

Give it another eight-week trial. If fatigue's still a problem, it may be that's it's not when you do a certain activity, but how !

Posture: Believe it or not, positioning your body correctly - which involves distributing your workload evenly over several sets of strong muscles - can help you conserve energy. Proper posture helps you avoid straining muscles and joints, whether you're sitting or standing.

If you compare the number of calories you burn per minute when sitting and standing, you'll discover that standing eats up almost twice as much energy. You can economize even more of your energy by adjusting the heights of your chair, your desk or worktable relative to one another.

Your chair's height from floor to seat cushion should be equal to the distance from the base of your heel to the back of your knee, plus 7 cm (3 in.), so that you can sit and stand easily. To take this measurement, you're going to need to ask your spouse, a friend or your occupational or physiotherapist for some assistance. For later reference, fill in the following statements:

The distance from the bottom of my heel to the back of my knee is ? cm ( ? inches). Add 7 cm (3 in.). The proper height for my chair is ? cm ( ? inches). When you're sitting at your worktable, your head and shoulders shouldn't stoop. The top of your table should be 5 cm (2 in.) lower than your bent elbows when you're sitting up straight.

When I sit in my chair, adjusted for correct height, the top of my worktable should be ? cm ( ? inches) from the floor. To conserve more energy while sitting, measure the distance of your reach (with bent elbows) on the right, left and top of your worktable surface.

Visualize an arc moving from one corner to the other, which is your normal work area. Place all the articles you use most along the imaginary arc, within easy reach with your elbows bent. Articles you use less should be no further than an easy reach with your arms straight.

Sitting at my worktable, my easy reach on the right is ? cm ( ? in.), at the top is ? cm ( ? in.), and on the left is ? cm ( ? in.). You can try the same exercise when you're standing at the kitchen cupboards. The normal range for an easy reach is from your shoulder height to your fingertips, with your elbow bent.

Standing at the kitchen counter, my easy reach over my head on the right is ? cm ( ? in.) and on the left is ? cm ( ? in.). Your countertop should be no deeper than your maximum reach without leaning forward and no higher than 5 cm (2 in) below your elbows.

The correct height for my counter is ? cm ( ? in). Just as you've done on your desk or worktable, keep all the articles you use most within this area in your cupboards. (Seldom-used articles can be stored in areas that are harder to reach; think about recycling or discarding rarely used ones - a real energy-saving move.)

If all you do is dream of a good night's sleep, then try some of these proven strategies that will help: Invest in a quality mattress that provides firm yet comfortable support. Avoid waterbeds.

Note your body's preferred sleep cycle. If sleeping longer and more soundly means going to bed later and waking up later, if at all possible, adjust your schedule to that rhythm.

Stick to your schedule: Go to bed every night and get up every morning at the same times - even if at first you don't sleep very well - to establish a routine that accommodates your preferred sleep cycle.

If pain is keeping you from falling asleep, try taking a warm bath or shower before hitting the sack. That should help relax knotted muscles and relieve your joint pain.

If pain is waking you during the night, get into the practice of doing relaxation and distraction techniques before bed.

If you're still waking during the night, ask your doctor to adjust your medication schedule so that your medications' pain-relieving component kicks in just before you're ready to nod off.

Exercise regularly, so that you feel pleasantly tired and relaxed at day's end.

Adjust your sleep environment so that there are no distractions that prevent you from sleeping. Is your bedroom too light or too dark, too noisy or too quiet? What about room temperature?