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If a person's had more than six weeks of "just a little arthritis," they really do need to talk to a physician to find out a couple of answers. One, they would like to know, "What is my diagnosis?" Two, if the diagnosis is rheumatoid arthritis or another form of arthritis, they want to know what their prognosis is: what to expect in the near future as well as the long-term future.
 
Then they really need to sit down with the primary care physician or rheumatologist to discuss treatment options, both what's available currently that will make them feel better, what's available currently that will slow or stop the disease from progressing and causing the disability that can happen with rheumatoid arthritis, and then what the side effects and the risks are of the treatment.
 
Rheumatoid arthritis can be very aggressive and has been shown even to shorten one's life expectancy. The other important point is that rheumatoid arthritis is not a benign disease. It's really a disease that can be very aggressive. It can limit not only one's ability to do things, but it's been shown at a study at Vanderbilt University even to shorten one's life expectancy.
 
If the physician makes the diagnosis of rheumatoid arthritis early and responds to that with the appropriate aggressive therapy to slow the disease down, the prognosis becomes much, much better. The patient's ability to live a full and useful life is extended.
 
Since arthritis is viewed,as less serious than heart disease or cancer, people will live with some of the pain. The other thing is that patients with arthritis and arthritis symptoms will get advice, and they'll get advice from many of their friends about what to do, which foods they should eat, and which foods they shouldn't eat - advice which really has no basis in science, but everyone seems to have an opinion about arthritis
 
If someone had more than six weeks of minor arthritis pains, and they've been persistent for six weeks, and especially if they've been in more than one or two or three joints, this is something that they need to see their physician about. If there's difficulty in nailing down a diagnosis, this is the time to consider a referral to a rheumatologist for an opinion.
 
If the general practitioner knows your symptoms are not rheumatoid arthritis and may just be due to some local infection or something else, and he or she is confident in that diagnosis and can tell you the prognosis, the therapy, and the side effects, that would be fine.
 
But if the diagnosis is unclear or the primary care physician or internist is not really sure whether to intervene with big-league, potent medicines, then a consultation with a rheumatologist would be appropriate.
 
The diagnosis is primarily made by a history and a physical examination; then ancillary, or secondary, blood tests and x-rays are done. The medical history and the physical examination of the patient will give us the diagnosis in about 95 percent of the patients.
 
The history is one of inflammation - again, pain and swelling - of small joints, namely the finger joints and the joints in the feet. The joint swelling and the pain is usually symmetric, meaning if it's on the right side, it's usually on the left side, as well.
 
That kind of history points the doctor or the rheumatologist to a diagnosis of rheumatoid arthritis. Then when the doctor or the rheumatologist examines the patient, they can actually feel the inflammation and feel some of the nodules or the bumps that rheumatoid arthritis can make. Rheumatologist are trained in a two-year program to feel the inflammation of rheumatoid arthritis.
 
Once they've done that, then they'll do some blood tests. The two most important blood tests check for inflammation, and there are actually two of those. One is called the ESR (erythrocyte sedimentation rate) or "sed" rate, and the other is called the CRP or C-reactive protein.
 
They're very similar tests, and they really just tell physicians that the patient has inflammation in the system, but these tests don't tell them that it's actually rheumatoid arthritis.
 
In 50 percent of patients with rheumatoid arthritis, the rheumatoid factor in early disease is negative. Physicians will look for the "rheumatoid factor," but the rheumatoid factor test can both be important and unimportant - because in 50 percent of patients with rheumatoid arthritis, the rheumatoid factor in early disease is negative.
 
The patient can have rheumatoid arthritis by history and exam, but the blood test could be negative. Twenty percent of patients with rheumatoid arthritis still have a blood test that's negative for the rheumatoid factor,it's a helpful piece of information if it's positive but not necessarily if it's negative.
 
Another important piece of information that the doctors and rheumatologists have to put together is that rheumatoid factor is just an abnormal protein, and it actually can occur in other diseases, so even people with diabetes or chronic infections will have a positive rheumatoid factor and not have rheumatoid arthritis.
 
It has to be used very judiciously. X-rays are very important because if doctors see rheumatoid arthritis on the x-ray, they know that the patient has it, and they also know that the prognosis is not very good and one has to be very aggressive in therapy.
 
Currently there is no cure for RA. The diagnosis is primarily made by a history and a physical examination; then ancillary, or secondary, blood tests and x-rays are done. The medical history and the physical examination of the patient will give physicians the diagnosis in about 95 percent of the patients.
 

For the individual patient one NSAID often appears to be best. To find one,sometimes,a sequence of NSAIDs is prescribed for relatively short trial periods of about 7 to 10 days each. By the time a couple or sometimes,more have been tried,the doctor has a pretty good idea of how much the patient is going to be helped by an NSAID,and which one is best. Trying more would waste time and money.
 
Ideally,the NSAID chosen will be cheap,well tolerated,easy to remember to take and effective. Few drugs meet all these criteria. The decision is also influenced by whether or not a patient has a drug plan to help with the cost,because some are expensive.
 
You can bleed on any of the traditional NSAIDs,(even without symptoms),particularily if;you are older (the risk increases with age),you have had a ulcer before,you are taking high doses of one NSAID,or combing,which should not be done,sometimes,if iff you are taking a corticosteriod such as predisone (even some DMARDs-in different people ), you are on blood-thinning drugs and if you have a serious medical condition and,althought this is less certain,if you smoke cigarettes or drink alcohol. Your doctor is the expert,and he has to assess each individual situation,not you.
 
Choosing the right NSAID depends on a number of factors. Some are clearly more risky then others. People with a previous ulcer should probably be prescribed either ulcer protection (with misoprostal combined with an NSAID in a single pill or omeprazole added to an NSAID or one of the newer COX-2 specific agents. Older people and those on anticoagulant (blood thinners) should be individually considered And people with borderline kidney function should probably not take any type of NSAID.
 
In the old days,one consideration that may have been exaggerated is conveinence. Some NSAIDs need to be taken 4 times daily,others twice daily and a small number once daily. For most patients this is not important,but for others,especially if they're likely to forget a midday dose at work,it very definitely is.
 
The choice of the NSAID tried,and the order in which they are tried,is influenced by their safety profiles. If one don't seem to be working or a drug that once worked has lost its efficacy,let your doctor know.
 
In RA common practise is to find the best NSAID and then decide on a second-line drug to be added. It is seldom that the disease is so mild (non-erosive) as to be controlled by NSAIDs alone.
 
In OA there may be an inflammatory component that is helped by an NSAID,but the chief benefit seems to be pain control, Acetaminophen is often just as good as an NSAID,and safer and cheaper.
 
In some diseases NSAIDs ae very effective,in crystal arthritis,such as gout,NSAID response is terrific-unless treatment is started too late,or the dose is inadequate. In ankylosing spondylitis,an NSAID usually results in a patient's first good night of sleep in years.
 
Side effects of the older NSAIDs;rare side effects-skin rash,including photosensitivity (a rash provoked by going out in the sun) and hives,jaundice or other evidence of liver problems,bowel ulceration and bleeding,impaired production of blood cells (aplastic anemia ), asthma, significant kidney impairement,confusion,headaches and neck stiffness--VERY RARE SIDE EFFECTS.
 
COMMON SIDE EFFECTS are indigestion,stomach ulceration and bleeding
 
Some of the rarer side effects are linked to specific NSAIDs (such as alastic anemis with phenylbutazone),while others may be seen with any NSAID. For example,if an asthma attack is provoked by one NSAID,all (including ASA) should be avoided. In special circumstances, if the NSAID is badly needed,the patient can be desesitized.
 
All NSAIDs also appear to affect kidney blood flow. This is not a problem for most people,but its a big problem for (some) older people, people with kidney function that is alredy below normal people on some other drugs (such as dieuretics,given to rid of excess body fluid or to treat high blood pressure)
 
The common side effects,those affecting the stomach,are the real problem NSAID indigestion is common,about 10 to 20 % of users will experience it at one time or another. But it's an unreliable marker for an ulcer,which can bleed without any warning signs. And many with indigestion don't have ulcers.
 
Taking an NSAID increases the risk of developing an ulcer,having gastrointestinal bleeding or experiencing an ulcer perforation by about five times. The risk of a bleeding ulcer in an other wise healthy person taking one of the older NSAIDs has been estimated at 1 to 2 for every 100 patient years. In plain English,if 100 patients take the NSAID for a year,1 or 2 of then will develop an ulcer in that year
 
Only about half of ulcers will cause symptoms. Very often the first sign of an ulcer is evidence of bleeding,such as vomiting of blood,black bowel movements or rarely,light-headedness and fainting.
 
There are a number of ulcer-protective drugs available,but only misoprostol and omeprazole have been convincingly shown to reduce the risk
 
For indigestion alone,anti-ulcer drugs can be tried. They may or may not clear u the symptoms. Since the cause of non-ulcer indigestion isn't knwn (the true cause of back-pain is unknown in many cases ).it can be difficult to deal with,at time. Sometimes it's so bad the best solution is simply to stop the NSAID,but when that time approaches, your physician will know.
 
If one worries about everything,one won't take any medication for any medical purposes. The physician will weigh the risk and benefit ratio.

Taking an NSAID on an "as needed" basis (a pill or two today,then a few days skipped) is foolish. NSAIDs need several days to develop their full effect,and little can be expected from occasional doses except possibility of a heartburn or an ulcer. The ulcer doctors see much more ulcer bleeding in occasional NSAID users than they do in patients with arthritis, It's surprising how many people take ASA fro stomach aches or insominnia.
 
Most pharmacists and doctors recommend that an NSAID be taken with food. It's doubtful this really helps prevent an ulcer,but meals do help as reminders.
 
NSAIDs come in suppository forms as well as tablets and capsules,but there's no real evidence that supporitories cause fewer ulcers.
 
NSAIDs may interact with other drugs (this applies to all forms of drugs,herbs included),and can cause problems with blood-thinning agents,serious bleeding may result,with lithium,toxic blood levels of lithium can occur with a variety of blood pressure medications,high blood pressure may worsen Sulindac may possibly be the safest NSAID in this setting.
 
There is nothing magic about an NSAID If you don't think it's it's helping,and your disease control has improved to the point of little pain,stop taking it. If symptoms of pain or pain or even increased joint swelling reappear,you need it,and can restart it. Your doctor will determine this phase. You may have to wait a few days to feel its full effect,but if it was helping before,and nothing else has changed,it will work again.
 
From my personal experience; It was a question whether NSAID was helping me. My RA was so poor at that point that No NSAID seemed to help,this also applied to DMARD and predisone. It was not until later in my personal disese course that I relized the benefit of these medications. Simply,put the disease was so rampart that medication did not SEEM to help.
 
Another point;The decision to take Vioxx and Celebrex (in my case ) I tried Vioxx first,it seemed to work. Later Celebrex was suggested, (insurance company-at that time Celebrex was cheaper-pennies). I tried Celebrex. The problem with RA is that it waxes and wanes and sometimes,you think one NSAID is better,but in reality( in my case),the long term result is that there was no "real" difference. This has happened with other RA medications. Sometimes,we will be fooled and more is likely then less. You may no have a choice with some insurance company plans.
 

The name "second-line" comes from the fact that in RA the NSAIDs were used first. When their effects has effects has been determined ( in the old days ).assuming there is still a problem,theDMARDs were called upon.
 
They used to call it remitting drugs,but it's clear that they don't cause the disease to go away completely.  Some doctors call them SAARDs ( Slow-acting anti-rheumatic drugs,which they are.  The two major differences,in pratical terms,between these drugs and NSAIDs are they take much longer to have an effect ( usually months ),and they are much more effective in (pain relief) suppressing  the disease process.
 
 Unfortunately,another characteristic of drugs in this category is the fact that they often lose their effect as time goes by.
 
This means that,after several years,many patients will have experienced with quite a number of these agents. Fortunately,research into new drugs in this area have kept up.
 
These drugs were unrelated to each other chemically. Almost all were first used in arthritis for reasons that were later shown to be wrong,or as a result of a series of chance observations
 
Gold,was used because RA was once thought to be caused by tuberculosis and gold salts have some activity against TB in a test tube.
 
Methotrexate ,when it was first used in psoriasis,was observed to work even better It in only now,in the age of biologic engineering we have found drugs specifically designed to treat RA.
 
In RA DMARDs should be introduced as soon as the diagnosis of RA is established. We have come to appreciate that effective treatment must not be delayed,that this class is far superior to NSAIDs and the risks of side effects have been deeply exaggerated.
 
Investigations makes a convincing case that many DMARDs are actually less harmful then NSAIDs in practise. But each drug has many possible side effects which can be controlled by careful monitoring,should such side effects appear on the scene (DMARDs and NSAIDs).
 
Unfortunately,these agents are not uniformly effective in all forms of arthritis. They are used primarily in just two forms of inflammatory arthritis,rheumatoid and psoriatic (generally speaking).
 
Some are used as "supportive" treatment in a few other conditions,in particular ankylosing spondylitis,systemic lupus erythematosus,polymyositis and dermatomyositis.
 
There is no "second-line" treatment available for the most common problem of all,osteoarthritis. Nor is there specific treatment for fibromyalgia,scleroderma, choncrocalcinosis,polymyalgia rheumatica,or Sjorgren's syndrome.
 
There is non-erosive RA,but this is in the minority. The typical polyarticular rheumatoid arthritis is a progressive,systemic,sero-positive (R.F.),on-going disease where radiographic disease process is occuring on a daily,(however,minute) progressive basis,and the purpose of DMARDs is to partially,or if possible,completely stop,this destructive radiographic damages from continuing.
 
There are many DMARDs,some more suitable,w.r.t. severity and type,then others. There are many other important factors such as patient suitability. Not all patients can take the present "gold standard" methotrexate due to patient differences in "tolerability",effectiveness,and side effects.
 
Hydroxychloroquine is considered to be much weaker than most all the other DMARDs. But it has a relativvely high safety profile,so in a patient with relatively mild RA rheumatologists use it. It takes effect in 3 to 6 months, Its long-term benefit has been proved to be not so good as some others.
 
It's used in systemic lupus erythematosus,also,particularily if skin,joint and muscle symptoms are prominent. It appears to counteract the blood-fat elevating effect of the corticosteriods that are often used in lupus patients. Occasionally it's very useful in psoriatic arthritis,although in a few patients it has been demonstrated that the psorisis will often worsen significantly.
 
It's very important,if the risk of eye damage is to be avoided,that,in addition to annual eye checks,the dose is carefully calculated,based on the patient's ideal body weight. The maximum daily dose is 400 milligrams of HCQ (200 milligrams twice a day),but that is for anyone over 130 pounds (59 kg.) Those who weigh less must take less. A 110 pounder (50 kg.) should get 300 milligrams daily.
 
Side effects of HCQ; Common to occasional;-nausea,mild abdominal discomfort. Rare;-skin rash,muscle wekness,dizziness. Very rare;-permanent damage to the retina of the eye,leading to blindness. Fewer than a dozen cases of this have been reported in the world medical literature in patients whom HCQ (as opposed to the older drug chloroquine) was used,where kidney function was normal and the dose was based on body weight. Nonetheless,an annual eye check is recommended. Plaquenil is the modern upgrade and is used most commonly now. Chloroquine is rarely,if ever used now.
 
 

North American experience with Sulfasalazine (SSZ) in the treatment of RA has been limited (it's used more frequently now).  It's very popular in Europe and the British Isles. It's a mainstay in the treatment of inflammatory bowel disease,its side effects are well documented.  Its safety profile is very encouraging,and to rank it somewhere near intramuscular gold. Its safety profile is very encouraging,its fairly effective,and it takes action in 2 to 3 months. Its benefits are sustained moderately well over the long term. It may be an option for those that can't tolerate methotrexate,some say it is equal to methotrexate,but the majority will list it below MTX in terms of efficacy,in the long term.
 
Sulfasalazine should be started with a low dose and grdually built up. Usually,start with one tablet (500 milligrams) a day for a week,then increase the daily dose by one tablet each week until,by the fourth week,the patient is taking two tablets twice a day. Occasionally the dose is increased to 3 tablets twice a day. Once a final dose has been settled on,complete blood counts (CBC) and liver tests are done monthly.
 
HCQ does not require laboratory monitering.
 
SSZ contains sulfa and should not be taken if you're allergic to sulfa drugs Common to occasional side effects;-Nausea or vague abdominal upset,.loss of appetite,dizziness,headache,temporary lowering of the sperm count in men (reversible when drug is stopped ),yellowish-orange discoloring of the urine. RARE; Skin rash,which may be quite extensive and severe. VERY RARE-Severe drop in white blood cell count and platelet count,with infection and bleeding possible,allergic hepatitis,allergic pneumonia.
 
I hesistated to list side effects on any medication as most are long and the majority will never occur,but I listed it as a help to patients who are on the drug  Millions of patients in Europe are on SSZ without side effects and that applies to NSAIDs,DMARDs,Corticosteriods--be aware if it happens !
 
 

Different Strategies:
 
Corticosteriods are the most powerful anti-inflammatory drugs we have. Were it not for their side effects we would use them much more freely. They are essentil in the treatment of some forms of arthritis,such as systemic lupus erythematosus and polymyalgia rheumatica,where the decision to use them is taken with full knowledge of the risks invoved (patients react more favourable to these medications). They are also widely used,over the short term or in low doses in which the risk of side effects is minimized,to supplement the main treatment in several other conditions.
 
Rheumatoid arthritis is a good example of such a condition. Problems with corticosteriods are of two types-those arising from using doses higher than the amount the body normally makes each day ( about 7.5 mg ),and those arising from the sudden withdrawal of the medication. The likelihood,and severity,of both are directly related to the size of the daily dose and the length of time it is given.
 
When the dose of predisone ( or another similar synthetic corticosteriod ) exceeds 7.5 milligrams a day for more the a few weeks or months,signs of hypercortisonism begin to develop. Cushing's syndrome,a disease state where the adrenal glands produce cortisol in excess and develops hypercortisonism is identical.
 
Fully developed,hypercortisonism may include any or all of the following features : Increased appetite and weight gain,especially on the trunk and face. A chubby face is typical of someone on high-dose,long-term predisone. Easy brusing and skin fragility of the arms and legs,especially in older people. Cataract development. Mood changes. Mild euphoria is common,but depression may occur. Insomnia is frequent. High blood pressure. Extra insulin required by diabetics because of higher blood sugars,and pre-diabetics becoming overtly diabetic. Stomach ulcers,if the patient is taking NSAIDs at the same time. Stunting of growth in children.
 
Osteonecrosis (rare) is a specific type of dead bone,the kind that results when an area of bone loses its blood supply. If this happens near a joint-and the hip is a favorite target-the area of dead bone may collapse-ending up in surgery and a total hip replacement. Cortisone-like drugs have been seen for a long time responsible for osteonecrosis,although this is hard to prove. Fortunately, osteonecrosis from predisone is very rare. Crohn's disease and Lupus patients use corticosteriod more,and it may be responsible. for osteonecrosis. in patient's who develop it. There is no question that the long term use of predisone in SLE increases the risk of hardening of the arteries and,in particular,coronary artery disease. These condition increase the risk of stroke and heart attack,substantially there is some debate as to whether or not predisone has the same effect in RA
 
Osteoprorosis; Bone is a living tissue. Old bone is continually being broken down,in patches. This process is followed almost immediately by the laying down of new bone by bone-forming cells. The new processes of breakdown and repair exceeds repair,bone mass (solidity ) is reduced. Thuis is called osteoporosis.
 
Between 10 and 20 % of all patients with RA,who are on long-term corticosteriods,will experience crush fractures of one or more vertebrae in the backbone. The risk of hip fracture in these patients is 50 %.
 
This risk of fracture can be estimated in any patient,on corticosteriods or not,by measuring bone mineral density (DEXA-dual energy X-ray absorptiometry ). Ordinary x-ray won't do-up to half of bone bass must be lost before they will detect the loss.
 
Bone breakdown continues at a constant rate throughout life. The rate of bone repair,slows down in older people. It also slows in those who are physically inactive,in postmenopausal women with the drop in estrogen production,and in those who get inadequate supplies of calcium and vitamin D. Often,many of these factors are combined.
 
Corticosteriods magnify problems in bone repair. They can cause osteoporosis in anyone,young or old,but the effect is obvious in post-menopausal women (who already exhibit many of the osteoporosis risk factors ). They do this quite quickly,particularily within the first 6 to 12 months of treatment. Corticosteriods affects several elements in bone repair. The amount of calcium available for new bone formation is reduced. They both slow dietary calcium absorption in the intestine and speed its removal from blood by the kidney. They stimulate the bone cells that promote bone breakdown and inhibit the bone cells that promote bone growth.
 
What this means is that every patient who is started on predisone for anything,but a very short period should also be atarted on an anti-osteoporosis program.
 
If the patient is a post-menopausal woman,replacement estrogen should be seriously considered. Raloxifene is an alternative to estrogen,although it doesn't help menopausal symptoms like hot-flashes It does resemble estrogen in its beneficial effects on bone,yet if there is a fear of uterus or breast cancer,it does not affect the lining of the uterus or breast tissue,
 
A regular program of aerobic physical activity should be designed with the assistance of a physiotherapist,keeping the problems imposed by arthritis in mind.
 
A daily intake of at least 1,000 milligrams should be achieved. One cup of milk will provide 300 milligrams,a cup of yogurt about 400 milligrams. Calcium-containing antacid tablets are another inexpensive souce.
 
Aow dose (800 or 900 units ) of vitamin D daily is desirable. Vitamin D is essential to normal bone development. People who are elderly or housebound are very often vitamin D deficient,and have a increased risk of fracture.
 
If it is likely that prednisone will be needed for more than a few weeks,a bisphosphonate can be used to slow bone breakdown. Etidronate,alendronate and pamidronate are bisphosphonates. They have been proved effective in both the prevention and the treatment of osteoporosis. Your physician will decide what is best for you.
 
Problems from the sudden withdrawal of corticosteriods is documented elsewhere on the site.
 
Regrettably,it is not always possible to avoid corticosteriods. Your doctor will use the lowest dose necessary to maintain efficacy with the shortest possible period in mind.
 
I was on low dose predisone for approximately 5 years and have not suffered any lasting, side effects. At the beginning of my disease I was ill informed of cortisone "shots" and sometimes refused cortisone them when I needed them. " I listened to patients who knew absolutely nothing about the real science abou the subject." Believe me,I suffered pain unnecessary especially in my fingers.
 
The rhuematologist knows all about possible side effects and he will not administer  the drug more frequent then necessary and use the lowest dose possible to prevent injury to you. Predisone when used under expert supervision can be a "god-send" at times.

Steriods injected into a joint often stop inflammation almost immediately,and the effect may last for a few months. It is very useful,and welcomed during flare-ups. Normally,20 to 40 mg of methylprednesolone or triamcinolone are injected into a large joint and 10 to 20 mg of drug are injected into a small joint .
 
The intra-articular approach is preferable if only a few joints are inflamed,if oral steriods are not easily tolerated,or if other diseases such as diabetes or glaucoma are present.  Within the first day or two after a steriod injection,some of the steriod moves from the joint into the blood,making you feel,generally,better. The bigger joints like the knee  can be   injected less frequent then the smaller  joints,like fingers.

Can diet actually help with the symptoms of RA? Can diet affect inflammation?
There's a very interesting study that had been in Florida. The researchers asked for patients who thought that certain foods or food groups would make their arthritis better or worse. And they advertised for these patients to come to the clinical research unit at the University of Florida, and essentially what they did is they locked them up in this unit so they couldn't go out for a pizza at night and have foods that were not on their diet.
 
In some patients specific foods or food groups made worse their rheumatoid arthritis, and some food groups actually improved-their RA.  And then they looked, using either freeze-dried capsules of the food or food group or a placebo freeze-dried capsule with none of the food or food group, and they were able to show that in some patients specific foods or food groups actually exacerbated or made worse their rheumatoid arthritis, and some food or food groups actually improved their RA. And this was both on what's called the joint count where the rheumatologist came, examined the joints to look for pain and swelling, as well as looking at immunologic parameters or looking at blood tests for the immune system. Food can make a difference although the individuality of this is very important to consider.
 
The foods were different. There were some cases where dairy or milk-type products made people worse. There were some nightshades that made some people worse. But the problem was that they couldn't take this and say that was true for every patient with rheumatoid arthritis. It was only true for a subset or a small subgroup of patients.
 
What about somebody trying that, for example, eliminating dairy products to try it out for themselves?  As part of a complete treatment program in rheumatoid arthritis, it is worth thinking about. One needs to obviously discuss this with their rheumatologist or physician because this should not be done instead of standard therapy as  mentioned, that this will probably give them symptomatic relief at best but not slow the radiologic or x-ray progression or destructive changes.
 
And then the other thing that's very important, and that is that the other thing that we see in rheumatoid arthritis is thinning of the bones or osteoporosis, so if a person with rheumatoid arthritis decides to eliminate let's say dairy or any calcium-rich foods and not substitute that with calcium tablets, we may have increased osteoporosis, increased fracture as research has showen. Again, one has to take care of the whole patient.
 
What about somebody eliminating certain foods from their diet to see if that makes a difference?  It's very critical to not avoid certain food groups or any particular food group in growing children, so those per se with juvenile rheumatoid arthritis. So, that becomes a critical issue when you perhaps delete certain foods. Or,for example,the nightshade foods, which include things like potatoes and tomatoes,(let's stop at that as they're many others ) and not name the additional nightshade foods.
 
Think what you're potentially eliminating from a child's diet: it's pizza, it's spaghetti, any type of potato product, and that would be a big cornerstone of what their typical intake might be. Therfore,it can be very critical in terms of being well-meaning to eliminate certain foods but really creating a potential nutritional disaster.
 
The other thing is that we don't think that certain foods actually really cause or are the trigger for rheumatoid arthritis. We're talking about the patients who have rheumatoid arthritis already and the foods either making them worse or exacerbating their disease or making them better or ameliorating their disease.
It's most important to note that the avoidance of certain foods that claim to promote or exacerbate disease symptoms are just that. They're claims, and there's not adequate scientific evidence to support these claims. And that's not to say that an individual might benefit from these dietary alterations, but to broaden that scope and apply it to the general arthritis population is really inappropriate.
 
Avoidance of certain foods that claim to promote or exacerbate disease symptoms are just that. They're claims. Mention of those foods that are commonly indicted, so to speak, for causing these disease exacerbations, and dairy products comes high on the list. And just to give some scope as to how few individuals are actually affected by that, there's only one case report in the literature of a patient with juvenile rheumatoid arthritis that had exacerbation of disease symptoms related to ingestion of milk. Again, to date, there are few scientific rigorous studies that have been conducted to authenticate that certain foods cause or prevent arthritis.
 
It's difficult because we are all exposed to many kinds of foods, especially when we eat prepared foods because we don't know exactly what's in them. What I've told my patients is that if you find a specific food or food group that makes you worse, then eliminating that with discussion with your registered dietitian and physician would be appropriate.
 
Allergies and food sensitivities or intolerances sometimes get pulled together and oftentimes an elimination diet is something that can be implemented in order to pare out what might be causing these allergies or food sensitivities. Now, I wanted to go on to explain exactly what that means -- an elimination diet -- and to underscore the fact that it's important to have a trained healthcare professional -- a physician, a dietitian -- to oversee this elimination diet.
 
To begin, an elimination diet typically takes several months to do appropriately. It's conducted by eliminating or pulling out the diet foods that are thought to cause food allergy or intolerance and then over the course of time once you've seen an outcome in terms of if it improves disease symptoms or whatever, then they would reintroduce that and see if the symptoms return. It's done in a very systematic, scientific way in a fairly controlled manner, and it's important if you want to implement this type of an elimination process to pare out what foods might be giving one problems, to do it in a very specific way and not just by happenstance in order to really be able to determine the outcome and be able to interpret those results.

The American diet is notorious for its increased fat composition. Typically, the American diet is as much as 40 to 50 percent of total calories ingested come from fat sources. The important thing to keep in mind is not only to reduce it down to 30 or 35 percent of total calories but to also look at the composition of the types of fat included in that 30 to 35 percent. The goal is to minimize saturated and even polyunsaturated fats and to also replace those polyunsaturated/saturated fats with mono-types of fats, and monounsaturated fat examples are like canola or olive oil, and to also to decrease the amount of cholesterol intake to a maximum of 300 milligrams a day.
 
There have been some studies, and they're actually very well-done clinical trials where they've taken patients with rheumatoid arthritis and they've given them omega-3 fatty acid or placebo pills, and they've been able to show that the patients given the omega-3 fatty acids versus the placebo did much better. They actually used the patients as their own controls because what they did is cross them over, meaning that after a certain number of months the patients on omega-3 fatty acid would stop and then get placebo, unknown to either the physician or rheumatologist or the patient, and the patients getting placebo would get omega-3 fatty acid. Omega-3 fatty acid is a fish oil that's rich in tuna fish and mackerel among other fishes and that seems to benefit patients with arthritis including rheumatoid arthritis.
 
The use of fish oil supplements or these omega-3 fatty acids appears to be most potentially useful in the early stages of disease, and it's unknown if it affects disease progression. Some of the pitfalls in prescribing and utilizing fish oils is that there's no universal standardized dose. In most of the clinical trials the dosage has been approximately three grams per day. And fish oil that's sold as a dietary supplement can be packaged in varying dosages, so you may have to take between 10 and 15 capsules a day.
 
There are side effects that have been reported in the use of fish oil, and most commonly are gastrointestinal symptoms such as diarrhea or nausea or abdominal cramping, but usually not so great as to discontinue supplementation in most instances.
 
Dietary supplements, and one being fish oils but there are many others; they're not federally regulated by the government like drugs, and therefore there's no insurance that the levels of active ingredient are what is stated on the ingredient label and the purity, to be free of contaminants. In the case of fish oils, the fish in and of themselves, especially cold-water fish that are high in omega-3s, can have toxins like mercury or dioxins or CBs in the product, and so contamination is a potential concern.
 
None of these supplements are guaranteed, and in a recent independent product review of 20 different fish oils that are currently available, six were found to be inadequate in their levels of omega-3s. And two of these stated, and I thought this was quite interesting, that on the label it stated that the potency of the product had been tested and verified. And also take into account that there are really no long-term safety and efficacy trials that have been conducted on the use of fish oils.
 
It's partly appropriate to go ahead and include fish regularly in your diet. Two to three times a week would be desirable, but the point being with the possible variation in potency of the different supplements of fish oil, it's hard then to improve symptoms through the fish oil when there is this variance. It's a bit questionable and a bit of a dilemma when we talk about the use of any dietary supplements.
 
The studies that I discussed were for signs and symptoms, again meaning swelling of the joints and pain and how patients felt. There were no long-term x-ray studies to show that this was truly slowing the x-ray damage and destructive changes of rheumatoid arthritis. And the fellows in Washington at the FDA are trying to decide whether some of these over-the-counter preparations need to be better regulated so that when one does buy, say, omega-3 fatty acid and you think you're buying three grams of it, you know you're really getting three grams.
 
Just to give you a backdrop as to what's beneficial about these different types of plant oils, flaxseed being one, others being evening primrose, borage oil, even black currant seed oil may have a different type of essential fatty acid, gamolenic acid. And this is thought to be anti-inflammatory, and the studies are more minimal. There're fewer of these studies than clinical trials using fish oil, and dosaging is a bit more questionable as to what should be recommended as dosage. But there is scientific evidence that these plant oils may be beneficial in terms of an anti-inflammatory response.
 
A research scientist said,it's about five or six cans of tuna fish to get three-grams of omega-3 fatty acid. Tuna's not your best bet. It is mackerel, as mentioned, and salmon. Those are the heavy hitters, and then tuna's a little lower on the list. So, it's like those cereal commercials. You've got to really stack it up and eat quite a bit to get just a minimal recommended dose of three grams. We might gain a bit of weight eating five cans of tuna fish a day.  Unfortunately, especially if it's oil-based, which would be more beneficial omega-3 fatty acid-wise, but not in terms of calorie content.
 
What about vegetarian diets? They're typically lower in fat than the American diet in general. Would vegetarian diets be good for people with RA?
This is subject to personal preference and perhaps a bit controversial, but vegetarian diets are typically low in fat. Because they eliminate animal products, and what is the greatest contributor to the diet of saturated or animal fats? And that's meat protein from animals. And so the reduction of that may help to better balance the reduction of N6 types of saturated fatty acids.
 
The increased intake of plants and vegetables and maybe even fish and those types of things may increase not only the omega-3 fatty acid intake but also the antioxidant intake with increased fruits and vegetables and overall may have a beneficial effect for patients with arthritis. And that is more anecdotal.
 There have been some small trials that have shown improvement, but it's unknown the sustained effect of vegetarian diets. And also to say that vegetarian diets are typically lower in calories because it's a lower amount of fat than the typical American diet, and so that again as we have been saying may be beneficial for patients with rheumatoid arthritis.
 
Many patients with RA read about fad diets, either in written or electronic publications such as magazines or Internet, especially chat sites, and they wonder if these fad diets and nutritional supplements that are recommended will really work to improve their disease.
 
What kind of advice should we give to people with arthritis, especially rheumatoid arthritis, regarding these kinds of diets they read in magazines and on the Internet and the supplement information?  If it sounds too good to be true, it's probably not true. 
 
How to go about interpreting nutrition information from all the wide variety of sources that you've mentioned. Lets-just go through what are some of the hallmarks of nutritional fads or quackery, and the first one being if it sounds too good to be true, it's probably not true.
 
The second is that oftentimes this information infers a distrust of current methods of medical practice or it also infers suspicion of the regular food supply, and therefore you need alternatives, and then they list different types of food products.
 
A third one is to take into account that many of the stories or anecdotes that are given are testimonials, and they don't have scientific evidence backing them. And also it's easy to get fake credentialing, to say that you're a nutritionist and hang your shingle in mail-order catalogs, so you can be fooled in terms of fake credentialing as to who may have the authority to lend sound nutritional information.
 
And the other item is that sometimes in these chat rooms or in the lay literature, they refer to studies that are unpublished, and they refer to these results, and they're cited, but they can't be critically examined because they haven't be published. So, that makes for difficulties in terms of being able to tell, and these are all items that should make you suspicious of nutritional information.
 
How do you go about identifying valid nutrition information; results obtained by conducting properly-designed scientific experiments are those that are typically valid. Again,to recognize anecdotal or testimonial evidence. We also realize and recognize that scientists who conduct animal research but don't apply their findings to humans should be a bit suspect in terms of valid results. And those that limit the sample of research participants to very few, which we've mentioned in many of these different types of dietary-related trials, it makes it very difficult to generalize those results to the entire population of patients with arthritis.
 
Most people don't want arthritis. They specifically don't want rheumatoid arthritis, and they would love to find the food or the easy-to-fix cause that would make them all better. People often go to their physicians (some physicians will ignore thsis)with either a printout from the Internet or something in a magazine.
 
And what patients need of the medical community as physicians and rheumatologists to then say, "Let's look at the data or the information behind this and see if it's in what's called a peer-review journal," meaning that some people who really know the field,a nutritionist, would have looked at this information and said, Yes, this is really worth publishing and looking at. Unfortunateliy,doctors get little training at medical school in nutrition,but they are our next best friend.
 

Most rheumatologist emphasizes good general health,that includes watching what you eat.exercise and mental health and outlook. He never says rheumatoid arthritis can't be cured. He tries to give us hope and encouragement. Yes! we have pain,fatigue but he wants us to have hope and vision. Another thing is emotion,If you're depressed you're going to have more fatigue and etc.
 
People with chronic ailments-they need to get involved.do something they have interest in and joy in doing it. Not something you don't enjoy doing but am doing it because someone said to do it. And,don't isolate yourself. Research shows that the more you isolate yourself,the more tired you will become and more pain. One has to participate in their own pleasures
 
Having supportive people around you that can share to help you cope. That slso means to have a rapport with your physician,a relationship that enables you to go to your physician and share your heart and get the "real" answers. there are many other techniques,mind-body development,thought-feel therapy in conjunction with conventional medicine.
 
Everyone says joint a support group,but we are individuals each with different thoughts,moods and preference. I found joining support group was not the answer in my case,because at the beginning I wasn't getting the true picture of my disease by comparing and listening to patient "suggestions",I found it counter-productive in my case. Instead I visited elderly relatives and found they had physical problems and I enjoyed trying to help them even though I had limited abilities.
 
I enjoy cooking as a hobby and the joy I seen on some elderly relatives when I cooked them their favorite dishes was reward in itself. Funny,when I was in  support groups and heard pity patient complaints magnified,it made me angry my muscles tensed and I could feel it in my stomach. With my elderly friends we joke about "aches and pains " and I never took what they said seriously,we joked and laughed about "arthritis". I could just feel the "happy' juices flowing,but again not everyone is made the same.
 
The most important thing is to get the disease under control (easier said then done ) before you can fool around with this herb, that food,supplement  or whatever, because there's a time limit,perhaps,4 months-that we need to curtail or prevent,permanent damage,which usually occurs most in the early stages which is not reversible.but there is no such thing as "too-late". It is never too late for DMARD therapy.
 
Worried about side effects? You should know the side effects when they occur and what to do,but if you read about most medications and side effects,closely,you may not take any medication again.
 
Some patients will have deformed joints regardless of what medication they took,but do you want to gamble your choices,when there is a sensible,scientifically proven, path to follow  (DMARDs)?
 
We need to control that "run-away" inflammation !! The earlier the better.

If you have arthritis you'll almost inevitably require some kind of medication. That could mean daily and for the rest of your life. To minimize your risks and mazimize your benefits,you're going to have to become an enlightened consumer and learn to work as part of a team with your doctor and your pharmacist.
 
Consider this scenerio: You haven't been feeling well for some time,persistent joint pain,flu-like malaise and morning stiffness. You visit your family physician who does a physical exam and orders some lab tests. At a follow-up appointment,your doctor says that you might have RA and an appointment is being set up with a rheumatologist. In the meantime,he says,have the pharmacist fill out this prescription and follow the instructions on the label. You're so stunned by the diagnosis you barely absorb anything the doctor said.
 
You follow instructions blindly,not knowing what to expect and several months later,just as you're beginning to feel a little better,you're totally unprepared when your RA flares up again. Or you throw your pills away and gradually get worse. Or you take the pills when you feel bad and stop when you feel better . Sure,your doctor's confused. Although you're not getting better and he starts adjusting your drug regiman,once again !
 
Here's an alternative: you seize the initiative. You learn everything you can about your condition,become an arthritis self-manager,someone who knows about "risk-to-benefit ratios","optimum blood serum levels" and "indications and contraindications". Now,you know what the medication's supposed to do,when,and why, You know what to do if it doesn't and what side effects to look for,which are serious and which can be easily delt with,either by you or or by a phone call to your doctor or pharmacist.. You will know when drug is working and when it is not,the approximate time to expect before you expect any change in symtoms.
 
You're not buffered by every change in your condition. You're less anxious and far less fearful. You're in control Now,you've made yourself a key player on your health-care team
 
The first thing to understand is that there's no "magic bullet". Currently available medications treat the symptoms and some of the underlying disease mechanisms. There is no "cure" at present. The physician will try to identify which medications respond to you individully and hopefully responds best,and what is the lowest daily dose that will achieve maximum benefit with a minimum risk of side effects.
 
The doctor may have to change your prescription from time to time,perhaps he may have to change it many times,over the course of years. Theirs a certain amount of experimentation that goes on,as the arthritis responds,or doesn't,to one medication or another. That's normal. Not every medication works the same way for everyone.
 
If you're allergic to a specific medication or you're taking medication for another long-term health problem such as heart,dibetes,liver and kidney conditions,make sure your doctor knows. Arthritis medications can interact with medications for other conditions in a number of adverse ways.
 
If you're pregnant,trying to become pregnant,or breastfeeding,inform your doctor,since certain medications can be passed through the placenta or mother's milk.
 
Age is a key factor in medication useage. Generally,if you're over 65,your metabolic rate will be slowing down. Because of natural declines in liver and kidney function,your body won't process and eliminate medication as quickly or efficiently as it once did:not only will you require lower doses ( usually ) of any medication,but any drug you take will have a longer "half-life" in the body,which means the doctor should monitor the effects more closely. Also,seniors are more vulnerable to stomach and digestive tract upset,because of natural thinning of the lining that protects the stomach wall. Many arthritis medications are acidic in nature,so this is an important consideration.
 
For explanation purposes,it's easier to divide arthritis into two categories: inflammatory arthritis ( RA,PsA,lupus,any arthritis with persistent joint inflammation,including short-term problems,such as bursitis and tendenoitis etc. ) and non-inflammatory,or degenerative arthritis,such as osteoarthritis (OA). It's not a clean division,however,because cartilage erosion in OA sometimes causes loose oarticles and debris to irritate the synovial membrane in a joint,causing inflammation,in which case anti-inflmmatory medications may be appropiate. One thing just about every arthritis have in common is pain