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
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
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
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.
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.
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
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
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
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
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