Researchers Link Selenium Levels, Knee Arthritis

CHAPEL HILL, N.C. -- University of North Carolina researchers have found a link between a mineral found in the soil and osteoarthritis.Nearly 1,000 people in Johnston County are part of a study tracking arthritic knees and analyzing the levels of selenium in their bodies.Selenium is a trace mineral that's essential to good health. People get it through foods like beef, tuna and oatmeal -- over-the-counter supplements also are available -- but the amount absorbed into the body depends on the soil the food is grown in, and people who grow their own foods are often found to be selenium-deficient."We definitely have shown in this sample having low amounts of selenium does seem to be associated with being more likely to have osteoarthritis and being more likely to have more severe condition in both knees rather than one," said Dr. Joanne Jordan, a UNC rheumatologist who is leading the study.Judy Rose, of Princeton, is participating in the study and has answered lots of questions about her diet and has had blood drawn, X-rays taken and toenails clipped for analysis."If they can help other people -- younger generations -- to cope with arthritis and then possibly cure it, that would be wonderful," Rose said.Osteoarthritis is the most common form of arthritis -- it affects about 1 million North Carolinians -- and Jordan hopes the study will lead to a way to prevent or limit the pain from the disease."The next step is to look at some other joints to see if this (relationship between selenium and arthritis) bears out as well," she said. "Wouldn't this be a wonderful thing if we could test to see if a selenium supplementation would prevent arthritis or stop it from getting worse?"

Wrist splint can help rheumatoid arthritis patients

NEW YORK - Using a wrist splint can improve performance of some daily activities in patients with rheumatoid arthritis, according to Canadian researchers, but for some tasks splints can be a hindrance.

In a study published in The Journal of Rheumatology, the researchers examined the influence of wearing a wrist splint on performance of daily activities in 30 rheumatoid arthritis patients with wrist involvement. The subjects were an average of 57 years old and had rheumatoid arthritis for about 9 years.

Dr. Ada Pagnotta, of Jewish Rehabilitation Hospital, Quebec, and colleagues assessed pain, work performance, endurance and perceived task difficulty with the splint on and off.

Using a work simulator, the subjects performed 14 tasks -- 10 that assessed work performance and four that assessed endurance. The subjects rated pain, task difficulty and perceived splint benefit.

Pain was significantly lower in five tasks with the splint on, including three work performance tasks and two endurance tasks. There was no significant difference in work performance with the splint on versus off.

Endurance scores were always better with the splint on, according to the researchers. However, the differences were statistically significant on only one task - "pulling an electric cord."

On a 10-point scale, the average perceived splint benefit on the endurance and work performance tasks ranged from 3 to 5. The task with the highest perceived splint benefit was "chopping with a knife."

Overall, "17 percent reported less pain when using the splint, while 79 percent reported no difference," the team reports.

"When exploring the effects of the splint on work performance, 24 percent of participants had better work performance with the splint on, 62 percent had no difference in work performance, and 14 percent were worse," they note. "Forty-eight percent had improved endurance with the splint on and 20 percent had poorer endurance."

Pagnotta and colleagues conclude that "wrist splint prescription is not a simple process; clinicians and clients need to work together to determine the daily wear pattern that maximizes benefit and minimizes inconvenience."

New unit to help arthritis patients

ARTHRITIS patients in Glasgow will be able to get treatment without being admitted to hospital with the opening of a new day unit. MSP Wendy Alexander officially opened the Rheumatology Day Unit at the Southern General Hospital yesterday. More than half of the patients treated at the centre are expected to be under 50 with treatment designed to cause minimum interference in their daily lives. Ms Alexander, who is expecting twins in February, said the unit would make a huge difference to people's lives. She said: "The new Rheumatology Day Unit will make a real difference in the lives of hundreds of people. "Hundreds of sufferers will now be able to have the best of treatment without having to stay in hospital. That in turn means they can hold down jobs and bring up families. "It's been a real team effort to make this vision a reality and I think it's a fantastic example of what can happen when people pull together." Despite the perception that arthritis is an older people's disease, many sufferers are actually younger people and the average age for onset is about 40. Around £15,000 of the cash for the project was raised by the public and one former patient Kathleen Donaldson left several thousand pounds in her will to the unit. Mrs Donaldson's nephew, Robert Bruce, attended the opening ceremony. He said: "I can't tell you how glad we are that the new unit is coming to fruition today, and how proud we are that my aunt, who suffered greatly from arthritis could make such a difference. "As a family, we know the quality of care at the Southern General is excellent, and we hope very much that the new unit will help make it even better."

Enbrel, Humira to dominate TNF-alpha market

By Steve Mitchell

---

An analyst firm predicts that Amgen/Wyeth/Takeda's Enbrel and Abbott Laboratories/Eisai's Humira will dominate the market of tumor necrosis alpha inhibitors for the next ten years.

"Enbrel and Humira are going to continue to grow," Cynthia Mundy, an analyst with Decision Resources in Waltham, Mass., and author of a new report, told United Press International.

TNF-alpha inhibitors are used to treat a variety of auto-immune diseases, including psoriasis, Crohn's disease, and rheumatoid arthritis. Decision Resources estimates the market for TNF-alpha inhibitors in the United States, Western Europe and Japan will grow from $7.1 billion this year to almost $12 billion in 2014.

Mundy's reasoning for the predicted success of Enbrel and Humira is that both drugs will continue to get approvals for and be increasingly used for new indications. In addition, they have the advantage over other drugs in this market of being self-administered agents that provide ease of use.

"Basically, these are drugs that are really treating indications that are underserved ... and they're fairly convenient," Mundy said.

Another agent, Remicade, which is marketed in the United States by Centocor and elsewhere by Schering-Plough, will do well over the next decade but "its going to be little bit flatter" than Enbrel and Humira, Mundy said. One reason for this is that Remicade has to be administered by a physician, making it less convenient, she said.

Other drugs that could make a showing in this field include UCB's certolizumab pegol, which is in late phase clinical development but is expected to launch for Crohn's disease and rheumatoid arthritis in late 2006 or 2007, and Centocor/Schering-Plough's golimumab, which is in phase 2 trials.

However, these drugs are likely to run into the same problems that other new entries will face in this field, Mundy said. They will need to offer characteristics that distinguish them from the approved agents used to treat these diseases and they lack the long-term efficacy and safety data of Enbrel and Humira.

The long-term data is "a big issue for all the specialists that treat these chronic disease, because these drugs are used for long-term chronic administration," Mundy said.

Looking several years ahead, Mundy thinks novel cytokine inhibiting agents, such as interleukin-12 inhibitors, could also have an impact on this market. Drugs in this class are "on the horizon as the next wave of biologics for this set of immune disorders," she said.

Mundy added that it's too early to know if these agents will offer sufficient efficacy to allow them to compete head-to-head with the TNF-alpha inhibitors, but she noted that all the companies with TNF-alpha inhibitors also have other cytokine inhibitors in development.

"They're definitely agents to watch," she said.

Matthew Murray, senior biotechnology analyst with Rodman and Renshaw in New York City, agreed that Enbrel and Humira will dominate the field for the foreseeable future.

"Enbrel's primary competition going forward will be from Abbot's Humira, not Johnson and Johnson's Remicade," Murray told UPI.

One issue that previously hindered Enbrel was manufacturing limitations, but Amgen has now resolved that and expanded its production capacity, Murray said. This should enable Enbrel to capture more of the market, but the drug will have to overcome the fact that it requires more frequent dosing than Humira, he noted.

"Now that Amgen has addressed the manufacturing issues that limited Enbrel's market share competitiveness against Remicade in the past, I think its challenge going forward will be to use the larger amount of clinical data available for Enbrel to counter-balance Humira's advantage on dosing frequency," he said.

Juvenile idiopathic arthritis

Joint in pain

Juvenile idiopathic arthritis (JIA) is a persistent or recurring inflammation of the joints similar to rheumatoid arthritis, but in occurs in children, usually those below the age of 16. Though uncommon, it can be a crippling condition.

HIS fingers are crooked and gnarled, awkwardly bent at the joints. These hands are unable to hold a pencil or a spoon, or do up the buttons of a shirt.

These are not the hands of an elderly man. They belong to a seven year-old boy with juvenile idiopathic arthritis. But this seven year-old cannot copy notes in class, grip a badminton racket or tie his shoelaces.

Inflamed joints

Juvenile idiopathic arthritis (JIA) is persistent or recurring inflammation of the joints similar to rheumatoid arthritis in adults, but beginning before the age of 16,� says consultant rheumatologist Dr Chow Sook Khuan.

Children as young as six months can develop JIA, an uncommon disease that is believed to affect one in every thousand children around the world.

Doctors are still at a loss to explain what causes JIA, which is why the term idiopathic exists in the name (meaning the cause is unknown). However, we do know that it is not caused by an infection, eating the wrong types of food, events during pregnancy, injury or the weather.

JIA can affect children in different ways, for example the number of joints involved, and the symptoms can vary. This has given rise to three main classifications of JIA: pauciarticular JIA, polyarthritis and systemic disease (see table).

Western data shows that pauciarticular JIA is more common, forming up to 40-50% of all JIA cases. About 30% have polyarthritis and 10-15% have systemic disease,� says Dr Chow, although in practice, she sees more patients with the more severe forms of the disease.

Most children with JIA feel well, are fully active and have normal growth, although some may feel run down during flare-ups. More severe forms of the disease may cause problems with activities like walking, getting dressed, bathing and eating.

Juvenile idiopathic arthritis should be treated as early as possible to prevent joint deformities as seen in this picture.

Getting the diagnosis right

Diagnosis of JIA is a tricky thing, as there is no foolproof test and the symptoms are wide-ranging, fluctuating and vague.

Curiously, joint pain or swelling is not always the most obvious symptom, particularly in infants and very young children.

Fever, fever, fever! Dr Chow exclaims. Unexplained fever in a child and failure to grow, she says, are the main features that should alert parents and doctors.

Fever and rashes, often seen in systemic JIA, is a response from the immune system to the disease. Parents may also notice that their child stops growing or starts losing weight, although these features are not immediately obvious and will only be apparent after a few months.

The parents' or caregivers' observations of the child are crucial. An infant does not know how to explain (the symptoms), Dr Chow cautions, so parents need to keep their eyes peeled for unexplained behaviour, such as if the infant stops using a particular joint.

A baby may refuse to reach for the milk bottle, or a toddler may suddenly not want to get out of bed or walk, she describes.

Sometimes, blood tests are carried out to test for rheumatoid factor and antinuclear antibodies, which are present in some people with rheumatoid arthritis and related diseases. However, up to 80% of children with JIA do not have rheumatoid factor or antinuclear antibodies in their blood, while children with other conditions may have it.

What's the cure?

There is no cure for JIA, but there are ways to control the disease so that the symptoms will not limit the child's daily activities, or cause joint deformity and damage. This can only be achieved if proper treatment comes in as early as possible.

Dr Chow Sook Khuan...'Unexplained fever in a child and failure to grow should alert parents and doctors to the possibility of JIA.'

Polyarthritis and systemic disease have to be treated early and aggressively, Dr Chow stresses.

If you don't treat them early with special drugs like DMARDs (disease-modifying anti-rheumatic drugs), they will develop irreversible deformities and will need joint replacements. They may even develop life-threatening complications.�

DMARDs like methotrexate and sulphasalazine are very effective in controlling the progression of the disease. However, these drugs take several months to show any benefits.

Parents and doctors are worried about using DMARDs, as they are chemotherapy drugs, says Dr Chow. But if you delay using these drugs, joint deformities will set in.

Dr Chow assures parents that there is a lot of evidence to back the use of DMARDs in children with arthritis.

Other medications also have a role in controlling the symptoms of pain, stiffness and swelling. These include non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids.

Steroids are fast acting medications that are prescribed in low doses for a short period to control the inflammation. However, the child will not grow if you use too much steroids and do not know when to stop, cautions Dr Chow.

The good news is, most children will not grow up to have active adult arthritis. About two-thirds of children will outgrow JIA when they reach adulthood, says Dr Tang Swee Ping, consultant paediatrician and paediatric rheumatologist.

JIA usually follows a pattern where the disease flares up, then goes into remission, then flares up again. Some children are lucky, they may have only one or two flares. But some may have many flares, says Dr Tang.

On the other hand, there may also be children who just have chronic, low-grade activity for a prolonged period of time.

The ultimate aim of treatment is for JIA to go into remission, so that the child will be able to do everything that normal children can do, she says. But in reality, this can be a frustrating journey.

As is usually the case, up to four or five different types of medications and supplements are prescribed for an indeterminate period of time. The lack of an endpoint makes it difficult for children to weather it out.

A lot of patients have no problems taking the medication initially, but when they get older, they start refusing,� Dr Tang shares her experience.

She has a suggestion for parents: We compromise. We tell them, 'If you don't want to take all five medications, you take at least three. So you decide whether you want to take three or four today.'

This tactic makes the children feel like they have some sort of control, and compliance then becomes better.

Parents also need to realise that the treatment of JIA is a slow process, especially with the use of DMARDs that take several months to show any benefit.

A lot of parents end up frustrated, especially those whose children have difficulty controlling the disease. They will ask why the child is not getting any better, even though they keep bringing the child for treatment.

However, Dr Tang assures that although there is no cure, there is always hope that we can control the disease.

Note: Juvenile idiopathic arthritis is a relatively new term. Older terms used to describe this disease were juvenile chronic arthritis or juvenile rheumatoid arthritis.

Natural combo helps in severe arthritis

As painkilling arthritis drugs prove increasingly unsafe, the largest study ever done of popular, natural alternatives - glucosamine and chondroitin - shows they can significantly reduce moderate to severe joint pain.

Used widely in recent years to battle osteoarthritis - the "wear and tear" form of arthritis afflicting more than 20 million Americans - the glucosamine-chondroitin combination of over-the-counter nutritional supplements is coming under heavy scientific scrutiny.

However, this latest study - involving patients at the University of Arizona - is proving highly controversial, with some evidence suggesting the supplements actually did no better than inactive placebos for arthritis sufferers.

"The primary outcome of the study was negative - it was not a ringing endorsement of glucosamine and chondroitin," said Dr. Jeffrey Lisse, interim director of the Arizona Arthritis Center, where some 30 patients were enrolled in the nationwide study.

"But when you look only at those patients with the worst pain, in the moderate to severe range, then glucosamine and chondroitin did better than placebo, or even Celebrex. So it's a confusing trial, depending on how you spin it."

But because glucosamine and chondroitin - dietary supplements containing natural substances found in the cells of joint cartilage - are known to be safe, with very few side effects, Lisse will continue to advise his arthritis patients to give them a try.

"It takes awhile, two to three months, for them to work, and the response is varied," he said. "But you can take them without the fear now linked to many arthritis drugs, and you may get a good response."

Glucosamine-chondroitin therapy burst on the medical scene in the late 1990s, when a Tucson-based sports medicine physician, Dr. Jason Theodosakis, wrote the best seller "The Arthritis Cure." In it, he argued that these easily obtained supplements were far more effective, and safe, than prescription painkillers for osteoarthritis.

Taken together, they not only ease pain, but actually repair damaged, thinning cartilage that causes the pain, according to Theodosakis.

At first, most physicians derided these claims as unproven "snake oil." But as a series of scientific studies began to demonstrate effectiveness, doctors gradually joined the glucosamine-chondroitin bandwagon, with many - including specialists at the Arizona Arthritis Center - now routinely recommending them.

The supplements have become increasingly popular as prescription painkillers known as nonsteroidal anti-inflammatory drugs (NSAIDs) - most notably Vioxx - were yanked off the market, blamed for causing heart attacks, strokes and death in regular users.

Those left on the market - mainly prescription Celebrex, also over-the-counter pain relievers such as Advil and Motrin - must all now carry "black box" warnings of dangerous side effects.

That is why the results of the largest study ever done of glucosamine and chondroitin - the nationwide Glucosamine/ Chondroitin Arthritis Intervention Trial - have been so eagerly awaited by patients and physicians wanting to know what really works on this painful disease that affects so many.

Launched two years ago, the trial tested the effects of the two supplements alone and in combination, comparing them to Celebrex and inactive placebo, when used for six months in nearly 1,600 patients suffering arthritis of the knee with various levels of pain.

Funded by the National Institutes of Health, the $16 million study was conducted at 16 U.S. medical centers, including the UA, where some 30 arthritis patients were tested.

Across the whole spectrum of arthritis patients, glucosamine and chondroitin, either alone or together, did no better at relieving pain than placebo pills, while Celebrex did show a response.

But in what some say is the study's key finding, those results changed dramatically among patients with greater pain. In that smaller group - about 20 percent of patients - nearly 80 percent of those taking the glucosamine/chondroitin combination experienced significant pain relief, compared with 69 percent who took Celebrex, and 54 percent taking placebo.

"Given the fact that the combination of supplements blew away Celebrex in those people who actually needed intervention (the high-pain group), it's clear that it may become malpractice to use anti-inflammatory drugs as first-line therapy, unless the patient has failed six months of (glucosamine-chondroitin) therapy," said Theodosakis in a statement on the trial results.

Considerably more cautious, the American College of Rheumatology - where the results were announced this month - said only that the supplements "may be an effective combination in reducing pain associated with osteoarthritis of the knee," in a statement.

The group pointed out that the glucosamine and chondroitin used in the NIH study was specially formulated, and is not the same as what is available to consumers in drugstores.

Also, the study findings are considered preliminary at this point, because they have not yet been reviewed and published in a medical journal, said the NIH, refusing to comment on the results until they are.

Treating Hindfoot Arthritis

Rheumatoid Arthritis Rheumatoid arthritis is a type of arthritis in which the lining of a joint (synovium) becomes inflammed, causing warmth, tenderness, swelling and pain. The inflammation eventually damages the cartilage and bone in the joint. The condition is an autoimmune type disease, caused when the body's immune system inappropriately attacks its own tissue.According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases, rheumatoid arthritis affects about 2.1 million Americans. It can develop at any age, but is most commonly diagnosed in people of middle age and older. Women are affected two to three times more often than men.Arthritis of the Foot The foot is made of 28 bones and 30 joints. Ligaments support the joints and muscles, and tendons help it move.Patients with rheumatoid arthritis of the foot may experience foot pain, swelling and stiffness. Sometimes the foot feels warm. Patients may have a hard time fitting into their shoes or walking. Some people may develop corns, bunions or foot deformities.About 90 percent of patients with rheumatoid arthritis eventually develop symptoms in their feet. Usually arthritis starts in the joints of the toes and the forefeet. Over time, the symptoms spread to the hindfeet and finally the ankles.Treating Hindfoot Arthritis The hindfoot consists of three joints: (1) the talocalcaneal (subtalar) joint, where the bottom of the talus (ankle bone) connects with the calcaneus (heel bone), (2) the talonavicular joint, where the talus meets the inner midfoot bone (the naviculus), and (3) the calcaneocuboid joint, where the heel bone connects to the outer midfoot bone (the cuboid).Initially, doctors may try to treat the arthritis symptoms with pain medications, braces or canes and physical therapy. When conservative treatments don't help, or when the patient has severe deformity, surgery may be recommended.One type of surgery for severe rheumatoid arthritis of the hindfoot is called triple arthrodesis. Arthrodesis is a fusion surgery, where the bones of the joint are permanently welded together. Ideally, the procedure eliminates pain and provides stability for the affected joints. In triple arthrodesis, the three joints of the hindfoot are fused.Traditionally, triple arthrodesis is performed through two incisions, one on each side of the foot. Surgeons at Mercy Medical Center are now using a single incision approach to minimize trauma to the foot (there is only one incision to heal). Once the incision is made, the surface of the bones are cleaned and any remaining cartilage is removed. The bones are properly positioned and then held in place with screws. The procedure realigns the heel with the body and improves the patient's step. Since foot deformity can also cause hip and knee pain, the surgery may also improve those symptoms as well.The single incision triple arthrodesis is a technically difficult procedure and carries a higher risk of injury to nerves and blood vessels. So patients who are considering the surgery should make sure their physician has training and experience with the technique. Doctors say the procedure is ideal for patients with hindfoot arthritis who need surgery, but have problems with wound healing. For those patients, the single incision enables the body to concentrate its resources on healing just one incision. Besides rheumatoid arthritis, triple arthodesis may also be beneficial for those who have traumatic arthritis in the hindfoot (arthritis that has developed from an old injury).For general information arthritis or foot problems: American Academy of Orthopaedic Surgeons, public website, http://orthoinfo.aaos.org Arthritis Foundation, http://www.arthritis.org, or contact your local chapter National Institute of Arthritis and Musculoskeletal and Skin Diseases, http://www.niams.nih.gov

The FDA Kills

by Bill Sardi
by Bill Sardi

More than twenty years after four controlled studies showed that glucosamine and chondroitin supplements allay the symptoms of wear-and-tear (osteo) arthritis, the National Institutes of Health finally backs two studies to confirm what was known two decades ago. [November 2005 American College of Rheumatology meeting]

It’s not just that millions of arthritics endured pain while modern medicine drug its feet over acceptance of these dietary supplements, it’s that the delay actually cost many thousands of people their lives. Oh, arthritis is not life threatening, but the pain relieving drugs arthritics take are. Had modern medicine embraced these safe and natural remedies two decades ago, relatively unsafe drugs like Vioxx, Bextra, and Celebrex, as well as aspirin and ibuprofen, would have never been used so widely.

Dr David Graham, an official at the U.S. Food and Drug Administration, independently reported that the use of painkillers known as Cox-2 inhibitors since 1999 resulted in between 89,000 and 139,000 premature deaths from heart attacks or strokes. [Lancet 365(9458):475–81, 2005] Both the COX-2 inhibitor drugs (Vioxx, Celebrex, Bextra) and ibuprofen increase the risk for a mortal heart attack. [British Medical Journal 330:1366, 2005] The heart attacks and strokes emanate from an increased risk for blood clots caused by the COX-2 drugs. [Annals Rheumatic Diseases June 7, 2005]

“Whistleblower” Dr. Graham had to travel outside the country to disclose the mortal risks associated with these drugs. His superiors at the Food & Drug Administration were covering up the problem. What goes unreported is that since the 1980s the FDA was also abrogating its duty to educate the public that safer and more appropriate remedies for osteoarthritis are available – namely glucosamine and chondroitin.

The FDA did more than just approve problematic pain relievers, it promoted them over glucosamine and chondroitin. The May-June 2000 issue of FDA Consumer Magazine, reported on arthritis remedies and under the sub-headline “unproven remedies” said the following:

“Two controversial nutritional supplements, not approved by the FDA, have catapulted into the spotlight because of claims that they rebuild joint tissues damaged by osteoarthritis – or halt the disease entirely. But at this time, the use of glucosamine and chondroitin sulfate supplements warrant further in-depth studies on their safety and effectiveness, according to the Arthritis Foundation. … The Arthritis Foundation says there's no evidence that swallowed chondroitin is absorbed into the body and deposited into the joints. (Author’s note: this is untrue) The Arthritis Foundation urges anyone considering using these supplements to become fully educated about potential positive and negative effects. In addition, people are encouraged to consult their physicians about how the supplements fit within their existing treatment regimens. Above all, do not stop proven treatments and disease-management techniques in favor of the supplements.”

The newly published studies involved 1800 patients, the earlier studies nearly 1300 patients. [Pharmatherapeutica 3: 157–68, 1982, 2: 504–08, 1981; Current Medical Research Opinion 8: 145–49, 1982; 7: 110–14, 1980] How could the FDA say glucosamine and chondroitin were unproven?

Not only were there four more recent studies that confirmed glucosamine and chondroitin were safe and effective [Osteoarthritis Cartilage 6: A39–46, 1998; 6: A25–30, 1998; 12: 269–76, 2004; Journal American Medical Assn 283: 1469–75, 2000], the FDA knew that use of pain relieving drugs like aspirin, ibuprofen and acetaminophen result in thousands of avoidable hospitalizations, liver transplants and death. In 1997 there were 107,000 hospitalizations and 16,500 deaths from drugs like ibuprofen and aspirin. [Current Topics Medicinal Chemistry 5: 517–25, 2005] Add these morbidity and mortality figures to the problems caused by the COX-2 inhibitors like Vioxx to fully realize the misdirection by the FDA.

Improve your arthritis with exercise

Kenneth Gardner

PHYSICAL EXERCISE is recommended for individuals who have arthritis to help preserve muscle strength and joint mobility. Exercise will also improve their functional capabilities, relieve pain and stiffness. Exercising prevents further deformities, improve their overall physical conditioning and re-establish neuromuscular co-ordination, and mobilise stiff or contracted joints.

Exercise prescription needs to be developed on the basis of the functional status of the individual. Based on the stage of the problem, some persons can perform most activities that the typical healthy individual can. Weight-bearing activities such as cycling, warm water exercises and walking can be managed comfortably by others.

Exercise should be avoided during an acute arthritic flare. Arthritic individuals often report fatigue and some discomfort as common complaints following exercise. Exercise programmes need to balance the levels of immobilisation of affected joints and exercise to reduce the severity of the inflammatory joint disease.

Research has confirmed that many persons with arthritis can safely participate in appropriate regular exercise programmes and achieve better aerobic fitness. Low-impact exercises such as swimming and water aerobics can be well tolerated by persons with arthritis. Improved strength, endurance, flexibility, and better ability to walk or perform daily tasks are all benefits of exercise. A comprehensive exercise programme for persons with arthritis include flexibility, strengthening and aerobic activities. The content and progression of the programme depend on individual needs and capabilities.

Persons with long-standing or severe arthritis, or multiple joint ailments, should undertake exercise in collaboration with trained personnel. A successful exercise programme can be worked out with the support of a rheumatologist who is experienced with both arthritis and exercise.

Risk of Skin Cancer Increased in Rheumatoid Arthritis Patients

By Will Boggs, MD

NEW YORK NOV 21, 2005 (Reuters Health) - The risk of non-melanoma skin cancer is increased in rheumatoid arthritis patients, especially those that use prednisone and tumor necrosis factor (TNF) inhibitors, according to a report in the November issue of The Journal of Rheumatology.

"We hope that studies like these will not only help physicians and patients to be aware of possible risks so that they may institute appropriate surveillance measures, but will also begin to help us understand the biologic effects of systemic cytokine inhibition," Dr. Eliza F. Chakravarty from Stanford University School of Medicine, Palo Alto, California told Reuters Health.

Dr. Chakravarty and colleagues investigated the incidence of non-melanoma skin cancer (NMSC) in rheumatoid arthritis patients compared with osteoarthritis patients and sought to evaluate the role of several immunosuppressive medications in the development of NMSC.

After adjustment for known risk factors for the development of NMSC, patients with rheumatoid arthritis had a 19% higher risk of NMSC than did patients with osteoarthritis, the authors report.

In a multivariate model, the diagnosis of rheumatoid arthritis, increasing age, male gender, Caucasian ancestry, being married, and a history of NMSC were associated with an increased risk of NMSC.

Among patients with rheumatoid arthritis, the use of prednisone was associated with a 28% increased risk of NMSC, the researchers note, and the use of any TNF inhibitor was associated with a 24% increased risk (the latter did not reach statistical significance).

Rheumatoid arthritis patients using both methotrexate and any TNF inhibitor had a twofold risk of developing NMSC, the report indicates.

"To our knowledge, this is the first large cohort study of the associations between NMSC, rheumatoid arthritis, and immunosuppressive medications," the investigators write. "The increased hazard for the development of NMSC in patients with rheumatoid arthritis is in concert with that found in other studies of European populations."

"Currently, there are no clear recommendations for routine skin cancer screening in the general population," Dr. Chakravarty said. "If it is confirmed that rheumatoid arthritis itself and/or immunosuppressant medications do confer an increased risk, it may be prudent to recommend annual screening in these high-risk groups."

"The important thing will be to educate patients about this possible increased risk so that they are empowered to perform self-skin examinations, as well as being more attentive to protecting their skin from sun damage including regular use of sun screen and protective clothing," Dr. Chakravarty added.

Rheumatic disease increases risks in pregnancy

Women with rheumatic disease experience greater pregnancy risks and longer hospital stays than the average pregnant woman.

The findings from the Stanford University School of Medicine provide women who have these conditions with a better understanding of the risks they face if they become pregnant and underscores the need for physicians to monitor closely their care.

Tina Chambers, at the University of California-San Diego, who was not involved in this study, said the findings fill a troubling gap in what is known about pregnant women who suffer from these autoimmune conditions. " Intuitively, you would think that it would be easy to access [such] data," she said, "but there is little to nothing in the literature about rheumatoid arthritis or lupus in pregnant women.".

In this study, Eliza Chakravarty aimed to see how the pregnancy outcomes for these women would compare with the outcomes for healthy women and women with diabetes. "Nobody knew these numbers," she said.

In autoimmune diseases such as lupus or rheumatoid arthritis, the immune system turns against parts of the body it is designed to protect, leading to inflammation and damage to joints.
More than 2 million Americans have rheumatoid arthritis, while another 500,000 suffer from lupus. According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases, rheumatoid arthritis and lupus affect far more women than men, leading researchers to believe that hormonal factors may prompt their onset.

Chakravarty was able to determine the incidence of lupus and rheumatoid arthritis pregnancies by sifting through records of pregnancies and deliveries using the Nationwide Inpatient Sample, a database of hospital discharge summaries from the entire country. In 2002, the latest year in which data was available, she found that at least 4,000 of the approximately 4 million total deliveries occurred in women with lupus or rheumatoid arthritis. By comparison, about 13,000 women who delivered in 2002 had diabetes.

" Women with rheumatoid arthritis are typically somewhat older when they become pregnant," said Chakravarty. " However, even after adjusting for maternal age, they run a higher risk for adverse outcomes and generally experience longer hospital stays than other women." On average, hospital stays increased from about two days for the general population to between three and four days for the rheumatoid group.

Chakravarty's findings also show that, compared with the general population, women with lupus or rheumatoid arthritis are three times as likely to develop hypertension and one-and-one-half times as likely to have cesarean deliveries or deliver prematurely.

In a previous study, Chakravarty had gathered evidence on the effects of lupus in 63 pregnant women at Stanford. Her results revealed that more than half of the deliveries were premature, and one-fifth suffered from pre-eclampsia - a condition characterized by a sharp rise in blood pressure during the third trimester of pregnancy.

Taking action in managing your arthritis

Arthritis affects about 21 million Americans. Because of the concern for negative side effects from many of the pain medications used for arthritis, many people are seeking other ways to manage their symptoms.

There are two major forms of arthritis - osteoarthritis and rheumatoid arthritis. The first increases in incidence as we age. It results from a breakdown of cartilage, allowing bones to rub together, which causes pain. Rheumatoid arthritis is an autoimmune disease that affects about 2 million Americans. With this form, the body begins attacking its own bone tissue, which causes inflammation and pain.

Since extra body weight puts additional stress on already painful joints, weight loss can be a good goal for overweight individuals (in addition to all the other health benefits it provides). Even losing a few pounds can make a big difference. Losing one pound of weight reduces the load on your knees by four pounds. Being at a healthier body weight can also reduce the risk of developing osteoarthritis in the first place.

Regular exercise is another action you can take. This not only can help with weight control, but it allows for improvements in joint function. Range of motion exercises keeps joints more flexible and allows for continued exercise. In the research, weight loss paired with exercise appears to be a winning combination to reduce pain.

A lack of regular exercise can almost guarantee decreases in joint function and increased pain. Plan an exercise program that includes range-of-motion exercise (stretching and flexibility), strengthening exercises (helps muscles and bones), and endurance (cardiovascular) exercises. Work with a physical therapist who can guide you through exercises that are just right for you. It is important to exercise safely. Drinking enough water is necessary for the health of all body tissues and the amount consumed should increase as exercise increases.

There are some dietary approaches to reducing the risk of inflammation. Omega-3 fatty acids (such as those found in fish oils), are known for their anti-inflammatory properties. Specifically, fish oils have been shown to decrease joint pain and stiffness, delay fatigue, and improve overall mobility. Higher levels of these can be consumed by eating fish or by taking supplements. Some other sources include ground flax seed/flax seed oil, canola oil and walnuts. If you choose to take a supplement, take about 3 grams of EPA/DHA. A diet high in omega-6 fatty acids can increase inflammation, so decrease your intake of the fats found in animal products and many processed foods. The current American diet contains a much higher level of these fats than in past decades.

A recent study has also suggested that a substance in olive oil is also anti-inflammatory. Previous studies had shown a benefit to people following a Mediterranean diet - high in fruits, vegetables, beans, olive oil, whole grains and fish, with limited amounts of saturated fats (animal-based fats).

Some researches found that a diet high in colorful fruits and vegetables (red, orange, and yellow) - which contain carotenoids and zeaxanthin - were less likely to develop rheumatoid arthritis. Vitamin C is another important nutrient in the arthritis picture. Drinking orange juice daily would help you to get both these benefits.

Numerous supplements are touted to help with arthritis. Of these, glucosamine and chondroitin appear to have the most potential for osteoarthritis. Anecdotally, many people state these two supplements, used alone or together, have shown benefit. To date, however, the National Arthritis Foundation claims it wants to see more concrete evidence before it can recommend taking these supplements. If you choose to take these supplements, the recommended doses are glucosamine sulfate (1200 mg/day) and chondroitin (1500 mg/day).

Vitamin D is another nutrient that may help. Some studies have shown that osteoarthritis progresses much faster in people who are deficient in vitamin D. The bone pain that results from a vitamin D deficiency can also be mistaken for arthritis. Older adults should try to get at least 600-800 IU of vitamin D per day. This can also help maintain bone density.

Remember that dietary changes and supplements generally work more gradually than medications. Do not expect immediate results. The benefit to including these dietary changes, is that they also help to reduce the risk of other medical concerns - so you can’t lose. As in treating many other medical conditions, there are a number of action steps that can choose to take.

So the bottom line is to maintain a regular habit of exercise, eat meat and poultry less often and replace them with oily fish or plant sources of protein such as beans, nuts, or seeds. Use olive or canola oil. Make fruits and vegetables a large part of your day. Add supplements as needed, such as vitamins C and D or fish oils, and drink plenty of water.

Pamela Stuppy is a registered, licensed dietitian with nutrition counseling offices in York, Maine, and at Whole Life Health Care in Newington. She is also the nutritionist for Phillips Exeter Academy.

Lupus and its varied symptoms hide behind mistaken diagnoses

BY MICHAEL GRANBERRY

Allison Koeninger has had symptoms of lupus since childhood. (DARNELL RENEE/KRT)

What is lupus?

Lupus is a chronic autoimmune disease that causes the immune system to attack the body's own tissue and organs, including the joints, kidneys, heart, lungs, brain, blood or skin. Researchers do not know what causes lupus. It is not infectious, rare, cancerous or AIDS-derived. Scientists believe there is a genetic predisposition to lupus, but it is known that environmental factors also play a role in triggering the disease. The Lupus Foundation of America estimates that about 1.5 million Americans have a form of the disease. Men and women of all ages can be affected, but lupus occurs 10 to 15 times more frequently among adult females than adult males. Source: American Lupus Foundation Source: American Lupus Foundation

DALLAS -- For Allison Koeninger, symptoms began as early as age 7. She felt aches and pains "and a lot of fatigue," and no one could figure out why.

"They would X-ray me, and nothing would show up," she says. "I even began to think I was imagining things."

Now 44, Koeninger failed to get the answer she was seeking until 1990, when she went to a dermatologist for a rash that began on the bridge of her nose and spread to her cheek. She remembers him saying, "I think you have lupus." He was right.

An archivist at the University of Dallas, Koeninger lives in Dallas and suffers from lupus, for which there is no cure. In her case and those of millions of others, lupus is often misdiagnosed.

About 1.5 million Americans suffer from it, and most of its victims are women. It's a chronic autoimmune disease that causes inflammation and tissue damage to almost every organ in the body, including the brain and heart. Its symptoms, which tend to arrive with devastating severity, include achy and swollen joints, fevers, fatigue and obvious skin rashes.

"Lupus is a classic example of an autoimmune disorder in which your own immune system has become imbalanced," says Dr. Edward K. Wakeland, director of the center of immunology at UT Southwestern.

Wakeland received a recent research grant from the Alliance for Lupus Research, or ALR, which was founded in 1999 for the purpose of raising money to prevent, treat and eventually cure lupus. The Lupus Foundation of America is also aggressively involved in raising funds.

"Lupus can lead to a whole variety of problems, including kidney abnormalities, rashes, photosensitivity, neurological disorders, vascular disorders ... and there's currently no good way to treat it," said Wakeland. "Oftentimes, the therapy is almost as bad as the disease itself."

In Koeninger's case, steroids caused her to gain weight and hit her with a severe case of depression and anxiety. Anti-inflammatories tore up her stomach for 10 years. "I can no longer take them, because my stomach is just shot," she says.

Dr. Nancy Olsen, professor of medicine at the University of Texas Southwestern, has treated lupus patients for years. The worst scenarios she sees usually involve kidney failure, which "is not as dire as it used to be," she said. "We've gotten a lot better at treating it." Koeninger is among the relatively fortunate who have never suffered kidney problems.

Patients "usually come in with one of several symptoms," said Olsen. "It's a very heterogenous disease, so it affects people differently. People often come in with a skin rash, which can be on their face. Others have joint pain, arthritis-like symptoms. It's usually less intense than rheumatoid arthritis, but there can be swelling or pain.

"Some patients come in with high blood pressure, then we find their kidneys aren't working. And then a biopsy will show lupus in the kidney. Most people don't have all of the symptoms."

Of the 1 in 2,000 it victimizes, it targets women at least 10 times as often as men, said Wakeland. And no one knows why. One of the men who died from lupus is famed CBS broadcaster Charles Kuralt.

"The disease tends to be much more severe in women who are reaching their child-bearing years," he says. "The frequency and severity is also much more prevalent among African Americans and Hispanics. They more commonly get it, and when they do, it's more commonly severe among those populations."

Just as no cure exists for lupus, neither is there an identifiable cause. Lupus patients often undergo the frustration of suffering swelling of the joints or bruising, only to have the symptoms subside by the time they get to a doctor's office. It's often wrongly diagnosed as arthritis.

Unpredictability, Koeninger said, makes it difficult to cope with. "You can wake up today feeling great," she says, "and wake up feeling horrible tomorrow. It's hard to make long-term plans. I always take out vacation insurance, because I never know when a vacation comes around if I'm up to going."

And one of its saddest aspects is the suspicion it sometimes arouses in others. "Most of the time, you don't look sick, and people just don't realize how much you're suffering. But believe me," she said, "you are suffering."

Arthritis Drug May Ease Another Joint Disease

-- Robert Preidt

FRIDAY, Nov. 18 The drug adalimumab (Humira) -- commonly used to treat rheumatoid arthritis -- may also help reduce the signs of symptoms of ankylosing spondilitis (AS), a painful and disfiguring autoimmune disease, according to an international study.

AS, which affects about one in 2,000 people in the United States, occurs when a protein called tumor necrosis factor (TNF) attacks certain spinal joints and causes inflammation those joints. Adalimumab is an anti-TNF agent.

This study included 315 AS patients in the United States and Europe who had no success with at least one other form of therapy. Patients were randomly assigned to receive either 40 milligrams of adalimumab or a placebo for 24 weeks.

Researchers used five assessment methods to measure the patients' clinical responses treatment. The goal was a 20 percent improvement in AS signs and symptoms.

At 12 and 24 weeks, more than twice as many patients taking adalimumab had achieved the 20 percent improvement goal, compared to those taking the placebo. Some of the patients showed improvement as early as two weeks into the study.

The findings were to be presented this week at the annual scientific meeting of the American College of Rheumatology in San Diego.

Arthritis awareness: Speakers touched by disease share 'Commitment to Cure'

By COLLEEN JOHNSON

As if speaking in front of a room full of people is not tough enough, Doug Young had to discuss his personal struggle with a painful disease.

"I was pleased to speak so people will be aware," said Young, a local businessman whose daughter was diagnosed with rheumatoid arthritis when she was just 23 years old. "The Arthritis Foundation is not new in the country, or to Middle Tennessee, but it is relatively new to Murfreesboro."

Modern medicines enabled Young's daughter to earn a diploma, become a teacher, marry a supportive husband, and have a child. However, many arthritis patients are not as fortunate.

Arthritis is a painful disease that causes stiffness and sometimes swelling in and around joints. For arthritis patients, everyday movements can become extremely difficult. There is no known cure for arthritis.

This past Wednesday, the Arthritis Foundation hosted a "Commitment to a Cure Breakfast" for the first time in Rutherford County. The event was held at the Stones River Country Club, and many members of the community attended.

One by one, arthritis patients stood before the audience and spoke about their personal struggles and accomplishments.

Melinda Poff, a former track star who was diagnosed with severe rheumatoid arthritis when she was just 25, described how the disease ended her ability to run, to finish college, and to have children. Teaching Sunday school at church will have to satisfy her childhood dream of one day teaching kindergarten, she said.

"I didn't think it was a disease I should have," said Poff as she described having to be carried around the house by family members when the disease was at its worst. "I thought it was an old person's disease."

Poff is not alone in thinking arthritis is a disease that only afflicts the elderly. This is a stereotype she and other patients are trying to change.

Arthritis appears in more than 100 different forms, and the cause of all of them remains unknown. There may be a genetic link, but doctors still do not know for sure.

According to the Arthritis Foundation, arthritis affects one in three adults, is the No. 1 cause of disability in the United States, and costs more than $86 billion a year. The Arthritis Foundation estimates that approximately 66 million adults are living with arthritis in the United States, and about 300,000 children have some form of arthritis.

Ashley Carpenter was just 16 months old when doctors diagnosed her with juvenile rheumatoid arthritis. Her condition is described as "onset systemic," which means she has a very active form of the disease. This form affects her five major joints as well as her five major organs.

Ashley's mother, Tammy Carpenter, fought back tears as she stood before the crowd at the recent breakfast and described their family's personal struggles. Ashley, now 6, comforted her mom and occasionally gave the audience huge smiles.

"As you can see, she looks like a normal child," said Tammy, her voice quivering. "But she is on all sorts of different medicines. We buy ibuprofen by the pint. It costs $3,000 a month just to pay for her medical needs."

When it comes to medication, little Ashley may be luckier than the arthritis patients who came before her. Improved treatments keep patients more comfortable than in previous years.

"There has been more improvements in the drugs in the last 10 years," said Tammy. "But we still need more research, so we can find a cure and the (next generation) will have hope. You feel so helpless and hopeless when this happens to your family."

Ashley takes an injection every morning, and Tammy said "right now she is doing pretty good."

Doctors predicted Poff would be wheelchair-bound by the age of 25. She is now 35 and still standing.

"Because of medications, I don't have the deformities in my hands," said Poff, as she held up her hands for the audience to see. "Just think of how much better the medications will be for future patients."

"As I understand it, the biggest improvements have been in pain management in the last 10 years," said Ronnie Shaw, a member of the Rutherford County Arthritis Advisory Council. "And in the medications that help to stop disfigurement."

In the past, many patients suffered severe disfigurement, especially in their hands. In a video titled "Faces of Arthritis," an elderly gentleman who was diagnosed more than 30 years ago described how he had become completely dependent on other people. His hands and fingers were permanently swollen, disfigured and almost useless.

"You don't really see that anymore," said Shaw. "Medicines have improved, but what we really need is a cure, and there is no cure."

The Arthritis Foundation is just one of many research foundations in need of support, but patients such as Poff, Carpenter and Young's daughter serve as living proof the research being done is producing results.

"When you take in account the number of caregivers as well as patients, it really affects a very large percentage of people," said Young. "And it can't be vaccinated or treated. It is going to take research to get it done."

---

Arthritis Supplements

The popular supplements glucosamine and chondroitin may not offer much benefit for people with mild arthritis pain, but could help people with more severe arthritis. Those are the findings of two studies presented at the American College of Rheumatology meeting in San Diego this week. The first study looked at about 1,600 people with knee osteoarthritis for six months. Most of the patients had mild arthritis; about 20% had more severe disease. The patients were treated either with glucosamine, chondroitin, the drug Celebrex, or a placebo. The patients were also allowed to take daily doses of acetaminophen along with the other treatment. The researchers found that Celebrex relieved pain, but the supplements did no better than the placebo at relieving pain. However, the findings suggested that glucosamine and chondroitin together could help people with moderate to severe osteoarthritis, The New York Times News Service reports. However, the second study by European researchers, which looked at about 300 women treated with acetaminophen, glucosamine or a placebo, suggested that glucosamine might work better than acetaminophen at relieving knee arthritis pain.

Arthritis pill discounted

Study shows no proof glucosamine, chondroitin ease knee pain, but they don't do any harm either.

What they are Glucosamine and chondroitin sulfate are substances found naturally in the body. � Glucosamine is a form of amino sugar that is believed to play a role in cartilage formation and repair. � Chondroitin sulfate is part of a large protein molecule (proteoglycan) that gives cartilage elasticity. � Both glucosamine and chondroitin sulfate are sold as dietary or nutritional supplements. � Both are extracted from animal tissue: glucosamine from crab, lobster or shrimp shells; and chondroitin sulfate from animal cartilage, such as tracheas or shark cartilage.

A clinical trial of the popular dietary supplements glucosamine and chondroitin found no evidence that they're better than placebos in easing arthritic knee pain, the study's lead investigator said Tuesday.

The good news: like placebos, the supplements aren't harmful, either.

The government-sponsored trial involving 1,600 arthritis sufferers at 16 medical centers across the country was designed to see if the supplements lived up to their billing as potent weapons against arthritis. Sales of the two supplements topped $700 million in 2004, according to the Nutrition Business Journal.

Dr. Daniel O. Clegg, speaking at a rheumatology convention in San Diego, said the supplements -- taken separately or in combination -- didn't fare any better than placebos, pills with no active ingredients. Some study highlights:

� Remarkably, about 6 in 10 patients reported that their knees felt better after six months of therapy -- whether they took supplements or the dummy pills. Psychology may have played an important role in how participants felt. "Patients really believe in dietary supplements, and I think patients wanted to do better," Clegg said.

� Patients taking the glucosamine-chondroitin combination fared slightly better than those on placebos, but not enough to qualify as statistically significant.

� Patients taking the prescription drug Celebrex did better than those on placebos -- by a 70 percent to 60 percent margin.

"It's a very confusing time right now," said Clegg, noting that some previous studies showed the supplements worked better than placebos, while others did not.

An estimated 21 million people in the United State suffer from osteoarthritis, a condition caused by the breakdown of cartilage that cushions the ends of bones in joints throughout the body.

Tackling arthritis ... gently

By MERYL NAIDOO

ARTHRITIS Tasmania will introduce a range of new prevention and management programs thanks to a $298,000 Federal Government grant.

The funding boost was welcomed yesterday by the organisation's chief executive Jackie Slyp.

She said the statewide Living Well with Arthritis project had a strong emphasis on better practical management of arthritis and osteoporosis.

Ms Slyp said gentle, ongoing physical activity was an important tool to help manage both conditions, which affected thousands of Tasmanians.

The healthy lifestyle and self-management programs aim to better control symptoms and improve quality of life for sufferers.

New programs include activities like Tai Chi, warm water exercises, chair-based exercises, and strength training.

The six-week Get the Most Out of Life course also offers emotional support for people with a chronic condition.

Arthritis Tasmania volunteer Carolyn Price, 61, first heard about Tai Chi about two years ago.

These days, she instructs weekly classes for beginners and swears by the ancient Chinese practice.

She said Tai Chi might not make people look younger, but it certainly made them feel it.

She believes it has improved her mobility, is a great relaxant and a fantastic way to meet new people.

Liberal Senator Eric Abetz, who announced the program funding, said it would be of great benefit to arthritis sufferers in the state.

Key Underwrites ‘Working Successfully with Arthritis’: New Educational Program Offered by Arthritis Foundation

CLEVELAND, November 16, 2005 – Helping employers and employees learn more about arthritis and its impact on the nation’s workforce is one of the goals of the Arthritis Foundation. Working Successfully With Arthritis – a new, free arthritis education program offered by the Arthritis Foundation, Northeastern Ohio Chapter and underwritten by a $15,000 Key Foundation grant – will bring this important information to the worksite.

“As more Americans are diagnosed with arthritis at younger ages (in their 20s, 30s and 40s), this disease is affecting an individual’s health and quality of life,” said John T. Petures, Jr., Chapter President. “As medical costs increase and younger, working-age people are diagnosed, issues of employability, income and economic self-sufficiency become paramount. There are many lifestyle changes that can improve functioning and minimize the impact of this disease.”

Working Successfully With Arthritis features a presentation designed for executives, managers, human resource specialists and employees. Perfectly suited for a brown bag lunch event, the 60-minute presentation includes information on arthritis diagnosis, treatment options and simple lifestyle changes that will help attendees function better and work more productively. For more information, contact Eileen Moeller at 800-245-2275, ext. 155, or email moeller@gwis.com.

Working Successfully With Arthritis is the next generation of the Northeastern Ohio Chapter of the Arthritis Foundation’s economic self-sufficiency project established in 2003, with support from the Key Foundation and KeyCorp (NYSE: KEY). Since that time, more than 750 individuals with arthritis, and their families, have benefited from educational programs led by a panel of volunteer experts including KeyBank representatives among professionals addressing medication access; financial planning; employment issues and, for those who can no longer work, the disability application process.

Why should employers care about this condition? Arthritis is the leading cause of disability in the United States, costing our economy more than $86 billion annually in lost wages, lost productivity and medical expenses. A staggering one in three Americans (70 million people) has arthritis, including 1.5 million individuals of all ages in Northeastern Ohio.

Arthritis Patients Missing Out on Aspirin Therapy

By Randy Dotinga

As preventive measures go, it's a pretty simple one: People with rheumatoid arthritis are more likely to develop heart disease, so they should take a low-dose aspirin once a day.

But new research suggests many patients aren't getting the message, potentially putting them at risk.

Researchers found that just 18 percent of rheumatoid arthritis patients are on aspirin therapy, widely considered an effective and inexpensive way to prevent heart attacks. Meanwhile, a similar group of people with other types of arthritis are significantly more likely to take aspirin each day -- 25 percent of them do so, the study found.

The reason for the oversight isn't clear, but it may have something to do with rheumatologists and primary-care doctors failing to consider a patient's overall health, said Dr. Eric Ruderman, an associate professor of medicine at Northwestern University's Feinberg School of Medicine. "Maybe we're not looking at the rest of the picture as much as we should," he said.

Rheumatoid arthritis is caused when the immune system begins attacking the body itself, causing pain and inflammation in the joints. It's one of the most serious and disabling types of arthritis, is most common among women, and often begins when people are in their 30s and 40s.

By contrast, osteoarthritis is caused when the cartilage that covers the ends of bones in the joint deteriorates, producing pain and loss of movement as bone begins to rub against bone, according to the Arthritis Foundation.

For reasons that aren't entirely clear, people with rheumatoid arthritis are twice as likely to develop heart disease, said study co-author Dr. Lee Colglazier, a rheumatologist in Crestview Hills, Ky., who worked on the study as a rheumatology fellow at Wake Forest University School of Medicine. Some theories suggest the inflammation triggered by arthritis contributes to cholesterol buildup and artery blockages.

Colglazier and colleagues are scheduled to report their findings Wednesday at the American College of Rheumatology annual meeting, in San Diego.

For the study, the researchers surveyed 18,123 arthritis patients, most of whom -- 14,114 -- had the rheumatoid form, over a three-year period.

Of the rheumatoid arthritis patients, only 18.4 percent took an aspirin a day to prevent heart disease, compared to 25.1 percent of the patients with other forms of arthritis.

Doctors believe that a simple low-dose -- or "baby" -- aspirin once a day, which costs pennies, can reduce the risk of heart attacks.

The findings are mystifying, especially because rheumatoid-arthritis patients are hardly strangers at doctor's offices, Colglazier said. "Maybe they're seeing the doctor a lot, a lot of acute things are going on, (but) doctors don't have time to say, 'Let's address prevention.'"

Ruderman agreed, adding that primary-care doctors might not realize the heart-risk urgency facing rheumatoid arthritis patients. Perhaps "they don't view these patients with the same concern that they may view a diabetic or a patient with significant hypertension or elevated cholesterol," he said.

Raynaud's pain and blanching has many causes

ALLEN DOUMA. ALLEN DOUMA spent 12 years in clinical practice. He has written, edited and advised on numerous medical publications.

For many years I've had problems with my fingers turning white and hurting whenever they get cold. Last year when I was breastfeeding, my nipples did the same thing. My pediatrician said that I had something called Raynaud's in my fingers but that the problem with my nipples was my child was latching on too tightly. But it didn't matter how hard she sucked, the same thing happened. What do you think is going on?

W.M., Harwich, Mass.



It sounds as if you may have Raynaud's, a condition in which small arteries go into spasm and prevent adequate blood flow. This causes the characteristic blanching and pain. Most commonly affected are the digits, and fingers are involved more often than toes. But Raynaud's can occur in the nipples as well. This usually happens during breastfeeding because of greater exposure and because the evaporation of moisture from the nipples causes cooling.

Raynaud's primarily occurs in young women. In men it is often the result of occupational trauma.

When the condition is related to another disorder, it is called Raynaud's phenomenon. This is the most common form. When no other underlying disease is found it's called Raynaud's disease.

Many medical conditions may cause Raynaud's phenomenon, including scleroderma, rheumatoid arthritis, atherosclerosis, decreased thyroid activity, injury and reaction to certain drugs. In a recent research study, the most common causes of Raynaud's phenomenon were the use of beta-blocker drugs (primarily used for blood pressure control and heart conditions), carpal tunnel syndrome and rheumatoid arthritis.

Episodes of Raynaud's come on quickly and are usually triggered by stress or exposure to cold. Rewarming the affected hands or feet usually restores normal color and sensation within a few minutes, but a burning pain is often felt as the tissue returns to normal.

Do what you can to keep your extremities and nipples warm. Some people with severe Raynaud's wear socks and gloves heated by battery power. Some even decide to move to warmer climates.

Even the slightest change in temperature may be enough to trigger the pain.

Avoid drugs that restrict blood vessels, including tobacco. If stress is a problem (and you certainly may be anxious about the condition of your nipples), you may want to talk to family doctor or a psychological therapist.

Q: TWO years ago I was diagnosed with rheumatoid arthritis. I was only given anti-inflammatory medication and if I stopped taking it, the pain and uneasiness would return. How can I reduce the pain?


A: RHEUMATOID arthritis (RA) is a chronic inflammatory condition that can affect the entire body. It is an autoimmune disease in which the immune system attacks the joints, including the synovial membranes surrounding the lubricating fluid in the joints.

Common symptoms of RA include fatigue, low-grade fever, weakness, joint stiffness, vague joint pain and appearance of painful, swollen joints. Involved joints will characteristically be quite warm, tender and swollen.

Some herbs may be beneficial for RA. For instance, celery seed has anti-inflammatory properties and combined with guaiacum can be very helpful for those suffering from RA.

A combination of antioxidants will help to protect against degenerative diseases like RA.

Omega-3 oil has produced favourable changes in suppressing the production of inflammatory compounds and shown to be effective in reducing the problem of tender joints and morning stiffness in patients with rheumatoid arthritis.

Reduce your meat intake, especially that of beef, and vegetables such as tomato, potato, eggplant and peppers. This is due to the toxin called sotanine which people suffering from RA are highly sensitive to. RA sufferers should exercise regularly. Go for swimming, stretching and walking. Try to reduce or avoid smoking and alcohol consumption as they can cause excessive free radical formation.

Combining drugs at the start of rheumatoid arthritis may help most

THE QUESTION As treatment of rheumatoid arthritis has expanded from simply relieving the chronic pain of inflamed joints to also preventing the destruction of bone and cartilage, an array of drugs has become available, for use alone or in combination. What strategy works best?

THIS STUDY randomly assigned 508 adults, mostly women, recently diagnosed with rheumatoid arthritis to one of four types of medication programs: (1) methotrexate alone, switching to a different disease-modifying, anti-rheumatic drug (DMARD) if needed; (2) a step-up program that starts with methotrexate but adds other DMARDs and the steroid prednisone; (3) an initial combination of methotrexate, sulphasalazine (an anti-inflammatory) and prednisone; or (4) a combination of methotrexate and infliximab, a drug that blocks a substance (tumor necrosis factor) that causes inflammation. After a year, the ability to function had improved in all groups, with the disease in remission in 32 percent of the participants.

But more people from groups 3 and 4 — those whose had taken a combination of drugs from the start — improved, and they improved more quickly, than the others. Compared with hand and foot X-rays taken at the start of the study, groups 3 and 4 also showed less progression of joint damage, with no progression shown for 87 percent and 93 percent of the groups, respectively, compared with 67 percent for group 1 and 73 percent for group 2.

WHO MAY BE AFFECTED BY THESE FINDINGS? People with rheumatoid arthritis, which most often begins between ages 30 and 50. Women are nearly three times more likely to get the disease, but it tends to affect men more severely.

CAVEATS About 41 percent of the participants, roughly divided equally among the groups, reported side effects, mainly gastrointestinal and skin problems. The study was funded in part by Centocor and Schering-Plough, which had paid fees to one author.

Halting arthritis damage

By LINDA SEARING

THE QUESTION: As treatment of rheumatoid arthritis has expanded from simply relieving the chronic pain of inflamed joints to also preventing the destruction of bone and cartilage, an array of drugs has become available, for use alone or in combination. What strategy works best?

THIS STUDY randomly assigned 508 adults, mostly women, recently diagnosed with rheumatoid arthritis to one of four types of medication programs:

methotrexate alone, switching to a different disease-modifying, anti-rheumatic drug (DMARD) if needed; a step-up program that starts with methotrexate but adds other DMARDs and the steroid prednisone; an initial combination of methotrexate, sulphasalazine (an anti-inflammatory) and prednisone; a combination of methotrexate and infliximab, a drug that blocks a substance (tumor necrosis factor) that causes inflammation. After a year, the ability to function had improved in all groups, with the disease in remission in 32 percent of the participants. But more people from the third and fourth groups - those who had taken a combination of drugs from the start - improved, and they improved more quickly, than the others. Compared with hand and foot X-rays taken at the start of the study, those two groups also showed less progression of joint damage, with no progression shown for 87 percent and 93 percent of the groups, respectively, compared with 67 percent for the first group and 73 percent for the second group. WHO MAY BE AFFECTED BY THESE FINDINGS? People with rheumatoid arthritis, which most often begins between ages 30 and 50. Women are nearly three times more likely to get the disease, but it tends to affect men more severely. CAVEATS: About 41 percent of the participants, roughly divided equally among the groups, reported side effects, mainly gastrointestinal and skin problems. The study was funded in part by Centocor and Schering-Plough, which had paid fees to one author. FIND THIS STUDY: November issue of Arthritis & Rheumatism; abstract available online at |interscience.wiley.com/journal|/arthritis. LEARN MORE about rheumatoid arthritis at arthritis.org and mayoclinic.com. THE QUESTION: In laboratory experiments, it appears that statins - which are taken to lower cholesterol and prevent heart disease - might also prevent cancer by inhibiting the growth and spread of tumors. Has evidence of this emerged among the millions of Americans who take this drug every day? THIS STUDY analyzed medical data on 79,994 women, with an average age in the mid-60s, who were cancer-free at the start of the study. During a 12-year period, breast cancer occurred in 3,177 of the women, including 1,727 who took statins. Those taking statins were no more - and no less - likely to have breast cancer than women not taking the drug. The length of time statins were taken did not alter the results. WHO MAY BE AFFECTED BY THESE FINDINGS? Women who take statins. Women are more apt to be taking this type drug, as they generally have higher cholesterol levels than men. CAVEATS: The study did not differentiate among different types of statins, and it did not consider other forms of cancer. It remains unclear whether taking the drug for longer than 12 years would affect the results.

Supplements May Help Knee Arthritis New Studies Give Mixed Signals About Glucosamine, Chondroitin Benefits

Nov. 14, 2005 -- Arthritis sufferers may -- or may not -- benefit from a pair of popular dietary supplements, two new clinical trials suggest.

One supplement is glucosamine, derived from the shells of crabs and lobsters. The other is chondroitin, usually derived from animal cartilage. These supplements are said to help relieve arthritis pain. They are also said to prevent the arthritic joint narrowing that causes one bone to grind against another.

Do these supplements really work? That is what two clinical trials -- a 1,583 patient study in the U.S. and a 318 patient study in Europe -- tried to find out. Researchers reported results from both studies at this week's annual scientific meeting of the American College of Rheumatology in San Diego.

"The supplements were not better than the placebo," Daniel O. Clegg, MD, tells WebMD. Clegg, chief of rheumatology at the University of Utah in Salt Lake City, led the NIH-sponsored U.S. study.

Arthritis Foundation spokesman Erin Arnold, MD, has a different interpretation. Arnold, a rheumatologist with the Illinois Bone and Joint Institute in Morton Grove, Ill., notes that Clegg is focusing on the study's overall results. She says she is more impressed with the study's finding that patients with more severe arthritis pain got significant relief from the glucosamine-chondroitin combination.

"I am very encouraged by the results of this study," Arnold tells WebMD. "The data presented certainly does not deter me from encouraging patients to try glucosamine and chondroitin."

There is less controversy over the smaller, European study led by Gabriel Herrero-Beaumont, MD, of the Jiminez Diaz Foundation in Madrid, Spain.

"Our results confirm previous studies," Herrero-Beaumont tells WebMD. "They demonstrate clearly that glucosamine was able to control knee osteoarthritis pain."

Glucosamine + Chondroitin: For Bad Arthritis Pain Only?

Glucosamine + Chondroitin: For Bad Arthritis Pain Only?

The U.S. trial enrolled patients aged 40 and older with knee pain due to osteoarthritis. They were randomly assigned to one of five treatments:

• Inactive placebo pills
• Glucosamine hydrochloride at a dose of 500 milligrams three times a day
• Sodium chondroitin at a dose of 400 milligrams three times a day
• Combination glucosamine and chondroitin
• Celebrex at a dose of 200 milligrams per day

It is common for a pain study to show that many patients report relief from inactive placebo pills. And that happened here. Nearly 60% of patients given only placebo pills said they had less pain. So did about 67% of patients treated with combination glucosamine and chondroitin. But that isn't what scientists call a significant difference -- that is, there's more than a 5% chance the findings are just coincidence.

"I really feel the study is a negative study," Clegg says. "I would say to patients that the safety data are really reassuring, the efficacy data are not."

When Clegg's team looked only at patients with moderate to severe pain. Only 54% of these patients got relief from placebo. But 79% reported relief from combination glucosamine and chondroitin. That is a significant difference. But there's a problem, Clegg says. The study wasn't designed to look at just this group. The effect here is based on only a small number of patients.

"About 20% of the study patients have moderate to severe pain," Clegg says. "Interestingly, in that subgroup, the combination of glucosamine and chondroitin appeared to be effective in relieving pain. I think this outcome is really interesting but just from a research standpoint. It is an exploratory, hypothesis-generating finding -- not a finding on which to base treatment."

Different Opinions on U.S. Study

Different Opinions on U.S. Study

The Arthritis Foundation says that the Clegg study "demonstrates that the combination of glucosamine and chondroitin may be a beneficial part of an overall treatment plan in individuals with moderate to severe knee osteoarthritis."

This conclusion did not change after conversations with Clegg, Arnold says.

"Based on the data we have had -- and on the use of glucosamine and chondroitin in clinical practice -- we think there is enough there to give glucosamine and chondroitin a try," she says. "It is safe."

The study isn't the first to show that glucosamine and chondroitin help arthritis, says Andrew Shao, PhD, vice president for scientific and regulatory affairs at the Council for Responsible Nutrition, a supplement industry trade group.

"There are at least 50 published clinical trials on either one of these supplements or the combination, with various relevant health outcomes, such as improved joint pain and improved joint space," Shao tells WebMD. "It's important to keep in mind these products support joint health. It is not necessary to restrict use to osteoarthritis sufferers. Although the research is not done yet, they might be useful for arthritis prevention, too."

Glucosamine Better Than Tylenol?

A more consistently positive result comes from the European study. This clinical trial randomly treated knee osteoarthritis patients with either glucosamine sulfate (one 1,500-milligram dose daily), acetaminophen (the active ingredient in Tylenol, given at the high dose 1,000 milligrams three times daily), or inactive placebo.

After six months of treatment, patients getting either glucosamine or acetaminophen had significantly less pain than patients getting placebo pills.

But researcher Herrero-Beaumont says that patients treated with glucosamine reported more kinds of improvement than those treated with acetaminophen.

"Glucosamine showed more positive effects than placebo in 10 of 10 measures, whereas acetaminophen was more positive than placebo in only five of the 10," he says. "But there was no statistical significance between glucosamine and acetaminophen."

Things to Know

Things to Know

Herrero-Beaumont says that because glucosamine is extremely safe, he recommends it to patients with arthritis. But since there's some evidence that the supplement accumulates in the body, he says he advises patients to use it in three-month-on, two-month-off cycles.

Arnold says she has yet to see any safety concerns with either glucosamine or chondroitin. She recommends that patients give it a try -- with the advice of their doctors.

"There are things that work for certain patients that don't work for others," she says. "Based on safety, I would continue to encourage my patients to use glucosamine and chondroitin. Some of my patients who use these supplements have been able to use [fewer] anti-inflammatory and pain medications."

Arnold is quick to warn that supplements will not cure arthritis -- and that they are only a part of a multiprong treatment.

What does Arnold tell her patients?

"I recommend first of all that they try only products evaluated by Consumer Laboratories or USP to make sure they have in them what they are supposed to have," she says. "Then I tell them to take half the dose in the morning and half in the evening. And I have them do at least a three-month trial before giving up."

Industry spokesman Shao says patients should be patient.

"Glucosamine and chondroitin are very different from some drugs used to relieve arthritis pain," he says. "Rather than mask pain, they are actually fixing the joint. But that takes time. It does not kick in after a few hours or days. It takes months for the effects to manifest."