Summary

Inflammatory Arthritis - RA

Summary

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Geocities Basic Treatment 6

RA is a serious debilitating disease whereby, the patient will have to take some form of medical treatment for the rest of their lives .

However,most patients with RA gets lost in a maze of treatment opinions.

While climbing the treatment pyramid,valuable time and opportunity to control the disease without causing irreversible damage is lost. This window of opportunity is estimated to be 2 years,at the onset of disease,when disease control is more manageable.

Currently RA can not be cured,but it can be controlled through better patient knowledge,and knowledgeable professional help.

RA is an inflammatory disease of the synovium,or lining of the joint,that results in pain,-- loss of function in the joints -stiffness,swelling,deformity.

The normally thin synovium memberane tissue which is microscopic in nature becomes thick and inflamed and can be felt by a rheumatoligist. The synovium becomes inflamed and filled with destructive white blood cells (cytokines etc.) and debris attacking cartilage,and bone. Inflammation most often affects joints of the hands and feet and tends to be symmetrical (ocurring equally on both sides of the body).

This symmetry helps distinguish RA from other types of arthritis About 2.1 millionof the U.S. population have rheumatoid arthritis. This low incidence means many physicians will have little experience with the complexities involved in RA.

Rheumatoid arthritis is characterized by the signs of inflammation: pain, swelling, heat,and stiffness. Pain is caused by inflamed cells and chemicals that affect the nerve endings. In RA,pain is felt in the joint or with joint movement. Swelling is caused by thickening of the synovial membrane,and sometimes by increased fluid or debris within the joint. Increased blood-flow to the inflamed joint results in heat and redness. Stiffness commonly called "morning stiffness",occurs in almost all inflamed joints after a period of disuse. To regain mobility inflamed joints must be loosened up by applying heat or doing exercise.

About 10% of RA patients have a form of RA charachterized by marked stiffness which usually leads to abnormal tightness rather than to swelling in the small joints of the hands,wrists,shoulders, and occasionally,the knees and feet. The joints may look normal.

Some of these patients will have difficulty raising their arms above their head within a matter of weeks. Mobility and day to day function will be severly affected in many of these patients.

With the exception of inflammation of the tendons (tendonitis) EAF's are rare in this type of RA. If left untreated,loss of function caused by this stiffness can be pronounced,and irreversible.

RA is an autoimmune disease,the immune system is a complex organization of cells and antibodies designed to "seek and destroy" invaders of the body,particularly infections. Patients with autoimmune diseases have antibodies in their blood which target their own tissues,where they can be associated with inflammation.

It is a chronic disease that can last for a short period (mild),years,or last a life time. Sometimes patients may experience long periods without symptoms (remission) while for others,the disease is continuous.

The inflammation associated with RA also occurs outside the joints. These inflammatory changes are called extra-articular features (EAFs). EAFs are more common with moderate or severe types of RA but they can occur in all types.

Tendons rheumatoid nodules (small bumps over pressure points,under the skin), heart, lungs, nervous system,blood vessels (vasculitis),and eyes can be affected.

Many patients with the more severe type of RA feel ill,much as though they have a chronic bad flu. Patients feel tired,have no energy,feel nauseated,lose their appetite, and sometimes lose weight. These symptons are typical of RA,and are called constitutional features.

All patients with RA may feel unwell,but patients with moderate and severe are most affected. Like EAFs,the severity of these symptoms help to separate RA from other forms of arthritis. Because it can affect mutiple other organs of the body,RA is referred to as a systemic disease.

When RA strikes the body,e.g., The arm or feet on the left side of the body,the right side is often simililarily affected. At onset of disease,this may not happen,but the tendency later is more-so.

Formal diagnosis of RA require that the case meet at least four of the seven criterias:

1)Morning stiffness lasting at least one hour. In fact,even stiffness for more than 30 minutes,strongly suggests inflammatory disease.

Alleviation of morning stiffness with activity is a hallmark of inflammatory arthritis. Later in the day,continued activiated activity will aggravate the problem and exacerbate the pain.

2) Swelling in three or more joints,simultaneously.

3) Swelling in the hand joints (PIP,MCP, or wrist).

4) Symmetric arthritis -- Initially,joints on only one side may be involved but the arthritis tend to spread to the other body parts and side of the body.

5) Erosions or decalcifications on x-ray of the hand.

6) Subcutaneous rheumatoid nodules (small bumps,usually appear over nerve pressure points,in some patients).

7) A positive serum rheumatoid factor assay.

These are guidelines,established under laboratory standards,and some patients may not exibit the full criterias. i.e. Some mild RA patients or at onset.

There are three principal types or classes of RA; mild,moderate and severe. Some RA patients will have a negative rheumatoid factor (R.F.). A antinuclear antibody test (ANA) will indicate a inflammatory presence, but it will not indicate RA by itself. RA cannot be detected by one test or by the physical appearance,usually,a number of tests is done and the whole big picture is analyzed. E.S.R. or "sed-rate" is one of the most often used blood test to check the inflammation rate present,but other diseases may indicate a higher than normal rate.

RA effects will vary with the individual patient,and type or classification . Some mild RA patients will have a short course of the disease,on others it may remain mild for a indefinite period.

Medications will also differ with the different classes. Severe,means severe,extra-articular features will usually accompany the disease (blood vessels, lungs, eye problems-etc.) disability may occur in some patients.

The number and severity of inflamed joints,whether or not the inflammation is symmetrical,gives the doctor of what type of arthritis you may have. The presence or absence of features such as tendonitis or nodules (bumps over nerve pressure points) is also important,and also helps the type of arthritis one have,and its severity. If damage or deformity have occurred,these help in predicting the type and course of the disease (progressive or controlled) as well.

RA is only one of over 100 arthritic or rheumatic diseases. Many other diseases can mimic RA.

These other diseases include osteoarthritis,gout,lupus,psoriatic arthritis, viral arthritis, haemochromatosis,psueudogout, and even fibromyalgia. The physician will be aware of these other forms of arthritis,and will come to some conclusion about whether one has RA or not.

Arthritis can be classified either inflammatory or non-inflammatory. Inflammatory arthritis features inflammatory white blood cells in the joint fluid. Forms of inflammatory arthritis include RA,lupus arthritis,gout and many others.

Forms of non-inflammatory arthritis include OA,arthritis of thyroid disease,arthritis after injury,and many others.

Blood tests are helpful in the diagnosis of RA,but a person's history and physical examination are more important. After the first visit, the physician will make a diagnosis based on medical history, joint examination,and the lab test results. In most patients, RA is readily identified. However,in some patients,the diagnosis may be more difficult,and delayed.

After making a diagnosis,the physician will decide on the severity of RA the patient has,and determine its course. Active or progressive,RA must always be treated to stop the progression.

To treat early (within 2 years) is always preferable,but treatment of all progressive RA, at anytime,is important. When physicians use the term "late" or "already damaged",the implication is not that nothing can be done. Nothing could be further from the truth. Rheumatoid Arthritis should always be treated, but the earlier, the better.

After the diagnosis ,the physician will prescribe some form of treatment,usually a combination of drugs and supportive therapy. The treatment will take a few weeks or months (dependent on medication used) before the effects are felt,in many cases. At which point,many follow-up appointment will usually occurr.

The patient must communicate with the medical team,educate themselves on every possible aspects of the disease,and the treatment plan that will include close future monitoring of the disease. The important fact is that the patient must understand the "whys,yes, and no's"of treatment.

Most patients are seen only occasionally,over a period of weeks and months,while trying different drugs. If after an appropiate period of time (up until 1 year),the disease is not brought under control,the patient is referred to a specialist. This is usually,very poor for prognosis.

The major problem is delay! Delays caused by poor diagnosis,long waiting lists,too short office-time visits,and inappropiate treatment,which mean that the "window of opportunity" to control,moderate or severe disease is missed. Persistence,and self- education are needed to ensure the patient get prompt,and appropiate treatment. The patient must take on the responsibility of managing their RA. Moving quickly from disease onset to disease control.

Once RA has been recognized,the physician can apply the treatment principles and treatment modalities most suitable for your particular type,and course of disease.

Research and development in the past few years have produced new medications that where not possible or thought about, in the past 20 years.

Management of rheumatoid arthritis involves,the onset of disease,he family physician,the rheumatoloigist,the institution of disease modifying anti-rheumatic therapy,physical or occupational therapy,patient education and control.

The patient and doctor must recognize when the treatment plan is not working,and therefore a change of therapy. A therapy that works for one patient may not work for another.

There are periods of time when the patient "feels good" and times when the patient "feels worse". There will likely be times that a patient with RA "feels cured". It is important to understand that there are very few patients that have "COMPLETE REMISSION" of the disease,and it is essential that the RA patient does not stop the treatment regimen established by knowledgeable health-care practitioners. Rarely does the disease "go-away",although at times the symptoms might temporarily remit,and in some cases,the periods may be longer.

Disability is higher among patients with RA with 50% being unable to work 10 years or shorter after the the onset of disease. Recent studies have demonstrated an increased mortality in rheumatoid arthritis patients. Median life expectancy was shortened an average of 7 years for men,and 3 years for women compared to controlled populations in more than 6000 patients with RA from 4 centres,the mortality rate was two times greater then in the control population.

Patients at risk for shortened survival are those with systemic extra-articular involvement,low functional capacity,low social-economic status,low education,and predisone use,according to the study.

The course of rheumatoid arthritis cannot be predicted in a given patient. Several patterns have been described; *A spontaneous remission particularily in the seronegative patient (mild RA) within the first 24 months of symptoms (less than 10%). *Recurrent explosive attacks followed by periods of quiescence most commonly in the early phases. *The usual pattern is of persistent and progressive disease that wanes and waxes in intensity. *Many RA patients develop "secondary osteoarthritis" as a result of the constant,long-term ravages of rheumatoid arthritis. Osteoarthritis is a disease of the cartilage.

The pain of arthritis varies greatly from person to person,for reasons that doctors do not fully understand. Factors that contribute to the pain include swelling within the joint. The amount of inflammation-heat present,or damage that has occured within the joint itself. The number of joints involved,location,severity--EAFs etc., are all important considerations. Many RA patients have double-digit,painful joints affected.

Beware of ads that refer to curing arthritis. There are over 100 rheumatic diseases and treatment is very different from osteoarthritis and RA.

Each individual has a different threshold,and tolerance for pain often affected by both emotional and physical factors. These can include depression,anxiety and even hypersensitivity at the affected sites due to inflammation or tissue injury. This increased sensitivity appears to affect the amount of pain percieved by the individual.

Pain is a private,unique experience that cannot be seen. The most common way to measure pain is through meaningful,communication with the physician and thus ensure a proper treatment regimen tailored to the individual's needs.

Living with RA,day after day can be emotionally draining at times. The stress of it make one sad and blue. Sometimes,one don't feel like doing anything,going anywhere,or being with family or friends. These feelings can make the patient feel additionally tired,in turn it can lead to depression if the disease is not properly controlled. It's a cycle at times will be difficult to avoid. Many patients find it difficult to pace themselves.

The fatigue and pain is always there,in varying degrees. Often it is difficult to know when one have reached their limit. People don't always heed or recognize the warning signs of fatigue and pain. When they feel good patients often "push themselves excessively",and "pay for it later".

The nagging pains and physical limitations of the more than 100 forms of arthritis are common to millions of people. Rheumatoid arthritis is among the most debilitating of all forms, causing joints to ache and throb and eventually become deformed. Sometimes these symptoms make even the simplest activities ,such as opening a jar or taking a walk .difficult to manage.

Unlike osteoarthritis, which results from wear and tear on your joints, rheumatoid arthritis is an inflammatory condition. The exact cause of rheumatoid arthritis is unknown, but it's believed to be the body's immune system attacking the tissue that lines your joints (synovium).

Rheumatoid arthritis is two to three times more common in women than in men and generally strikes between the ages of 20 and 50. But rheumatoid arthritis can also affect young children and adults older than age 50.

There's no cure for rheumatoid arthritis. But with proper treatment, a strategy for joint protection and changes in lifestyle, you can live a long, productive life with this condition.

Rheumatoid arthritis can affect other parts of the body as well as the joints. Some patients with severe disease may then be at higher risk for complications such as the following:

Peripheral Neuropathy. This condition affects the nerves, most often those in the hands and feet. It can result in tingling, numbness, or burning.
Anemia.
Scleritis. This is an inflammation of the blood vessels in the eye that can result in corneal damage.
Infections. RA patients have a higher risk for infections, particularly from some of the immune-suppressing drugs that they take.
Skin Problems. Skin problems are common, particularly on the fingers and under the nails. Some patients develop severe skin complications that include rash, ulcers, blisters (which may bleed in some cases), lumps under the skin, and other problems. Severe skin disease can reflects a more serious case of RA in general.
Gastrointestinal Problems. Although patients may experience stomach and intestinal distress, one 2000 study reported lower rates of stomach and colorectal cancers among RA patients.
Osteoporosis. Osteoporosis, a disorder in which bone density decreases, is more common than average in postmenopausal women with RA. The hipbone is particularly affected. The risk for osteoporosis also appears to be higher than average in men with RA who are over 60 years old.
Lung Disease. One small study found a very high prevalence of lung disease in newly diagnosed RA patients. The association between a history of smoking and a higher risk for RA, however, may at least partially account for this finding. (Cigarette smoking, in any case, may increase the severity of the disease.)
Heart Disease. Mounting evidence suggests that RA can increase the risk for heart disease, possibly because of the inflammatory response in RA, which may also injure arteries and heart muscle tissue. Some studies have reported that people with RA are 30 - 50% more likely to suffer heart vessel blockages and 60 - 70% more likely to die as result than people without RA. A smaller British study confirmed that about half of RA patients are likely to have silent symptoms of heart disease, and that it tends to develop about 10 years earlier than in people without RA.
Lymphoma and Other Cancers. Changes in the immune system associated with RA and certain RA treatments may play a role in the higher risk for lymphoma observed in patients. Some reviews report that patients with RA have a four times higher risk than healthy patients for developing non-Hodgkin’s lymphoma. A higher risk for lymphoma and blood cancers may also occur in patients who were given total lymphoid irradiation, an RA therapy used mainly in the 1980's when other therapies failed. Other cancers that may occur with increased frequency in RA patients include prostate and lung cancers..
Periodontal Disease. People with RA may be twice as likely as non-arthritic individuals to have periodontal disease. Chronic inflammation and immune dysfunction are central to both diseases.
Pregnancy. Women with RA have an increased risk for premature delivery. They are also three times more likely than healthy women to develop hypertension during the last trimester of pregnancy.

Approximately 15 % of cases will be come on suddenly,over a matter of days. Although not all the joints that will eventually cause trouble will be involved in this first attack,there may be two dozen,which is typical. They will include the MCPs and MTPs. Similar joints on both right and left sides will be involved. Morning stiffness and fatigue will be prominant.

About 75 % of the time the scenery is less spectacular. A wrist becomes swollen and for some time it's the only problem. Or a patient develops marked tenderness under the balls of both feet (MTP joints),particularily when first getting out of bed. Gradually,over several weeks to several months,more and more joints show up. Fatigue and morning stiffness also come into play. It may take a year or so before the pictire is clear enough for definite diagnosis.

In 10 % of cases,-A single joint such as the knee, wrist or shoulder,suddenly becomes very painful,swollen and warm. Often the pain is so severe that the joint can't be used. Two or three days later,it's back to normal. After a month or so another attack strikes,usually in another joint. With time,the attacks becomes more frequent. Gradually they are less and less severe but more and more frequent,and instead of clearing up,the pain starts to persist.

One day, perhaps after a year or more it becomes obvious that the problem is RA. This pattern is called palindromic rheumatism,and while it doesn't always turn out to be RA,it most often does. Palindromic rheumatism may clear up as mysteriously as it comes on,may continue indefinitely,or may evolve into very active rheumatoid arthritis, requiring aggressive action. Very rarely,RA first appears in an extra-articular (EAFs-non-joint) site,with joint symptoms appearing months later. When it does,it usualy takes the form of chest complications,and the patient is usually male.

The inflammation associated with RA also occurs outside the joints. Extra-articular features are more common in patients with moderate and severe disease,but they can occur in mild cases too. Since RA can cause EAF's,it can be viewed as a disease that affects the whole body and not just the joints. the most common EAf in RA is tendonitis or tenosynovitis. Tenosynovitis is inflammation of the tendon sheath.

Rheumatoid nodules (usually over pressure points may appear,it is associated with the moderate-severe type of RA.but it not limited to type. The heart may become involved in RA. (Pericardium-pericarditis-detected with simple ultra sound tests) Lungs-inflammation of lungs is comon. The nervous sstem can be affected-the most common is carpel tunnel syndrome (CTS). RA can also affect nerves in other parts of the body. In rare cases,RA can be so wide-spread that it causes withinin the linings of blood vessels. Eyes can be affected. These features are discussed in other section of my sites in more detail.

There are mild,moderate and severe types of RA (type is more in reference to severity of disease). The effects,medication,day-to-day living and prognosis will be individually different in each case. Being diagnosed with RA is one thing,but living individually is another thing."

Thirty percent of patients have the mild type of RA. Thirty to forty percent have the moderate form. Approximately ten percent will have the severe manifestations of RA to confront. Severe means severe. Ten to fifteen percent of all patients have the type of arthritis characterized by stiffness. This type leads to abnormal tightness than to swelling in the small joints f the hands,wrist,shoulders,and occassionallythe knees and feet The stiffness is marked In this type the joints may look normal,but the patient may find it difficult to hold a glass of water in their hands.Loss of function is the major problem caused by this stiffness.

The need of a rheumatologist is clearly,required for a successful conclusion. Due to the medical training system currently taught,family doctor are given less than 1 % of rheumatology training at medical school. They have a option to take this limited option in rheumatology and many family physicians and internists choose not to take this available option.

Rheumatologists are trained in feeling the normally microscopic synovial membrane lining (which becomes thick in RA) they are trained in "bone count" (number of tender joints). Family doctors and most internists are not trained at medical school in this,and other necessary procedures required in rheumatology. The number of rheumatic diseases makes it impossible for a general practice or internist to follow,in depth.. It is a matter of common sense and factual. Experience and knowledge is provided by a rheumatologist. The family doctor is invaluable,they take care of our general health,and a good doctor,will refer the patient to a specialist.

People have to take repossession of their lives. One of the simplest isn't always easy,but it's effective. Relax,pain,causes stress and tension,and not just psychological tension. Taking a relaxation training session teaches you to enter a more relax physical state that lowers blood pressure,respiratory rate,and adrenalin flow. You'll be taught to lie down and find a comfortable breathing rhythm. Close your eyes,focus on your body's different muscle groups,starting with your calf muscles. Slowly relax your muscles,moving progressively up your body to your neck and shoulders. As the muscles relax,there's a cocomitant release of the body's natural opiates (endorphins),pain relieving hormone's that are related to synthenic opiates like morphine.

Endorphins can be released by any number of stimuli,including laughter. A good belly laugh relaxes stomach muscles,and that may be one reason why it works,releasing muscle tension is a relief fron an unconscious source of pain and discomfort. The heart speeds up,blood pressure rises and,when respiration accelerates,there's an increase in oxygen exchange. A good belly laugh when watching a TV sitcom not only exercises your diaphragm and abdomen,but the muscles of your face and shoulders and sometimes even the muscles of your legs and arms.

By the time your laughter subsides at the commercial break,you've had a short aerobic workout. After an exhausting "laugh-out",don't underestimate the value of rest,energy conservation,and sleep.

Combination Therapy:

Some promising combinations include: 1) methotrexate (mtx) and sulfasalazine (ssz) and hydroxychloroquine. 2) mtx and intramuscular gold . 3) mtx and etanercept. 4) mtx and leflunomide 5) mtx and infliximab. 6) mtx and cyclosporin has been tried ,but due to higher toxicity of cyclosporin it is not used commonly,today. 7) mtx and arava might not work for everyone. Monitoring and selection will vary due to differences in patient efficacy.

Methotrexate has become the gold standard in North America. It promises early onset of action,usually within 4 to 6 weeks. MTX is usually given as tablets,but can be given subcutaneously. The effective weekly dose for a patient may be low as two 2.5 mg tablets,or as high as ten. The averag is % tavlets (12.5mg.) once a week. Because the effective dose range is so wide,its best to start low (3 tablets / week). and only slowly increase the dose by one tablet each time. changes in dose should occur no more often than every 3 weeks;once a month is the usual.

It is unusual to notice a good response at a fairly low dose at first,but then to require a higher dose later on to maintain that response. a complete blood count (hemoglobin,white cell and platelet counts ) is usually done every 2 weeks until the final dose is selected,then every 4 to 6 weeks Liver function test may be performed,depending on the patient situation. Some patients claim better response with the injection procedure with less side effects.

NSAIDs don't interact with MTX when MTX is taken in the doses recommmended; however,sulfa-containg antibiotics increase the risk of side effects and should be avoided. Side effects are ofen dealt with by decreasing the dose or temporarily stopping MTX and then restarting it.

Gold has the potential of disease suppression.,but it is more toxic The refular dose is (50 mg./weekly). To mke sure the patient isn't sensitive to gold,two small test doses of aurothiomalate are given,one week apart. The practise in the past was to do this,once a week,until 1,000 mg. had been given,and some doctors may still do this. If the patient is no better,then they try another drug

The major disadavantage include the need to visit the doctor each week,the longer time for efficacy (12 to 20 weeks), Blood tests and urine tests are usually done prior to injection. Twenty weeks is a long time to wait to see if the drug works or not. If it does not work,it is valuable "wasted time" w.r.t. to the ongoing disease process.

Azathioprine is taken daily. The initial dose is one tablet (50 mg) and later the dose is adjusted according to the patient's weight. Later,if the patient has done well,the dose can be reduced without losing the effect. Once a regular dose has been settled on complete blood counts (CBC) are needed less frequently than with mtx and gold,but it should still be checked at least every 3 months.

Sulfazaline is used more in Europe. The British rank it somewhere near intramuscular gold. Its safety profile is excellent. It takes action in 2 to 3 months

There are some conflicting reports as to whether ssz is useful in some of the seronegative arthritis cases, PA and AS. SSZ should be started with a low dose and gradually build up. Start with one tablet (500 mg) a day for a week,then increase the daily dose by one tablet each week until, by the fourth week the patient is taking two tablets twice a day, there are other variations to this schedule.

Hydroxychloroquine HCQ) is considered to be much weaker than almost all the other DMARDs (plaquenil). It's safety profile is excellent It takes effect in 3 to 6 months ,but its long-term benifit is not so good as the others. In the case of severe RA,six months is a long time to wait,and find the drug ineffective.

It's very important to get a annual eye check up. The maximum daily dose is 400 mg-calculated w.r.t. bodyweight--200 mg/twice/daily.

Auranofin-oral gold has been proven to be a disappointment .There is little flexibility in the dose of auranofin- one 3 mg. tablet twice a day. A complete CBC and urinalysis /monthly. Long time for efficacy results-six months.

D-penicillamine and cyclosporin is not commonly used today . With the many alternative,including the newer biologics the two are on the "back-burner" but when every thing else fails,they are available-they have higher toxicity levels,and hard to control,at times.

In 1998, a new agent, Arava (leflunomide), was approved by the FDA for use in the treatment of adult rheumatoid arthritis (RA). It is now available on the market. Leflunomide inhibits an enzyme that participates in inflammation in the joints of people with RA. Clinical studies lasting up to 12 months demonstrate that leflunomide improves the signs and symptoms of RA and may slow down joint damage as seen on x-rays. In two studies, leflunomides effectiveness was similar to sulfasalazine and methotrexate, two disease-modifying anti-rheumatic drugs (DMARDs) that have been widely used in RA for many years.

Leflunomide may cause diarrhea, hair loss, rash, and, rarely, liver disease. It is toxic to fetuses and should not be used in pregnant or nursing women, and women and men not using reliable birth control methods, or in children. Its long-term side effects are unknown. Leflunomide costs 4 to 5 times as much as generic methotrexate and is indicated for patients with active rheumatoid arthritis.

Celebrex (celecoxib) has recently been approved by the FDA and is currently available on the market. It is the first of a new class of drugs called COX-2 specific inhibitors. It is being marketed as a drug that will reduce pain and inflammation in arthritis while being less likely to cause stomach problems, such as ulcers, than current non-steroidal anti-inflammatory drugs (NSAIDs).

One of the major ways in which NSAIDs work is to inhibit enzymes called cyclo-oxygenase (abbreviated COX). There are two types of cyclo-oxygenase: COX-1 and COX-2. COX-1 enzymes are present under normal conditions in many tissues of the body and are beneficial. For example, they may protect the stomach lining and maintain kidney blood flow. COX-2 enzymes are produced during inflammation and contribute to pain and swelling in arthritic conditions.

Currently, all other NSAIDs available to the public inhibit both COX-1 and COX-2 enzymes. As a result, all other NSAIDs reduce inflammation and pain in many people but also cause stomach-related side effects such as ulcers and heartburn as well as kidney problems.Doctors know that some patients who take nonspecific NSAIDs for arthritic pain have a higher risk of stomach-related problems. Such people have already had ulcers, are older, or have other medical problems. There are strategies that doctors may use today that can reduce the side effects and permit some people to keep taking the nonspecific NSAIDs. For example, drugs such as misoprostol (Cytotec) and omeprazole (Prilosec) may reduce stomach ulcers in people who take nonspecific NSAIDs.

In clinical studies lasting up to six months, patients who took celecoxib were observed by endoscopy tubes inserted into their stomachs to have fewer stomach ulcers than patients who took other NSAIDs. It is not known whether this decrease in the number of ulcers will be associated with a lower frequency of complications of ulcers such as bleeding. The studies show that celecoxib works about as well as other NSAIDs such as ibuprofen or naproxen for arthritis pain. Celecoxib costs 4 to 5 times as much as generic ibuprofen or naproxen.

For non-inflammatory conditions such as low back pain or muscle aches, analgesics such as acetaminophen or low doses of ibuprofen are preferred because they are effective, usually safe, and inexpensive. In most arthritis patients who have no major risk factors for gastro-intestinal side effects, the nonspecific NSAIDs may be taken relatively safely in low doses. If stomach distress does occur, other medications may be effective in calming symptoms and/or preventing ulcers.

Any patient who has active ulcer disease or GI bleeding problems, is on multiple medications, has serious medical disorders, or is quite elderly, should be encouraged to use non-pharmacologic approaches for their osteoarthritis if at all possible. The exact role for celecoxib and other COX-2 specific inhibitors for the treatment of chronic arthritis pain and inflammation will emerge after more experience accumulates. Celecoxib is indicated for chronic arthritis pain with or without inflammation.

*NOTE ROFECOXIB (Vioxx) WAS TAKEN OFF THE MARKET BY THE FDA .