The Canadian Pharmacists Association advises that patients find out the answers to the following questions about their prescriptions: *Why is this medication being prescribed for me? *When do I take this medication and for how long? *What should I do if I miss a dose? *What are the common side effects? *What should I do if I experience a side effect? *Should I avoid any food,alcohol or other drugs when I'm taking it? *How will I know if the medication is working? *What should I do if the medication is not working? *How should I store my medication?

 

The more complex the regimen's specifies (i.e., with food,without food) and the more often people have to take it,the less likely they are to follow instructions properly. People are less likely to take a medication that has been prescribed many times a day than say two times a day. On the other hand there are substantial improvements when people take once-daily versus a twice-daily formulation of the same medication.

 

If you are having difficulty with your medication regimen,talk to your doctor about adjusting about the possibility of adjusting your schedule. Depending upon the type of medication, you may be able to combine the daily doses. Not surprisingly,people are more relunctant to take a medication if there are severe side effects,especially if they don't understand how the medication works.

 

Methotrexate,for example,can cause side effects such as fatigue, nausea, stomach problems (GI),or mouth sores. Before abandoning any medication because of any such negative symptoms, ask your physician. Some side effects are only short-lived;others can be alleviated with simple treatment (e.g.,taking folic acid with MTX may reduce the incidence of mouth sores, nausea, headaches,etc.) There are some additional medications that can control or eliminate certain other side effects.

 

When it comes to injected medications,the fewer shots the better. Most patients dislike the pain and discomfort of injections,they can be uncomfortable with the idea of injecting themselves with needles: * Talk to your doctor or pharmacist about how your medications works and exactly how you should take them and why. The more you know about your medications,the more likely you are to use them correctly. *Ask your physician about possible side effects. What signs you should watch for and what you should do when they occur. *Never change the dose of your medication or stop taking it without consulting with your doctor first. *Make sure your doctor and pharmacist have a complete list of all medications you are taking ,including both prescription and non-prescription or over-the-counter medicine.*When you miss a dose,don't double dose on the next day,forget about the missed dose.

 

When you visit your doctor write out any questions you have in advance,so you won't forget to ask them. Also write down your symptoms, allergies, medicines, previous medical procedures,conditions, and diseases,and show this list to your doctor,Talk about your biggest concerns first. Let your doctor know about the symptoms that bother you the most. Be clear about how you feel If you have pain describe how bad it is. Such descriptive words as aching, searing, unbearable,throbbing ,sharp,and burning can help your doctor judge the severity of your pain.

 

Point to the joint or show your doctor the exact location and movement that causes pain. Don't be afraid to ask questions. Make sure you know what to expect from your treatment and how long it will take for expected efficacy per medication. Be sure to ask the doctor for strategies for immediate symptom relief and long-term control of the disease. Ask the doctor to write down important therapy instructions. If a medication is not helping you,let him know,there are many alternatives.

 

When you are in pain,all you care about is feeling better now, but pain relievers--important as they are in relieving your immediate symptoms--NSAIDs--do nothing to stop the irreversible joint damage caused by uncontrolled RA. When your RA is uncontrolled that means more pain. In order to slow the progression of the disease a disease modifying drug (DMARDs) such as methotrexate is needed. However, 10 to 20 per cent of people with moderate to severe RA will not be able to control their disease effectively using the traditional combination of anti-inflammatories and DMARDs. If you live with moderate to severe RA--especially if you've tried mutiple traditional medications--you may have come to the conclusion that daily pain and disability are simply your lot in life. Do not accept this thought. You may find relief with biologic therapy drugs. Unfortunately,in Canada, government health plans, especially in Canada,don't fully understand the need. We must put more pressure on the politicians and civil-servants in the health department.

 

Pain location:*Where do you have pain and stiffness (feet,hands,knee,hip?). *Do you have symptoms anywhere else? *Does your pain or stiffness move from one area to another? *How often do you have symptoms (daily,weekly)? *Function--Are there things you could do one or two years ago that can't be done now or only with difficulty? *Severity--How bad are your symptoms? Do your symptoms interfere with any of your activities (bathing, dressing, exercising,playing with your children)? *What makes you feel better or worse--.What relieves your symptoms?(exercise,rest,medicine)? What makes them feel worse (inactivity,stress)? *Has any treatments worked for you? if so,which one? *Have you had any negative reactions to any treatment? These are questions that your healthcare provider should be aware of in the management of your disease-control. It is up to you as a patient to make them aware of your status. They have many patients and very busy with little time.

 

Educate yourself on all aspects of the disease including medication and physical therapy. Remember that rheumatoid arthritis affects different people in different ways and form and that applies to medication-therapy-management. The health-care provider may not always be right or knowledgeable in a certain situation or area. The family doctor has many new therapies and diseases to cope with daily,it is almost impossible for him to be up-to-date on everything. He doesn't have the time in many cases.The patient must learn to help manage their own disease.

 

Some patients have resistant disease and experience a progressive course, despite exhaustive trials of DMARDs whether used alone or in combinations. While the utimate goal of treating RA is to induce complete remission,this occurs infrequently. If complete remission is not achieved,the management goals are to control disease activity,alleviate pain, maintain function for activities of daily living and work,and maximize quality of life.

 

Achieving these goals challenges the managerial skills of the rheumatologist to determine the the most efficacious combinations of pharmacological therapy, which may include NSAID,DMARD(s),low dose predisone,local injection of glucocortoid,rehabilitation support and anagesics. Although adequate pain relief is an important goal with a chronic disease such as RA,the ACR,does not recommend narcotic analgesic dependency.

 

Given the chronic waxing and waning course of RA,a longitudal treatment plan needs to be developed,and the patient should be involved in developing the plan. The discussion should address disease progression, prognosis and treatment options,taking into account adverse effects,expected time for response,the patient's risk factors and comorbid conditions, monitoring ease,activity (i.e., ongoing disease activity after 3 months of maximum therapy ),or progressive joint damage require consideration of significant changes in the DMARD regimen.

 

If disease activity is confined to one or a few joints,then local glucocortoid injection may help. For patients with severe symptoms,systemic glucocortoids may need to be initiated,or the dosage may need to be incresed, for a short period of time. Active joint disease may impair physical function and may also be aggravated by physical activity. Therefore, consultation with a occupational therapist, physical therapist and/or nurse-counselor familiar with rheumatic diseases should be considered early in the disease course.

 

Periods of rest,job modification,time off from work, changes in occupation,or termination of work may be necessary. Reconstructive surgery should be considered for patients with end-stage joint damage that is causing unacceptable pain requirements of pharmacologic agents,and the patient's preference. Expectations for treatment and potential barriers to carrying out the recommendations should be discussed. Psychosocial factors,such as illness beliefs and perceived self-efficacy,have been shown to affect patient outcomes and treatment adherence Education and cognitive-behavioral interventions,such as the Arthritis Society Self-Management Program,can improve health status and decrease visits to the physician.

 

Angelfire RA Links Although there is little difference in NSAIDs pharmacologically,individual NSAIDs will show signiificant difference in efficacy and side effects in different individuals. NSAIDs,DMARDs and Steriods are covered in other articles , therefore,we give give some updates and a review. Patients with RA are nearly twice as likely as patients with osteoarthritis from NSAID treatment Risk factors for the development of NSAID-associated gastroduodenal ulcers include advanced age ( 75 years and older ),history of ulcer,cocomitant use of corticosteriods or anticoagulants,higher doseage of NSAID,use of mutiple NSAIDs,or a serious underlying disease.

 

The following approaches may be considered for patients with RA who would benefit from an NSAID but who are are at increased risk of serious adverse GI effects: use of low-dose predisone instead of a NSAID,use of which are effective in decreasing NSAID-associated gastroduodenal ulceration,include high dose H2 blockers,proton-pump inhibitors and oral prostaglanden analogs (Cytotec etc).

 

While symptoms of dyspepsia are often improved by treatment with H2 blockers,one study showed that asymptomatic patients with RA who were receiving both NSAIDs and low-dose H2  blockers were at higher risk of GI complications than those receiving NSAIDs alone. Therefore,routine use of H2 blockers to prevent dypepsia or to protect against NSAID-induced gastropathy is not recommended--ACR.

 

In two recent large trials comparing highly selective COX-2 agents with traditional NSAIDs,the patients in the selective COX-2 agent group had significantly fewer GI events. There are several caveats,however. If anticipated therapy is indicated (e.g.,as risk reduction for cardiovascular disease),an agent such as a nonacctylated salicylate,use of a highly selective COX-2 inhibitor,or use of an combination of an NSAID and a gastroprotective agent. Gastroprotective agents,addition of low-dose aspirin may partially ameliorate the benefit of less GI toxicity associated with highly selective COX-2 agents. Morever,the use of a highly selective COX-2 agent has been reported to be associated with a higher rate of thrombotic events, compared with traditional NSAID. Use of NSAID and selective COX-2 inhibitors should be avoided in conditions associated with diminished intravascular volume or edema,such as congestive heart failure,nephrotic syndrome,or cirrhosis and in patients with unacceptable serum creatinine levels .

 

All patients with RA ar candidates for DMARD therapy. Although NSAIDs and glucocorticoids may alleviate symptoms, joint damage may continue to occur and to progress. DMARDs have the potential to potential to reduce or prevent joint damage preserve joint integrity and function and ultimately reduce the total costs of health care and maintain economic productivity of the patient with RA. The initiation of DMARD therapy should not be delayed beyond 3 months for any patient with an established diagnosis,who,despite adequate treatment with NSAIDs has ongoing joint pain,significant morning stiffness or fatigue, active synovitis,persistent elevation of the ESR or CRP level,or  radiographic joint damage. For any untreated patient with persistent synovitis and joint damage,DMARD treatment should be started promptly to prevent or slow further damage.For 60 to 90% of patients the disease is progressive despite treatment, leading to disability and early mortality. This group of patients often shows extra-articular manifestations of the disease (e.g. vasculitis which can involve skin, lung, heart, kidney and ocular vessels).

 

In those with the poorest functional status and more involved joints the 5-year survival rate can be les than 50%; this is similar to mortality in other severe diseases such as stage IV Hodgkin's disease and 3-vessel coronary artery disease. But Not for All. Nevertheless, for a small proportion of patients (5 to 20%) the disease is mild and symptoms resolve within 1 to 2 years after treatment with NSAIDs alone. For a further 5 to 20% of patients the disease progresses slowly and response to DMARDs is usually satisfactory.

 

Although those with mild disease often have a smaller number of involved joints and rheumatoid factor is not detectable, there is no agreed prognostic marker(s) to determine which 'type' of rheumatoid arthritis a patient is likely to have at initial presentation. Treatment is therefore usually 'stepped up' gradually to avoid exposing patients with milder types of rheumatoid arthritis to poorly tolerated therapies.

 

The goal of treatment is to control inflammation sufficiently to prevent or retard joint damage with the ultimate goal being to induce complete remission. Unfortunately complete remission is rarely achieved. A number of criteria are used in clinical trials to measure response to treatment and are often combined to form a composite measure of treatment response, e.g. the American College of Rheumatology (ACR) criteria . Minimal clinical response is defined as a 20% improvement (ACR 20).

Try NSAIDs First-NSAIDs reduce joint pain and swelling and may improve function; however, they do not alter disease progression. Nevertheless, because of the unpredictable course of rheumatoid arthritis at presentation they are usually used as initial treatment. If patients continue to experience persistent joint symptoms, morning stiffness, and fatigue for more than 3 months, treatment with DMARDs is indicated.

 

Delaying treatment with DMARDs until joint damage is evident was found to be associated with poor long term outcomes. The current treatment strategy therefore involves the early use of DMARDs to limit joint damage and preserve function. The term DMARD applies to a diverse array of drugs such as penicillamine, oral or intramuscular gold, sulfasalazine, antimalarials (chloroquine and hydroxy chloroquine) and immunosuppressants (methotrexate, azathioprine, cyclosporin, leflunomide).

 

There is typically a delay in onset of clinical efficacy with these drugs which ranges from 4 weeks to 6 months depending on the DMARD being used. Adverse events are a major limitation of the use of DMARDs and monitoring of complete blood counts is recommended for all DMARDs (except hydroxy-chloroquine and leflunomide). Additional monitoring of liver function tests, serum creatinine and urine proteins is required for some DMARDs. The cost of adverse event monitoring adds significantly to the cost of treatment with these agents.

 

Nevertheless, the consequences of rheumatoid arthritis are so severe that the efficacy/toxicity ratio of drugs such as methotrexate, sulfasalazine and hydroxychloroquine appears to be favourable. Such treatments are best administered by specialist rheumatologists.

 

Among the older DMARDs, methotrexate appears to have the best long term efficacy and is often selected as the initial DMARD. This observation conflicts with the registered indication which is for patients with severe, acute disease who do not respond to a course of NSAIDs and at least one other DMARD. This caution is a reflection of the potentially serious adverse events associated with this drug including an increased risk of lymphoma. Despite methotrexate's ability to reduce disease activity and joint damage, it rarely leads to true remission and combination therapy is frequently required.

 

Leflunomide is a more recently introduced DMARD. Over longer treatment durations (24 months), leflunomide appeared to be at least as effective as methotrexate and more effective than sulfasalazine. Leflunomide also delayed radiological progression, assessed after 12 or 24 months of treatment, at least as effectively as methotrexate (in some patients ) or sulfasalazine and reduced functional disability (assessed using a Health Assessment Question naire) to a greater extent than either methotrexate or sulfasalazine after treatment durations of 6 to 24 months. The drug had a faster onset of action (4 weeks) than either methotrexate or sulfasalazine and was as well tolerated as both of these drugs in clinical trials.

 

Infliximab and etanercept have recently been approved for use in the treatment of rheumatoid arthritis ( 5 years ).Both drugs have been shown to reduce disease activity and joint damage so can be considered as DMARDs. However, unlike the more traditional DMARDs these drugs directly target TNF, a proinflammatory cytokine, which plays a key role in the pathological inflammatory process in rheumatoid arthritis. Both drugs have a faster onset of action (1 to 2 weeks) compared with other conventional DMARDs.

 

 They have been associated with an increased risk of upper respiratory tract infection and more rarely with cases of serious infection. For this reason they should not be given to patients with active infections and should be discontinued if a patient develops a serious infection or sepsis. Approximately 10% of patients receiving infliximab have developed antibodies to the drug but the clinical significance of this is not yet known.

 

In contrast, etanercept antibodies have only rarely been reported in etanercept-treated patients. Antinuclear antibodies and anti-double-stranded DNA antibodies ( Lupus )have been reported to occur more frequently in both etanercept and infliximab treated patients compared with placebo recipients, although drug-induced lupus has been reported in only 2 rheumatoid arthritis patients (both of whom were receiving infliximab).

 

Etanercept approved for use alone. Etanercept was the first TNFinhibitor to be approved for rheumatoid arthritis. It produced improvements in all components included in the ACR core set of disease activity measures  in patients who had failed to respond to conventional DMARD therapy, when used alone (at a dosage of 25mg subcutaneously twice weekly) or in combination with oral or subcutaneous methotrexate (10 to 25 mg/week).

 

 Etanercept (25mg twice weekly) was also at least as effective and well tolerated as methotrexate (7.5 mg/week increasing to a maximum of 20 mg/week) in a large double-blind comparative trial of patients with active rheumatoid arthritis who had not previously received methotrexate. Furthermore, etanercept reduced joint erosion significantly more effectively than methotrexate after 6 and 12 months of treatment in the same study ( the curve seems to drop on a  longer term trial ). Overall, etanercept has been well tolerated with injection site reactions being the most frequently reported adverse event occurring in up to 49% of patients receiving the 25mg twice weekly dose.

 

Infliximab for use with methotrexate. Infliximab, a chimeric mouse-human monoclonal antibody directed at TNF, has primarily been evaluated in combination with metho trexate and is therefore only approved for use in combination with this drug. Infliximab (3 or 10 mg/kg intravenously every 4 or 8 weeks) plus methotrexate (15 mg/week orally) elicited a greater response in ACR criteria after 30 weeks of treatment than methotrexate alone in a double-blind, placebo-controlled trial.

 

 All patients enrolled had failed to respond to more than 1 DMARD. Preliminary data indicate that response is sustained for up to 54 weeks and that joint damage is reduced compared with methotrexate alone. Adverse events, including serious events, occurred more frequently in infliximab-treated patients than in the placebo group ).

 

If residual inflammation remains after maximum doses of DMARD monotherapy, combinations of DMARDs should be considered. Methotrexate is the drug most commonly used in combination. These studies generally indicate increased efficacy for combination therapy compared with monotherapy and tolerability does not appear to be increased. The use of combination regimens is becoming more common for the treatment of patients with refractory rheumatoid arthritis but long term follow-up (5 years) is still needed to determine optimum strategies.

 

There's no point beating around the bush: If you have arthritis,you'll almost inevitably require some medication. That could mean daily,and for the rest of your life. To minimize your risks and maximize your benefits, you're going to have to become an enlightened consumer and learn to work as part of a team with your doctor and your other health care workers.

 

Consider this scenario: You haven't been feeling well for some time-persistent joint pain,flulike malaise and morning stiffness. You see your family physician who does a physical exam and order some lab test. May even give you a pill. At a follow-up appointment,your doctor announces that you may have rheumatoid arthritis (RA),and an appointment is being set up with a specialist. In the meantime,he says,have your pharmicist fill out this prescription and follow instructions on the label. You're so stunned by the diagnosis you barely absorb what the doctor has said.

 

You follow instructions blindly,not knowing what to expect, and, several months later-just as you're starting to feel some-what better-you're totally unprepared for the "flare-up" that appears. Or you throw away the pills and the RA gets worse. Or you take the pills "when you feel like it." Certainly,your doctor is confused. You're not getting worse,you're not getting any better.and she starts adjusting your treatment regimen...again !

 

Here's an alternative. Learn everything you can about your condition, become a arthritis self-manager,someone who knows about "risk-to-benifit ratios","optimum blood serum levels".and "indications and contraindictions." Now you know what you're medications are supposed to do,when,and why. You know what to do if it doesn't work,and what side effects to watch for-which can be serious-and which in most cases can be dealt with a change in dose ,the way it is delivered or a change in medication. You're not buffeted by every change in your condition. You're less anxious and far less fearful You will actually have less pain. You're in control of the disease. You've made yourself an very important member of the health care team ! Actually,a arthritis self-manager.

 

Rheumatoid arthritis patients have variable disease courses,therapy needs to be tailored for each individual. After diagnosis,it is important for the physician and patient to devise a treatment plan together. Since RA is an ongoing disorder involving the entire body,therapy is many-sided and includes both medication-based and non-medication-based treatments. The treatment plan generally requires a team approach with other professionals ,including nurses, physical and occupational therapists,orthopedic surgeons, psychologists and social workers, when applicable,depending upon individual patient needs.

 

Medication management of patients diagnosed with RA involves an initial assessment of disease stage and activity level. For patients with early mild disease, treatment with NSAIDs and continued rigourous evaluation of progression of disease is necessary. For patients with active, progressive disease,early aggressive therapy with DMARDs is indicated.

 

Therapy other than medications is a critical element of treatment for the RA patient A team approach with health providers is essential,both rest and exercise help in important ways. People with RA need a good balance between the two,with more rest when the disease is active and more exercise when it is not. Rest fights fatigue and helps reduce active joint inflammation and pain The length of time needed to rest will vary from person to person,but in general, occassional short rest breaks are more helpful than long periods spent in bed.

 

Exercise is important maintaining strong muscles and flexibility and preserving joint mobility. Exercise also helps people sleep well,reduce pain,maintain a positive attitude,and lose excessive weight. Exercise programs should be planned and carried out to take into consider ation the person's physical abilities,limitations,and changing needs.

 

During the course of RA,particular attention should be paid to maintaining functional status. This often requires input from physical and occupational therapists. With the exception of several specific types of oils (including omega 3 fatty acids),there is no evidence that any specific food or nutrient helps most people with RA. However,an nutritious overall diet with appropriate calories, protein and calcium is important. Some patients need to avoid alcohol consumption because of medication interactions. Physician and dietician guidance  on this issue is important (preferably dietician).

 

Osteoporosis prevention is an issue that needs to be addressed as part of long-tem.ongoing care. Rheumatoid arthritis substantially increases the risk of osteoporosis. This risk is further increased if patients are taking corticosteriods such as predisone. The benefits of calcium and vitamin D supple ments,hormone replacement therapy,or other treatments (such as bisphosphonate therapy) for osteoporosis should be discussed. Patients who are well informed and participate actively in their own treatment experience less pain and make fewer visits to the doctor than those who are not actively involved in their own treatment.

 

In some patients with advanced RA,joint destruction may occur despite appropiate non-surgecal attempts to preserve joint function. Surgery is necessary once a patient suffers significant functional decline on the basis of joint destruction or once the patient experiences relenting pain.

 

Herbs are the basis for many traditional medications as aspirin and morphine. Practisioners of some complementary therapies believe that certain herbs have anti-inflammatory properties. These herbs include cumin,coriander, celery, evening primrose oil turmic, devil's claw,thunder god vine, feverfew, capsicum, cinammon,yucca.dandelioin and ginger. Little research has been conducted on the plant's effectiveness. The results from clinical trials of evening primrose rose and capsicum for RA have been mixed. A trial for ginger as a treatment for OA found it may be useful A dieabitic should not use ginger. Research into turmeric, devil's claw,feverfew and willow found no benefit for the inflammation that occurs in arthritis.

 

For centuries,Chinese practisioners have used the herbal remedy tripterygium wilfordii hook f (TWHF) to treat inflammation and musculosketal injuries. TWHF is a vinelike plant found in southern China. However,TWHF can be toxic at high  doses (as many herbal products are) it can cause heart damage, kidney failure,intestinal problems, shock ,decreased sperm production and menstrual irregularities.

 

The toxicity and drug interactions with other medication can have serious,dire consequences. Furthermore, herbs are unregulated and inappopriate dosing can have many unforseen consequences. Research may someday help carve a niche for some herbs in arthritis treatment. For now, remember that many herbs contain powerful substances that can be toxic and interfere with medications.

 

One of the important questions always asked about a RA medication is whether or not people taking it will continue to respond favorably to it over an extended period of time. People can become refractory (non-respondent) to a medication,i.e., even though they continue to take it,the drug becomes less effective. Rheumatologists are regarding the biologics (5 year reports is favourable-Enbrel) and other intriguing TNF-alpha blockers with caution,but with optimism. As more experience is gained with their use,and as other forms of cytokine antagonists become available,this novel approach will more than likely become an integral part of treatment programs aimed at gaining control over RA. Current costs prevent wide spread use to all RA patients.but in many cases conventional medicine have proven adequate.