CD-ROM Today 1996 January

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$Unique_ID{BRK01750} $Pretitle{} $Title{Information for You about Arthritis, part I} $Subject{arthritis joints joint tendinitis bursitis stiffness rheumatoid gout bones elbow knuckle synovial membrane ligaments ligament tendons rheumatic ra immune system Swelling morning tenderness redness warmth fever weakness osteoarthritis rheumatoid systemic lupus erythematosus ankylosing spondylitis scleroderma psoriatic fibrositis autoimmune disease diseases knees knee hand hands feet uric acid probenecid sulfinpyrazone kidneys allopurinol aspirin acetylsalicylic acid gold salts penicillamine nonsteroidal anti-inflammatory drugs NSAIDs CORTICOSTEROIDS immunosuppressive hydroxychloroquine Quackery Ankylosing spondylitis Bursae Cartilage Flare flare-up Remission Synovectomy} $Volume{Y-0} $Log{ Osteoarthritis*0001702.scf Rheumatoid Arthritis*0001703.scf Tendons of the Wrist*0001705.scf Gout Affects the Elbow*0003801.scf Gout Affects the Kidneys*0003802.scf Gout Affects the Knee*0003803.scf Gout Affects the Ankle*0003804.scf Gout Affects the Toes*0003805.scf Gout Affects the Instep*0003806.scf Gout Affects the Hand*0003807.scf Gout Affects the Ear*0003808.scf Progressive Levels of Arthritis*0005601.scf Typical Rheumatoid Hand Deformities*0005602.scf Bursae of the Knee*0016401.scf Gout and the Kidney*0016701.scf} Copyright (c) 1991-92,1993 Health Update by Dr. Allan Bruckheim Information for You about Arthritis, part I ------------------------------------------------------------------------------ What is arthritis? Most people suffer various aches and pains during their lives. Over the years, as aches and discomforts in the joints occur, many people call it arthritis and chalk it up to aging. They're partly right, and partly wrong. Pain in the joints may be arthritis, but arthritis is not just a byproduct of aging. Arthritis is a condition in which one or more joint becomes inflamed ("itis" means inflammation and "arth" means joint), but it is not just one disease and does not affect only the elderly. It can be a crippling, extremely painful condition that harms other vital organs as well as the joints. There are more than 100 forms of arthritis and it's the most common chronic condition in the United States. If you suffer from arthritis pain, you are one of 37 million Americans with the same complaint. You may be very young; 250,000 children have juvenile arthritis. Several types of arthritis predominantly affect women. It almost certainly costs you money in some way; the Arthritis Foundation estimates that arthritis costs more than $13 billion each year in direct medical costs or lost wages. Some forms of arthritis, such as tendinitis and bursitis, can be cured completely with your doctor's advice and care. However, most forms are chronic, which means they last for years, usually for the rest of the patient's life. There are no cures for arthritis, there is only treatment and therapy, which can alleviate pain, relieve stiffness and prevent the disease from progressing and deformities from occurring. Like many chronic diseases, arthritis flare-ups may come and go. Some people may have an attack of rheumatoid arthritis or gout and then be fine for several years, while others have the condition almost continuously. Different people with the same type of arthritis may have a vastly different range of symptoms and so be treated quite differently by the same doctor. Arthritis is not a new disease; it has plagued humanity for a long time. Skeletons from ancient mummies show signs of arthritis. Judging from some of their bones, even dinosaurs may have had some morning stiffness. All forms of arthritis affect the joints of the body, the points where two bones meet. While not all joints are alike, almost all have certain structures that are affected by the inflammation and swelling of arthritis. A basic joint--one like your elbow or knuckle--is made up of two bones that come together. The tips of the bone do not touch within the joint because they are protected by a tough layer of plastic-like cartilage. This smooth material acts as a shock absorber. The area around the joint is enclosed in a lining called the synovial membrane. This membrane creates a slippery liquid called synovial fluid that acts as a lubricant for the joint. The bones of the joint are held together and are attached to the muscles that move them by ligaments and tendons, which are tough cord-like tissues. Ligaments connect the bones to each other while tendons attach muscle to bones. Most joints have several tendons and ligaments. To keep these structures moving smoothly, there are small sacs of fluid called bursae (the singular word is bursa) tucked between the structures. The group of conditions known as arthritis is just one part of all rheumatic diseases, which affect the joints as well as supporting structures like muscles, tendons and ligaments. In arthritis, inflammation of the joint causes swelling, loss of motion, redness and pain. Inflammation is the body's reaction to an injury, enabling it to fight bacteria or viruses. The body's immune system sends special cells to the injured area to fix the problem and repair any damage. When the job is done, the inflammation dies down. In arthritis, inflammation may be out of control. It does not go away after the first attack but returns causing more inflammation and a dangerous cycle starts. Joints become stiff and hard to move and delicate joint structures become swollen and pushed out of place. If inflammation is not stopped, the joint becomes deformed and permanently harmed. How do I know if I have arthritis? The Arthritis Foundation has published the seven warning signs of arthritis. You should be aware of them and should consult your physician if you spot them. -- Swelling in one or more joints -- Early-morning stiffness -- Recurring pain or tenderness in any joint -- Inability to move a joint normally -- Obvious redness and warmth in a joint -- Unexplained weight loss, fever or weakness, combined with joint pain -- Symptoms such as these that last for more than two weeks What are the forms of arthritis? While there are more than 100 forms of arthritis, the most common are osteoarthritis, rheumatoid arthritis, systemic lupus erythematosus, gout, juvenile arthritis and ankylosing spondylitis. Other forms of arthritis are scleroderma, infectious arthritis, psoriatic arthritis, fibrositis, tendinitis and bursitis. Each of these diseases has a different cause and may require different medications and treatments. Only a physician can differentiate between these diseases. If you have any of the symptoms, please consult your doctor. OSTEOARTHRITIS The most common kind of arthritis is osteoarthritis ("osteo" means bone). It is also known as hypertrophic arthritis and degenerative joint disease. In osteoarthritis, the cartilage and connective tissues of the joints have started to break down or wear thin. The ends of the bones start to overgrow, become thickened and form bone spurs. What's left of the cartilage becomes rough and the bones themselves start to rub together, making movement difficult. However, there is little inflammation in the joint itself and pain can vary from mild to excruciating. The motion of the joint becomes more limited as the disease progresses. There are no other symptoms of this disease. Osteoarthritis is thought to be caused by normal wear and tear on the joints. That's why the symptoms--pain and stiffness--usually begin slowly, then get worse gradually with age if treatment and medication are not followed. X-rays of almost anyone over age 60 will reveal some signs of osteoarthritis, but only a few people have pain or stiffness. Continued injury to a joint will also bring on osteoarthritis. Retired football players often suffer severe osteoarthritis in their 30's and 40's. Older ballet dancers may have osteoarthritis of the toes and ankles because of the stress placed on these joints over their careers. The joints most commonly hit by osteoarthritis are the fingers, hips, knees and spine. It may affect only one or two joints, or hit one knee and spare the other. When the fingers are involved, bony knobs may appear on the knuckles. These growths, which may be painful, can be unsightly, but most people who have them will retain fairly good use of the fingers and hands. RHEUMATOID ARTHRITIS Rheumatoid arthritis is an autoimmune disease that affects the joints and can also affect other parts of the body. Autoimmune diseases are conditions in which the body's immune system starts to attack healthy tissue. Researchers believe rheumatoid arthritis may be triggered by a virus that confuses the immune system and causes it to mistakenly attack joint tissue, especially the synovial membrane. This is a theory because the virus itself has not been found yet. Emotional stress, while it does not cause rheumatoid arthritis, appears to make attacks worse. Rheumatoid arthritis is one of the most serious forms of arthritis and is very hard to control. This is a disease that discriminates against women; three out of four rheumatoid arthritis sufferers are women. The disease usually starts when a person is between age 20 and 50, but has been seen in younger and older people as well. This disease is unpredictable and highly variable. Different people with rheumatoid arthritis may be affected differently; some may have a very mild case, while others are crippled. One person may have one flare-up of rheumatoid arthritis and never be affected again, while another has attacks every few months. Rheumatoid arthritis usually affects many joints at once, with the knees, hands and feet being commonly hit. Often, joints will be hit symmetrically, that is, in a matching pattern on both sides of the body. In addition to affecting joints, severe rheumatoid arthritis may cause problems in the lungs, eyes, spleen, lymph glands and skin. The symptoms of rheumatoid arthritis are painful, red, swollen joints. The joints may feel warm to the touch and the patient may run a fever or be very tired. Some people may lose weight due to lack of appetite. If the disease progresses--which does not always happen joint motion is lost and the joints become twisted out of shape. Fingers may become bent out of shape and legs may stiffen into one position. Because rheumatoid arthritis can be a disease that progresses, most physicians treat it in a systematic manner, using milder drugs at first and proceeding to stronger medications when necessary. In severe cases, very strong drugs are used that may have some severe side effects. SYSTEMIC LUPUS ERYTHEMATOSUS Like rheumatoid arthritis, systemic lupus erythematosus is an autoimmune disease. It is called systemic because many organs in the body are affected, including the skin, kidneys and lungs. Lupus, as the disease is called for short, is a leading cause of kidney failure in the United States. The majority of lupus sufferers are women, and the disease is slightly more common among blacks. There is another related disease called discoid lupus erythematosus, with a rash that forms discs on the skin. This is a milder form of lupus. Lupus can start in any organ and thus the symptoms and severity of the condition can vary greatly. One of the earliest symptoms of lupus is a rash over the nose and cheeks that resembles a butterfly. Arthritis is another early symptom. Lupus patients may become anemic and, because of a low white cell count, may come down with many infections and illnesses. Often, lupus patients are very sensitive to the sun. Sunburn may trigger a flare-up of lupus, so people with lupus should wear a strong sunscreen or blocking cream when outdoors on sunny days. As with rheumatoid arthritis, a physician will treat lupus with the mildest drug that will hold symptoms in check and then will proceed to stronger medications. GOUT Gout is an unusual form of arthritis caused by the inability of the body to properly handle a chemical called uric acid. Unlike rheumatoid arthritis and lupus, gout hits men almost exclusively. Uric acid is normally found in the bloodstream. It is a byproduct of the breakdown and rebuilding of proteins, especially proteins that are rich in substances know as purines. Gout patients have much higher levels of uric acid than people without gout. Levels of uric acid in the blood become so high that crystals start to form, like rock candy in a sugar solution. These crystals may be deposited in the kidneys (where they can create kidney stones and cause damage) and in the cartilage of the ears and joints. On the ear, the deposits form painless little lumps, but in the joints, the crystals act like sand in a fine motor. The prime location for uric acid crystals to form is in the joint of the big toe. Other joints may also be involved, including the knees, ankles, hands and wrists. For some reason, gout rarely causes a problem in the hips, shoulders and spine. A gout attack will begin quite suddenly. Abruptly, the toe will become agonizingly painful. It may swell up quickly and turn red as inflammation sets in. The inflammation then causes conditions that further damage the cartilage of the joint. It used to be thought that gout was the result of years of overindulgence and gluttony, and that a gout sufferer deserved his suffering, but this is not so. Gout is an inherited condition that may run in families. Although diet can help control gout, overindulgence does not cause it. Several drugs have been developed that help control the pain of gout and the levels of uric acid in the bloodstream. Two drugs, probenecid and sulfinpyrazone, lower uric acid levels by making the kidneys secrete more uric acid. Another drug, allopurinol, slows down the rate at which uric acid is created by the body. Gout is the only form of arthritis that can be controlled with diet to some extent. Although the body can create uric acid on its own, certain foods contain a lot of purines and eating them raises the blood levels of uric acid. Foods to avoid include organ meats (liver, sweetbreads, etc.), salmon, sardines, anchovies and gravies. Other foods, such as meats, beans, poultry, bran and wheat germ, have moderate amounts of purines and should be eaten in moderation. All other foods are low in purines and are safe. JUVENILE ARTHRITIS Several forms of arthritis affect children and differ from the types that affect adults. Each type of juvenile arthritis has different symptoms and may appear at any time. Juvenile arthritis may affect only one joint or it may involve many and, depending on the type of arthritis, may also affect other organs in the child. One piece of good news about juvenile arthritis is that often the child recovers completely and does not suffer any permanent damage to the joints. Others, however, may have arthritis throughout their lives. A major type is juvenile rheumatoid arthritis, which is relatively similar to rheumatoid arthritis in an adult. The symptoms for juvenile rheumatoid arthritis are fever, fatigue, skin rash, swelling and pain in the muscles and joints, slowed growth, and an inflammation of the eyes. Sometimes the first sign of juvenile rheumatoid arthritis can be seen when the child is holding a joint still because it hurts to move it. If the joint is held still for too long, it may become stiff and the muscles around it may tighten and contract. The various types of juvenile rheumatoid arthritis are treated differently, but for the most part, they are treated in the same ways as similar forms of arthritis that affect adults. However, one type of medication used in adults, corticosteroids, is not used often with children, because these drugs can stunt growth and cause softening of the bones. ANKYLOSING SPONDYLITIS This condition is an arthritis that primarily affects the spine. Ankylosing spondylitis may be inherited, but it may also be, at least in part, an autoimmune disease. It hits men, predominantly. Women who are affected have milder cases. In spondylitis, inflammation occurs around the joints of the spine and pelvis, rather than inside them, as in other forms of arthritis. In response to the inflammation, the vertebrae and other involved bones overgrow and fuse together, causing the spine to stiffen as the disease progresses. The ligaments of the ribs may also stiffen and make breathing difficult. Exercise and posture control are extremely important in treating ankylosing spondylitis. Exercise can help reduce stiffness, and keeping the spine straight will help prevent it from fusing into a bad position. What are the treatments for arthritis? The two most common treatments for arthritis are medication and physical therapy. Some combination of these may help prevent the arthritis from becoming worse, while helping the patient retain as much mobility in the joints as possible. It cannot be said often enough: no two people with arthritis will receive the same treatment. One person's osteoarthritis may respond to hot baths and light exercise, while another person must use strong medication and undergo physical therapy. One woman with rheumatoid arthritis may get sufficient pain relief with aspirin, while another may require injections of gold salts weekly. If you have arthritis, follow your doctor's advice. Don't accept medications from a friend or neighbor, and take their advice about arthritis with a grain of salt. What's good for them may be unsafe for you. However, if you feel your condition is not getting better with the drug or therapy you are using, sit down and talk about it with your physician. You must remember that with all treatments for arthritis--especially medications--there is what is known as the risk/benefit ratio. All drugs have side effects, ranging from minor to severe. The risk of these side effects must be weighed against the benefits of taking the drug. This is why drugs such as corticosteroids--which have many serious side effects--are reserved for severe cases of arthritis that have not responded to other medications. In such cases, the risks of the drug are outweighed by the benefits. In a less severe case, the risks of corticosteroids would be too great and other drugs could provide the same benefits with fewer side effects. Even something as simple as rest has a risk/benefit ratio. Arthritis victims should not overextend themselves and should get as much rest as possible, but too much rest and inactivity can cause joints to stiffen and immobilize. Medications The following medications are the ones most commonly used in the treatment of arthritis. Bear in mind that not all of these are used for all forms of arthritis. For example, gold salts and penicillamine are used in treating rheumatoid arthritis, but not for osteoarthritis. Gout calls for specialized drugs that reduce uric acid levels. You can be an informed drug consumer. If you ever have questions about your medications, ask your doctor or pharmacist. When your doctor prescribes a medication for you, make sure you know its name, whether it's a brand name or a generic name (for example, Bayer is a brand name for the generic aspirin). Make sure you know how often you should take the medication and how many pills or capsules to take each time. Some drugs must be taken on an empty stomach, while others should be taken with meals. Ask your doctor or pharmacist which way to take your medications. Your doctor should also discuss the side effects of your medications, so you'll know what to expect. ASPIRIN Don't be amazed if your physician prescribes aspirin (acetylsalicylic acid) for your arthritis. The majority of all cases of arthritis will respond to this inexpensive and easily available drug. Aspirin, which has been used to treat arthritis for more than 100 years, is a pain reliever and an anti-inflammatory medication. This means that while it relieves the discomfort in the joint, it also reduces the inflammation. Aspirin reduces fever. Your doctor may tell you to take more aspirin tablets than you are used to taking. The anti-inflammatory properties of aspirin are not effective at the dose you would take for a headache. Because you may be asked to take high doses of aspirin, your doctor may need to check the aspirin levels in your blood periodically. Large amounts of aspirin are helpful in treating arthritis, but too high a dose is toxic. When you buy aspirin, check the box to see how much of the drug is in each tablet. The usual strength for a regular tablet is 325 mg (milligrams) of aspirin. An "extra strength" tablet usually contains 650 milligrams. Your doctor will tell you how many tablets of which size to take. Store brand aspirin is the same product as brand name aspirin and will usually save you money. It is also usually cheaper to buy the largest bottle of aspirin tablets available. If a bottle has a "child-proof" top that you have trouble with, ask your pharmacist to put the tablets into an easy-open container, but be sure to keep all pill containers out of reach of children. If your aspirin tablets ever develop a vinegary odor, they may be too old. Throw them out and buy a new supply. Check the product you buy to see whether it contains other ingredients, such as caffeine. Some aspirin products (such as Bufferin and Ascriptin) contain small amounts of antacid, which may help if aspirin upsets your stomach. Others, such as Ecotrin, have a special coating. Talk to your doctor before switching products. Do not switch to a "nonaspirin" pain reliever, such as Tylenol or Datril, unless your doctor approves. These products contain acetaminophen, which is a pain reliever but not an anti-inflammatory agent. Your doctor may prescribe salicylates instead of aspirin. These drugs are close cousins of aspirin and have many of the same properties. But since lower doses of salicylates are needed, fewer tablets or capsules a day may provide the same benefits as aspirin. There are several salicylates on the market. Like all other drugs, aspirin and salicylates have side effects. Aspirin can irritate the lining of the stomach, causing an upset stomach or heartburn. Try taking aspirin with meals or with a glass of milk to protect the stomach a bit. Another common side effect from aspirin is ringing in the ears or a mild loss of hearing. Tell your doctor if you experience either of these, so he or she can check the level of aspirin in your blood. If the levels are correct, and if the problem isn't too annoying, you may be asked to simply tolerate the hearing problem. Aspirin also interferes with the clotting of blood; you may notice that you bruise more easily while taking aspirin. Aspirin will not be prescribed for anyone who has a problem with bleeding or is taking blood-thinning drugs. Some people are allergic to aspirin, and may react with an asthma attack, hives, runny nose or hay fever. These individuals should never take aspirin or salicylates. ---------------- The material contained here is "FOR INFORMATION ONLY" and should not replace the counsel and advice of your personal physician. Promptly consulting your doctor is the best path to a quick and successful resolution of any medical problem.