Arthritis: Types and Treatment
Fibromyalgia - Osteoarthritis

MYTH: Arthritis affects only older people.
FACT: Arthritis affects any age, including children. There's no
question that the incidence of arthritis increases with age, but
nearly three of every five sufferers are under age 65.

MYTH: Arthritis is just minor aches and pains.
FACT: Arthritis can be permanently debilitating.

MYTH: Arthritis cannot be treated.
FACT: FDA recently approved several new treatments for
osteoarthritis and rheumatoid arthritis.

The fact is, these myths keep people from seeking a doctor's help against
the number one cause of disability in the United States, according to the
national Centers for Disease Control and Prevention (CDC). Arthritis
disables more Americans than heart disease and stroke, and CDC says it's
what Americans don't know about the disease that can hurt them.
"People ignore arthritis both as public and personal health problems
because it doesn't kill you," says Chad Helmick, a medical epidemiologist
at CDC. "But what they don't realize is that as Americans work and live
longer, arthritis can affect their quality of life and eventually lead to
disability." Current costs to the U.S. economy total nearly $65 billion
annually--an impact equal to a moderate recession.
And the extent of the suffering is going to get worse. Arthritis already
affects more than 42 million Americans in its chronic form, including
300,000 children. By 2020, CDC estimates that 60 million people will be
affected, and that more than 11 million will be disabled.

The Arthritis Foundation and the American College of Rheumatology agree
that awareness, early diagnosis, and an aggressive treatment plan
developed by a doctor are key to stopping arthritis from taking over your
life.

What Is Arthritis?

Although the term literally means joint inflammation, arthritis really
refers to a group of more than 100 rheumatic diseases and conditions that
can cause pain, stiffness and swelling in the joints. Certain conditions
may affect other parts of the body--such as the muscles, bones, and some
internal organs--and can result in debilitating, and sometimes
life-threatening, complications. If left undiagnosed and untreated,
arthritis can cause irreversible damage to the joints.
The two most common forms of the disease, osteoarthritis and rheumatoid
arthritis, have the greatest public health implications, according to the
Arthritis Foundation.

Osteoarthritis

, previously known as "degenerative joint disease," results
from the wear and tear of life. The pressure of gravity--the load of
living--causes physical damage to the joints and surrounding tissues,
leading to pain, tenderness, swelling, and decreased function. Initially,
osteoarthritis is noninflammatory and its onset is subtle and gradual,
usually involving one or only a few joints. The joints most often affected
are the knee, hip and hand. Pain is the earliest symptom, usually made
worse by repetitive use. Osteoarthritis affects more than 20 million
people, and the risk of getting it increases with age. Other risk factors
include joint trauma, obesity, and repetitive joint use.

Rheumatoid arthritis

is an autoimmune disease that occurs when the body's
own immune system mistakenly attacks the synovium (cell lining inside the
joint). This chronic, potentially disabling disease causes pain,
stiffness, swelling, and loss of function in the joints.
To see an illustration of the cross section of a normal knee joint and the
effects of osteoarthritis and rheumatoid arthritis, select the graphic at
right.
While the cause remains elusive, doctors suspect that genetic factors are
important in rheumatoid arthritis. Recent studies have begun to tease out
the genetic characteristics that can be passed from generation to
generation. However, the inherited trait alone does not cause the illness.
Researchers think this trait, along with some other unknown
factor--probably in the environment--triggers the disease.
But rheumatoid arthritis can be difficult to diagnose early because it may
begin gradually with subtle symptoms. According to CDC, this form of
arthritis affects more than 2 million people in the United States, and two
to three times more women are affected than men.

Finding Effective Treatments

For years, the pain and inflammation of arthritis have been treated with
varying success, using medications, local steroid injections, and joint
replacement. Seldom did the therapies make the pain go away completely or
for very long, nor did they affect the underlying joint damage. Just ask
Jo Ellen Gluscevich, who has tried more drugs and treatments than she can
remember, to no avail.
"It seems I've tried them all," says the 50-year-old from Frederick, Md.,
who was diagnosed with rheumatoid arthritis 10 years ago. "Every year
continues to be a challenge for me medically."
But now there are some new treatments available, and patients should
consult with their doctors to determine which are the most appropriate for
their conditions.

Osteoarthritis

When taken regularly and at high doses, traditional nonsteroidal
anti-inflammatory drugs (NSAIDs) used for pain relief can cause
gastrointestinal (GI) bleeding or ulcers. But a new type of NSAID,
cyclooxygenase-2 inhibitors, better known as COX-2 inhibitors, has joined
the old standbys and helps suppress arthritis with less stomach irritation.

Cyclooxygenases are enzymes needed for the synthesis of hormone-like
substances called prostaglandins. There are two types of cyclooxygenases:
the COX-2 enzyme that mediates inflammation and pain, and the COX-1 enzyme
that helps maintain other physiological functions in the body. Traditional
NSAIDs inhibit both enzymes. The new NSAIDs, however, block mostly the
COX-2 enzyme, offering a new treatment option for people who have had
difficulty tolerating the old NSAIDs.
"COX-2 inhibitors are just as effective in treating osteoarthritis as
other NSAIDs," says Maria Villalba, M.D., a medical officer with FDA's
Center for Drug Evaluation and Research. "And they have similar renal
effects, liver effects and the potential for allergic reactions. But they
seem to have a better GI safety profile than traditional NSAIDs."
FDA approved the first COX-2 inhibitor, Celebrex (celecoxib), in December
1998 to treat rheumatoid arthritis and osteoarthritis. Vioxx (refecoxib)
became the second COX-2 inhibitor to receive approval, in May 1999, but
only for the treatment of osteoarthritis, dysmenorrhea (pain with
menstrual periods), and the relief of acute pain in adults, such as that
caused by dental surgery.

Both drugs, taken orally, were found to substantially lower the risk of
stomach and upper intestinal ulcers detected by endoscopy in clinical
trials, compared with other NSAIDs. Additional studies are needed to
determine whether Celebrex and Vioxx actually cause fewer serious stomach
problems, including GI ulceration, bleeding and perforation. Until such
studies are done, FDA is requiring the drugs' labeling to include the
standard warning about the GI risks that are associated with NSAIDs.
Two non-drug alternatives for the treatment of pain in osteoarthritis of
the knee were approved by the Center for Devices and Radiological Health
in 1997 for patients who have failed to respond adequately to simple
analgesics, such as acetaminophen, and to conservative nonpharmacologic
therapy. Hyalgan and Synvisc are viscous solutions composed of hyaluronan
(hyaluronic acid, a lubricant found naturally in the joints), and are
injected directly into the knee joint. Both are believed to increase the
quality of synovial fluid, although the mechanism of action for these
products is not well understood. The most common side effects reported
from these treatments--injection site pain and knee pain and/or
swelling--were found to be temporary. For patients who cannot tolerate
oral medications and who are not candidates for surgical knee replacement,
these treatments may be an ideal option.

Rheumatoid Arthritis

In recent years, the typical treatments for rheumatoid arthritis relied on
combination NSAIDs, such as ibuprofen and aspirin. These drugs reduce
swelling and alleviate pain but do little to change the course of the
disease. Another class of treatments relied on disease-modifying,
antirheumatic drugs (DMARDs), such as methotrexate and sulfasalazine.
DMARDs work to slow inflammation and can, in many cases, alter the course
of the disease. Because of their adverse effects, most doctors reserved
these more powerful drugs for patients who failed to respond to other
therapies. Now, many physicians are using DMARDs early and aggressively in
the hope of slowing disease progression and preventing damage to joints
and internal organs.
The most recently approved treatment regimen for rheumatoid arthritis is
one that combines the genetically engineered biological drug Remicade
(infliximab) with the drug methotrexate. (Not all patients with rheumatoid
arthritis can tolerate or respond to methotrexate alone, a standard
treatment for the disease.) Remicade is the second in a new class of drugs
known as biologic response modifiers, which bind to and block the action
of a naturally occurring protein called tumor necrosis factor (TNF),
believed to play a role in joint inflammation and damage. Elevated levels
of TNF are found in the synovial fluid of rheumatoid arthritis patients.
Remicade, which is administered intravenously by a health-care
professional in a two-hour outpatient procedure, was approved by FDA in
November 1999 to reduce the signs and symptoms in patients who have not
experienced significant relief from methotrexate alone.
Enbrel (etanercept) is the first biologic response modifier to receive FDA
approval for patients with moderate to severe rheumatoid arthritis. Taken
twice weekly by injection, Enbrel was shown to decrease pain and morning
stiffness and improve joint swelling and tenderness.

Jeffrey N. Siegel, M.D., a medical officer with FDA's Center for Biologics
Evaluation and Research, says that Enbrel is an exciting breakthrough
because it helps a majority of patients who have not responded to any of
the other commonly used therapies. Although it is injected, the treatment
can be administered at home. In addition, Enbrel has been shown to be
effective for children with the juvenile form of rheumatoid arthritis. In
clinical trials, Enbrel was generally well tolerated, and one of the most
common side effects was an injection site reaction.
Both Remicade and Enbrel show promise in treating rheumatoid arthritis,
although the long-term risks and benefits of these drugs are unknown.
Arava (leflunomide) is the first oral treatment approved for slowing the
progression of rheumatoid arthritis. Although its effects are similar to
those of methotrexate, this drug works by a different chemical mechanism,
blocking an enzyme in certain lymphocytes (a type of white blood cell that
is part of the immune system) and thereby retarding the progression of the
disease.

Arava is not a cure, however, and studies have suggested that the drug may
cause birth defects. Therefore, its labeling carries a special warning for
pregnant women, women of childbearing age, and those who want to become
pregnant.

The first non-drug alternative for adult patients with moderate to severe
rheumatoid arthritis and longstanding disease who have failed or cannot
tolerate DMARDs was approved by FDA in March 1999. The Prosorba column,
which was initially approved in 1987 to treat an immune blood disorder, is
a single-use medical device, about the size of a coffee mug, containing a
material that binds antibodies and antigen-antibody complexes.
In a two-hour process performed in a hospital or specialized treatment
center, a patient's blood is removed and passed through a machine that
separates the blood cells from the plasma (the liquid portion of the
blood). The plasma is then passed through the Prosorba column, recombined
with the blood cells, and returned to the patient. Although this filtering
process is believed to remove proteins that may inadvertently attack the
joint cells, the mechanism of action of the Prosorba column is not well
understood. The treatment is once a week for 12 weeks. The most common
side effects include joint pain and/or swelling, fatigue, hypotension (low
blood pressure), and anemia.

"For those patients who have failed or are intolerant to DMARDs, including
Arava and the anti-TNF agents," says Sahar M. Dawisha, M.D., a medical
officer in FDA's Center for Devices and Radiological Health, "the Prosorba
column may be an additional treatment option."

Exercise and Arthritis

Proper exercises performed on a regular basis are an important part of
arthritis treatment, according to the Arthritis Foundation. Twenty years
ago, doctors advised exactly the opposite, fearing that activity would
cause more damage and inflammation. Not exercising causes weak muscles,
stiff joints, reduced mobility, and lost vitality, say rheumatologists,
who now routinely advise a balance of physical activity and rest.
According to the 1996 Surgeon General's Report on Physical Activity and
Health, regular, moderate physical activity is beneficial in decreasing
fatigue, strengthening muscles and bones, increasing flexibility and
stamina, and improving the general sense of well-being. The National
Institutes of Health advises that the amount and form of exercise should
depend on which joints are involved, the amount of inflammation, how
stable the joints are, and whether a joint replacement procedure has been
done. A skilled physician who is knowledgeable about the medical and
rehabilitation needs of people with arthritis, working with a physical
therapist, can design an exercise plan for each patient.

Three main types of exercises are recommended:
Range-of-motion--moving a joint as far as it will comfortably go and
then stretching it a little further to increase and maintain joint
mobility, decrease pain, and improve joint function. These can be
done daily at least every other day.
Strengthening--using muscles without moving joints to help increase
muscle strength and stabilize weak joints. These can be done daily,
at least every other day, unless there is severe pain or swelling.
Endurance--aerobic exercises such as walking, swimming and bicycling
to strengthen the heart and lungs and increase stamina. These should
be done for 20 to 30 minutes, three times a week, unless there is
severe pain or swelling.

Unproven Remedies
Many people with arthritis become discouraged with typical treatments
because the disease progresses over time and the symptoms worsen.
Consequently, they search for alternative therapies aimed at arthritis.
But arthritis patients need to be careful because treatments not shown to
be safe and effective through controlled scientific studies may be
dangerous. According to the Arthritis Foundation, the benefits of a
treatment in controlling arthritis should be greater than the risk of
unwanted or harmful effects. Since arthritis symptoms may come and go, a
person using an unproven remedy may mistakenly think the remedy worked
simply because he or she tried it when symptoms were going into a natural
remission.

Two controversial nutritional supplements, not approved by 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. NIH plans to study the
effectiveness of these supplements.

Both glucosamine and chondroitin sulfate occur in the body naturally and
are vital to normal cartilage formation, but the Arthritis Foundation says
there's no evidence that swallowed chondroitin is absorbed into the body
and deposited into the joints. Moreover, no one knows how much glucosamine
and chondroitin sulfate are in the bottles since current law does not
require dietary supplements to be manufactured under the same good
manufacturing practice standards as pharmaceuticals. As reported in the
December 1999 UC Berkeley Wellness Letter, "It's a hit-or-miss proposition
because there's no standardization and no guarantee that you're getting
what the label says."

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 Arthritis Foundation also says that copper bracelets, mineral springs,
vibrators, magnets, vinegar and honey, dimethyl sulfoxide, large doses of
vitamins, drugs with hidden ingredients (such as steroids), and snake
venom are all unproven remedies. And any unproven remedy, no matter how
harmless, can become harmful if it stops or delays someone from seeking a
prescribed treatment program from a knowledgeable physician.
Prevention Measures

There are ways to help prevent arthritis. Both CDC and the American
College of Rheumatology recommend maintaining ideal weight, taking
precautions to reduce repetitive joint use and injury on the job, avoiding
sports injuries by performing warm-ups and strengthening exercises using
weights, and by choosing appropriate sports equipment.

Lyme arthritis may develop after a bacterial infection is transmitted to
humans through tick bites. To prevent this type of arthritis, health
experts advise people to use insect repellents, wear long-sleeved shirts
and pants while walking near wooded areas, and check for and remove ticks
to help reduce the risk of getting the disease. CDC also recommends the
prompt use of antibiotics for Lyme disease symptoms. In December 1998, FDA
approved the first vaccine, Lymerix, to help prevent Lyme disease.

Hope for the Future

The recent rise in the number of effective new arthritis treatments offers
the hope that still better therapies are just over the horizon. For Jo
Ellen Gluscevich, the results have not been so dramatic. She remains
mostly housebound and must avoid crowds because her immune system is
compromised and susceptible to infection. But as the population ages and
arthritis becomes a growing problem, the Arthritis Foundation believes
that "more physicians are recognizing the severity of the disease and the
need for a broader approach toward treatment."
Common Forms of Arthritis and Related Conditions

Juvenile arthritis is a general term for all types of arthritis that occur
in children. Juvenile rheumatoid arthritis is the most prevalent form in
children, and there are three major types: polyarticular (affecting many
joints), pauciarticular (pertaining to only a few joints), and systemic
(affecting the entire body). The signs and symptoms of juvenile rheumatoid
arthritis vary from child to child. There is no single test that
establishes conclusively a diagnosis of juvenile arthritis, and the
condition must be present consistently for six or more consecutive weeks
before a correct diagnosis can be made. Heredity is thought to play some
part in the development of juvenile arthritis. However, the inherited
trait alone does not cause the illness. Researchers think this trait,
along with some other unknown factor (probably in the environment),
triggers the disease. The Arthritis Foundation says that juvenile
arthritis is even more prevalent than juvenile diabetes and cerebral
palsy.

Gout is a disease that causes sudden, severe attacks of pain, tenderness,
redness, warmth, and swelling in some joints. It usually affects one joint
at a time, especially the joint of the big toe. The pain and swelling
associated with gout are caused by uric acid crystals that precipitate out
of the blood and are deposited in the joint. Factors leading to increased
levels of uric acid and then gout include excessive alcohol intake,
hypertension, kidney disease, and certain drugs.

Ankylosing spondylitis is a chronic inflammatory disease of the spine that
can fuse the vertebrae to produce a rigid spine. Spondylitis is a result
of inflammation that usually starts in tissue outside the joint. The most
common early symptoms of spondylitis are low back pain and stiffness that
continues for months. Although the cause of spondylitis is unknown,
scientists have discovered a strong genetic or family link, according to
the Arthritis Foundation. Most people with spondylitis have a genetic
marker known as HLA-B27. Genetic markers are protein molecules located on
the surface of white blood cells that act as a type of "name tag." Having
this genetic marker does not mean a person will develop spondylitis, but
people with the marker are more likely to develop the disease than those
without. Ankylosing spondylitis usually affects men between the ages of 16
and 35, but it also affects women. Other joints besides the spine may be
involved.

Systemic lupus erythematosus is an autoimmune disease that can involve the
skin, kidneys, blood vessels, joints, nervous system, heart, and other
internal organs. Symptoms vary among those affected, but may include a
skin rash, arthritis, fever, anemia, hair loss, ulcers in the mouth, and
kidney sediment or function abnormalities. In most cases, the symptoms
first appear in women of childbearing age; however, lupus can occur in
young children or older people. Studies suggest that there is an inherited
tendency to get lupus. Lupus affects women about 9 to 10 times as often as
men. It is also more common in African-American women.

Related Arthritis Conditions

Bursitis, tendinitis and myofascial pain are localized, nonsystemic (not
affecting the whole body) painful conditions. Bursitis is inflammation of
the sac surrounding any joint that contains a lubricating fluid.

Tendinitis

is inflammation of a tendon, and myofascial pain is a problem
that results from the strain or improper use of a muscle. These conditions
may start suddenly, and usually stop within a matter of days or weeks.

Carpal tunnel syndrome

is a condition in which pressure on the median
nerve at the wrist causes tingling and numbness in the fingers. It can
begin suddenly or gradually, and can be associated with another disease,
such as rheumatoid arthritis, or it may be unrelated to other conditions.
If untreated, it can result in permanent nerve and muscle damage. With
early diagnosis and treatment, there is an excellent chance of complete
recovery.

Fibromyalgia syndrome

is a condition with generalized muscular pain,
fatigue, and poor sleep that is believed to affect approximately 2 percent
of the U.S. population, or 5 million people. The name fibromyalgia means
pain in the muscles, ligaments and tendons. The condition mainly affects
muscles and their attachments to bones. Although it may feel like a joint
disease, the Arthritis Foundation says it is not a true form of arthritis
and does not cause deformities of the joints. Fibromyalgia is instead a
form of soft tissue or muscular rheumatism.
Infectious arthritis is a form of joint inflammation that is caused by
bacteria, viruses or fungi. The diagnosis is made by culturing the
organism from the joint. Infectious arthritis can be cured by antibiotic
medications.

Psoriatic arthritis is similar to rheumatoid arthritis. About 5 percent of
people with psoriasis, a chronic skin disease, also develop psoriatic
arthritis. In psoriatic arthritis, there is inflammation of the joints and
sometimes the spine. Fewer joints may be involved than in rheumatoid
arthritis, and there is no rheumatoid factor in the blood.

Reiter's syndrome involves inflammation in the joints, and sometimes where
ligaments and tendons attach to bones. This form of arthritis usually
develops following an intestinal or a genital/urinary tract infection.
People with Reiter's syndrome have arthritis and one or more of the
following conditions: urethritis, prostatitis, cervicitis, cystitis, eye
problems, or skin sores.

Scleroderma is a disease of the body's connective tissue that causes
thickening and hardening of the skin. It can also affect joints, blood
vessels, and internal organs. There are two types of scleroderma:
localized and generalized.

Arthritis Facts

Americans with Arthritis

1985 35 million

1990 37.9 million

1995 40 million*

2020 59.4 million**

* 1 in 6 people
** 1 in 5 people (CDC projection), or almost 20 percent of the population
Arthritis Prevalence
Osteoarthritis--20.7 million Americans, mostly over age 45
Rheumatoid arthritis--2.1 million, mostly women
Gout--2.1 million, mostly men
Fibromyalgia--3.7 million, mostly women
Spondylarthropathies--412,000 (includes ankylosing spondylitis, psoriatic
arthritis, and Reiter's syndrome)
Juvenile arthritis--285,000 children under 17
Juvenile rheumatoid arthritis--50,000 children
Lupus--239,000

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