Having the potential to significantly impair the sufferer's ability to lead a fully productive and enjoyable life, arthritis requires assessment and treatment as soon as possible. The problem is that the front line drugs used to treat arthritis can cause significant side effects and this reality has caused real worry for many sufferers since the recall of the drug Vioxx from the marketplace in 2004.The good news is that medical research has shown that NUMEROUS treatment options exist, that are often not mentioned to patients, that offer very effective results without the side effects of the
drugs commonly used. The following notes and lecture will describe these in some detail. None the less, patients require an appointment with a professional to know which of the many treatments described are best suited to their individual needs.
Understanding the types will help you understand the available treatments.
• Osteoarthritis: A progressive, chronic condition of the cartilage deterioration in synovial joints and vertebra. Generally, osteoarthritis (O.A.) is non-inflammatory with a subtle onset and involving one or more joints. Morning pain and stiffness improves within 15 to 30 minutes after getting out of bed. Joint motion is progressively lost over time and the joint can become enlarged due to bone overgrowth. Risk factors include simple aging and the overuse of the joint. Common locations include fingers (with Heberden or Bouchard nodes), hip, knees and spine.
• Rheumatoid: A chronic condition of inflammation (usually symmetrical) of the peripheral joints with potential destruction of the joint 'lining', as well as the surrounding joint.
• Gout: A recurrent, acute arthritis of peripheral joints which results from deposition of crystals (monosodium urate crystals) in or around the joints or tendons. While it is common in the big toe, gout can occur at the foot instep, ankle, knee, wrist and elbow.
Acute episodes can be triggered by minor trauma, overindulgence of certain foods or alcohol, surgery, fatigue and emotions.
• Psoriatic Arthritis: An arthritis that resembles rheumatoid arthritis in its presentation, but is frequently associated with psoriasis of the skin or nails.
• “Reactive Arthritis”: A recognized diagnosis for many decades, despite recent opinions by some that it is not existent. It's a progressive, chronic arthritis with a rheumatoid-like presentation that is triggered by an external factor including infections and toxic exposures to chemicals or heavy metals. Seen in veterans returning from various global conflicts, as well as in patients connected to toxic exposures through work or residence.
• Autoimmune connective tissue disorders: While these are not arthritis per se, certain autoimmune conditions can affect ligaments, tendons and tissues around the joints mimicking joint pain. Such autoimmune conditions usually look like a rheumatoid arthritis and can be caused by exposure to numerous toxic agents (chemicals, heavy metals etc.), as well as other autoimmune factors.
Just take two of these and call me in the morning The vast majority of arthritic patients are treated with medications with little to no assessment done with blood work or x-rays to determine exactly the cause of the arthritis. Most are treated with a class of drugs called NSAIDs, which stands for 'Non Steroidal-Anti-Iuflammatory-Drugs. Included in this class are many drugs from the common aspirin on through to drugs like Celebrex, Bextra and the now famous Vioxx. While NSAIDs can do a very good job for inflammatory types of arthritis, they have much less benefit for the non-inflammatory osteoarthritis, as well as gout or reactive arthritis. The larger concern with these NSAIDs has to do with the side effects of these medications. NSAIDs cause bleeding in the stomach and small intestine. Even a baby aspirin will cause micro-bleeding of these areas. Taken daily, they can lead to some serious consequences. Consider the following:
• Aspirin: The Medical Journal Epidemiology (2203, March; 14(2):240-6) discussed the role of Aspirin and heart disease. They reviewed two studies that indicated that patients using aspirin had a two-fold increase in the risk of hospitalization for congestive heart failure. What was interesting was that those patients who were also taking other medications (for example ACE Inhibitors commonly combined with Aspirin for heart disease patients) actually had a 5 fold increase in their risk for heart failure. This study was not reported by any Canadian, national media outlet. In another study by the American Association for Cancer Research, a review of 88,000 women showed that the women who took two or more tablets of aspirin per week (over a 20 year review) had a 58% increased risk of pancreatic cancer, as compared to non-users. In this study, the more Aspirin used, the higher the risk of the cancer went up. Those taking 14 pills or more per week had an 86 increased risk of pancreatic cancer (Medscape Health News, October 28, 2003).
• Vioxx: In September of 2004, the media extensively covered the recall in Canada and the U.S. of the very popular arthritis drug Vioxx. In doing so, the media drew important attention to the role this drug - as well as the class of drugs it belongs to AND the NSAID class of drugs - play in causing systemic (whole body) side effects. Since then, Canadians with arthritis have been increasingly concerned about the drugs they are using to help treat the pain and impaired movement caused by their arthritis. Here's a brief over-view of the subject:
• Vioxx is in a class of drugs known as Cox-2 Inhibitors. Also included in this class of drugs are Celebrex, Mobicox, Bextra and Prexige. These drugs were originally promoted as being “safer” than Aspirin (acknowledging that Aspirin has some side effects), as they were said to cause less bleeding in the stomach and intestine (ie. admitting that Aspirin and the NSAIDs do cause this bleeding).
• Vioxx and Bextra were recalled from worldwide markets in 2005. Celebrex has remained on the market with a 'black box' warning in many countries. Prexige, however, was allowed onto the market in 2006.
• The recalls were based on a study of 140,000 patients published in the medical journal lancet which showed that Vioxx caused significant gastric (stomach) bleeding and that this bleeding was, in fact, fatal in 44 of the cases studied. This information was not limited to just Vioxx. In a December 22, 2004 advisory Health Canada stated "accumulating evidence indicates that the use of selective COX-2 inhibitor NSAIDs, in certain individuals, is associated with an increased risk of heart attack or stroke when compared to placebo. The risk appears to increase with the total daily dose and the length of the treatment". They added in this advisory that "until further information from long-term clinical trials becomes available, one should consider that there is a strong possibility of an increased risk of cardiovascular events, including heart attack and stroke, when using selective
COX-2 inhibitor NSAIDs (Celebrex®, Bextra™, Mobicox*, and all generic forms ofmeloxicam).
• When Health Canada approved the new Cox-2 drug just two years after the recall of Vioxx and Bextra, Dr. Andreas Laupacis, who headed an expert panel that advised Health Canada on the safety of Cox-2 drugs, told they media he had 'mixed feelings about the news that Canada will join the approximately 55 countries that have approved Prexige'. The drug was approved anyway.
• A study by Wellpoint Inc. (a large insurance organization) has reported that Celebrex (still on the Canadian market) increases the risk of heart attack and stroke by 20. But this is not a lecture about Cox-2 drugs - so what should you take 2 pills of in the morning?? The answer, of course, is NOTHING - not unless you absolutely have to and other interventions have provided inadequate relief. The point is that treating arthritis should require more assessment and individualized treatment vs. a routine prescription for everyone who has arthritis. The treatment should attempt to determine the actual cause of the condition, so as not to just mask the symptoms. So what should be done if it's not popping morning pills?
The lecture started with a definition of the different types of arthritis and mentioned the potential causes of these forms of arthritis - remember the role infections, chemical and heavy metal toxicity and autoimmune disorders played in some forms of arthritis?? Well,
if you don't rule these in or out in your workup, your treatment is likely to have limited results.
i) Basic Blood work: Most patients will have had some basic blood tests done regarding their arthritis. This, however, is usually limited to a rheumatoid factor and E.S.R. to assess rheumatoid arthritis and little else. One should also have the following:
• D.H.E.A. - This adrenal gland 'pro-hormone' declines as we age. Deficiencies will allow for increased levels of inflammation in the body, aggravating degenerative conditions and leading to an overall loss of vitality (low energy, muscle mass decline etc.).
• HLA B27 - This blood test will assist in ruling out the psoriatic and reactive types of arthritis that could otherwise be confused for another form of arthritis.
• C-Reactive Protein - This is a more sensitive test of inflammation in tissues than the old standard E.S.R. test and assists in ruling our autoimmune conditions and in better understanding the treatment options for the arthritis.
• Urate - this will help assess if gout is playing a role in the arthritis. While gout frequently causes arthritic-like pains, this test is not often run - allowing for a misdiagnosis and treatment of the cause of the pain.
• A Full Thyroid Panel - while this is an entire lecture on its own, suffice it to say that thyroid problems can cause arthritic pain. Unfortunately, the test used to measure your thyroid (called the TSH) is NOT enough to fully assess if the thyroid is contributing to arthritic pains.
ii) More Advanced Functional Medicine Testing: As discussed, a variety of triggers can cause inflammatory conditions in the body and even stimulate autoimmune responses. Viral, bacterial or parasitic infections, heavy metal toxicity (such as lead or mercury) and industrial / household chemicals are all potential triggers of various forms of arthritis. If such is the case, conventional blood work will not detect the underlying cause of the arthritis and conventional medications will - at best - only serve to 'mask' the symptoms. Modem medical laboratory testing - which is NOT paid for by provincial health plans in Canada - is available to assess whether or not these various 'agents' are involved in the arthritic process in an individual.
In an era where people feel “real” medical care entails pharmaceutical prescriptions, conventional arthritis treatment shows why this method is absolutely inadequate.
• Food Allergies - Numerous studies, while being small in size, have demonstrated that foods to which people have allergies can significantly worsen arthritic pain. In one study, 91 of patients had an improvement in their arthritic pain by eliminating the allergenic foods (Allergy 1980; 10:463). The most common foods found in the studies seen to worsen arthritic pain were: corn, wheat, oranges, milk and dairy products, egg, tomato, potato and peanuts. Unfortunately, conventional allergy testing (called skin prick) only tests for what are called Type 1 allergies and often misses these food allergies. Modem medical laboratory testing allows for the testing of what are called Type 3 allergies that frequently are associated with such food allergies. One must seek the counsel of a Naturopathic or Medical Doctor who uses such modem testing.
• Non-Allergic, But Inflammatory - Avoiding a biochemistry class, inflammation in the body is made from what are called 'Prostaglandins' and other inflammatory mediators. Regardless of the cause of the arthritis, if inflammation is present, these prostaglandins and related mediators will be involved. The way in which our drugs work (be it the NSAIDs or Cox-2 classes of drugs) is to disrupt these prostaglandins from promoting increased inflammation. The interesting point is that some foods contain prostaglandins that promote inflammation, while other foods contain prostaglandins that inhibit inflammation. This has nothing to do with being allergic to the food - so ALL people who eat the foods that promote inflammation will get the same response - more inflammation. The foods that promote inflammation include animal proteins like red meat, eggs and dairy. Some foods that decrease inflammation include flax seed, soy, some nuts and ocean fish - or their oils taken as a supplement. A supervised, clinical evaluation of your diet may allow you to modulate the same chemical pathways that the conventional drugs modulate -without causing your stomach to bleed.
Right on the heels of the Vioxx news came the results of a large study on the use of acupuncture in the treatment of osteoarthritis of the knee. The study, conducted by the National Centre for Complementary and Alternative Medicine, received large scale national media coverage as it showed a remarkable improvement in treating O.A. of the knee with only acupuncture. Specifically, it showed that acupuncture on the knee resulted in a 40% reduction in pain and a 40% improvement in the range of motion of the knee - with no other intervention. Imagine the results if this was combined with some diet modification (discussed above) and some oral pills (discussed below). The media attention made this study sound as though these results were 'new' and not previously known. Asian studies have shown comparable data for generations. The key point is that acupuncture is a very effective tool that can be used for ALL forms of arthritis - not just O.A. of the knee. When combined with other interventions, its results can be even more profound.
Being pioneered in France over 50 years ago, Medical and Naturopathic Doctors in numerous countries are using mesotherapy in the treatment of both cosmetic and pain management cases. Describing mesotherapy requires more time than this lecture allows. In a nutshell, it involves injecting a vast array of individually selected substances (from conventional medications, to vitamins, minerals, plant extracts or homeopathics) into the 'mesoderm' -the middle layer, if you will, of the skin. The rationale is complicated, but suffice it to say that it stimulates specific repair mechanisms within the body - at the site of the condition or injury. While mesotherapy is most recognized in North America for its ability to fade age spots, eliminate wrinkles and dissolve cellulite, European and South American doctors use the treatment more frequently for arthritic conditions, sports injuries and generalized pain conditions.
Far too often patients report restricting their exercise due to pain experienced with the exercise or - most shockingly - on the advice of their doctor. The reality is that this is simply a recipe for further degeneration. Your body is meant to be in motion and active.
If one restricts movement, muscles deteriorate, as does the lining of joints and the supporting ligaments and tendons.
• The June 11 2009 Annual Congress of the European League Against Rheumatism in Copenhagen, Denmark reported on a three month study of rheumatoid arthritis patients. They reported that a supervised exercise program of only 50 minutes three times a week yielded significant improvements in the arthritis with decreased medication needs. Specifically, they reported that 62 of patients reported a reduced need for daily corticosteroid intake, while 32 of patients reported stopping concurrent NSAID (nonsteroidal anti-inflammatory drug) treatment altogether.
• The Mayo Clinic in the U.S. has a section on their website specifically about arthritis. The state “exercise is crucial for people with arthritis. It increases strength and flexibility, reduces joint pain, and helps combat fatigue”.
• The John Hopkins School of Medicine has an Arthritis Center website states that “physical activity is essential to optimizing both physical and mental health and can play a vital role in the management of arthritis” Regular physical activity can keep the muscles around affected joints strong, decrease bone loss and may help control joint swelling and pain. Regular activity replenishes lubrication to the cartilage of the joint and reduces stiffness and pain. Like diet changes, however, patients have to recognize that their treatment involves them - their doctor can't wave a magic wand and cure them – they need to help cure themselves.
Rather than the NSAIDs and Cox-2 drugs that have the side effects discussed earlier, patients can be successfully treated with a wide range of very beneficial natural substances - all with a lot of medical study proving their benefits.
Some of these include:
i) Neutraceuticals - sounding like pharmaceuticals (which are synthetic, man made creations) these are pills composed of natural vitamins, minerals and substances. Some that have a real benefit for arthritis include:
• Niacinamide - This is a form of Vitamin B3. Significant study has shown its ability to improve arthritis. In a supervised dose, studies have revealed that joint mobility, decreased pain and decreased inflammation were all achieved by using niacinamide (J Am Geriatr Soc 1955; 3:927- 936, J Int Acad Prev Med 1983;8:5- 25). More recent research has confirmed these trials, showing that niacinamide achieved a 13 reduction in pain medication use, increased joint mobility by more than twice the placebo group and showed a decrease in the E.S.R. blood test by 22 (a measurement of inflammation) - as reported in Inflammatory Research (1996;45:330-334).
• S-Adenosylmethionine (SAMe) - This amino acid has been shown to stimulate the production of the 'proteoglycans' which make up a component of joint linings. In a review of 22,000 patients, the SAMe was shown to be as effective as NSAIDs in treating osteoarthritis, while being better tolerated with NO side effects (Amer JMed 1987;83:66-71).
• Fish Oils - while eating fish every day is not encouraged, a supplement of their oil is very beneficial - especially for the inflammatory forms of arthritis, as with rheumatoid arthritis. There are over 14 medical studies that have shown fish oils, in specific daily dosages used for three months, significantly reduce the number and intensity of painful joints, as well as morning stiffness (J Epidemiol 1995;48:1379-90). Moreover, another trial showed that use of fish oils allowed patients to reduce their NSAID medication use with no worsening of their pain or mobility (BR J Rheum 1993;32:982-9).
• Gincosamine sulfate - there is very strong medical evidence showing the significant benefits of glucosamine sulfate (G.S.) in the treatment of osteoarthritis (O.A.), especially O.A. of the knee. One study showed ALL measurements used to evaluate a treatment improved with G.S. in treating O.A. of the knee (Arch Intern Med, 2003; 163:1514-22). Patients must realize that the benefits come after several weeks of use - not instantaneously, as the G.S. works by repairing the lining of the joints.
ii) Plant Based Medicines - Asprin, after all, is an extract of tree bark - as used by our First Nations for generations.
• Plant Sterols and Sterolins: While being used the most for immune support and cardiovascular disease, these substances derived from various fruits, vegetables and plants provide both immune modulation and anti-inflammatory capacity in treating inflammatory forms of arthritis and rheumatoid arthritis. One recent study on the use of these sterols in the treatment of rheumatoid arthritis patients showed
that a significant decrease in pain and a decrease in the E.S.R. blood test was achieved with use of sterols (Abstract: NutritionWeek Congress, 2002).
• Boswelia serrata: While more formal research is required, this plant has been used empirically for generations in the treatment of various forms of arthritis. Boswelia is known to block the production of bio-chemical inflammation chemicals in the body (specifically 5-lipoxygenase). One study reported an improvement in 44 of rheumatoid arthritis patients after treatment with this plant substance (Plant Med 1991;57:203-207).
• Curcumin longa (Turmeric) - Long used in the treatment of arthritis, this plant blocks the production of various inflammatory pathways in the body in a manner similar to NSAIDs and Cox-2 drugs. One study compared Turmeric to the NSAID drug phenylbutazone over two weeks and revealed no difference between the groups in improving morning stiffness, walking time, and strength (Indian J Med Res 1980;71:632-4). While several other plants have been used to treat various forms of arthritis (including Devils Claw, Ginger and Stinging Nettle) the point is merely that scientific research exists and the patient needs the right substances chosen for their individual needs and presentation. Arthritis treatment in North America has often been reduced to a redundant process whereby the patient is prescribed the same drug as the next person with little time spent on evaluating particular causes of the condition, or attempts to individualize the treatment. This lecture has attempted to reveal that a great many interventions exist, with ample medical science, to allow you to treat the condition without a litany of side effects. By combining some of the interventions described, you have a significant ability to control your arthritis and even to be able to do so without taking medications.
Dr. Oxbro completed her undergraduate science degree in Biology and Psychology at Trent University and then completed a Masters of Science Degree in Pharmacology at Queen’s University in Kingston, Ontario. Upon completion of her Masters degree, Dr. Oxbro entered the 4-year Naturopathic Medical Program, obtaining her Doctorate of Naturopathic Medicine upon graduation in 2008. She currently treats patients, at her naturopathic medicine clinic Nova Health Naturopathic Centre in Kingston, Ontario.