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MSM


Arthritis and Joints
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[Osteoarthritis | Rheumatoid arthritis | Worsening & remission]
[New arthritis treatment options | Standard treatment options]
[Use it or lose it | Avoiding fraud | Research]
[Common types of arthritis | References]

Standard Arthritis Treatment Options
Proper treatment depends on correct diagnosis of the specific arthritis, and varies with severity and location, as well as from person to person. But arthritis treatment need not wait for a final diagnosis because initial treatment options, such as anti-inflammatory drugs and exercise, are similar for many forms of arthritis. Arthritis treatment should begin early to reduce joint damage.

The drugs used for treating most types of arthritis are drawn from many categories, but can be thought of in a few broad groups, such as anti-inflammatory drugs and disease-modifying drugs. For treating gout, there are also drugs that reduce the amount of uric acid in the blood. More than one medication may be required for treating arthritis.

Anti-inflammatory agents generally work by slowing the body's production of prostaglandins, substances that play a role in inflammation. Many have an analgesic, or painkilling, effect at low doses. Usually, higher, sustained doses are required to see sufficient anti-inflammatory activity for treating arthritis. The most familiar anti-inflammatory agent is aspirin, often a good arthritis treatment. Like aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) fight pain and inflammation. More than a dozen NSAIDs are available, most by prescription only. At press time, FDA was considering whether labeling changes to prescription-strength NSAIDs are necessary, due to gastrointestinal side effects.

FDA has approved three NSAIDs for over-the-counter (OTC) marketing: ibuprofen (marketed as Advil, Nuprin, Motrin, and others), naproxen sodium (sold as Aleve), and ketoprofen (marketed as Actron and Orudis). Although these drugs are available OTC, a doctor should be consulted before taking any medication for arthritis symptoms.

"People shouldn't be mixing these medications," says Linda Katz, M.D., of FDA's Center for Drug Evaluation and Research, and anyone regularly taking NSAIDs should carefully read the labels of OTC products to make sure they don't contain similar drugs. For example, many cough and cold preparations contain analgesics such as aspirin, acetaminophen or ibuprofen.

The most potent anti-inflammatories are corticosteroids, synthetic versions of the hormone cortisone. Like prednisone and dexamethasone, the generic names often end in "-one." They're usually reserved for short periods of use during intense arthritis flares or when other drugs don't control unrelenting arthritis. Relief can be dramatic, but long-term use causes side effects, such as weight gain, high blood pressure, and thinning of bones and skin. Usually given orally, they can also be injected directly into an arthritic joint to reduce side effects.

Disease modifiers slow the arthritic process in autoimmune diseases such as rheumatoid arthritis or systemic lupus erythematosus. Patients taking these drugs are closely monitored. It may take weeks or months to learn if a drug works. During that wait, it's important to keep taking other arthritis medications such as NSAIDs. Gold salts have been used to treat rheumatoid arthritis for 60 years, although nobody knows why this treatment works. Penicillamine, methotrexate, and antimalarials such as hydroxychloroquine are also used. Doctors usually reserve other powerful drugs that suppress the immune system for extremely serious arthritis cases.

Most people with arthritis never need surgery, but when all else fails, it can dramatically improve independence and quality of life by reducing pain and improving mobility. The surgeon may remove arthritis damaged or chronically inflamed tissue, or replace the joint entirely. Artificial replacements are available for all of the most commonly affected joints.

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Use It or Lose It
In the past, doctors often advised arthritis patients to rest and avoid exercise. Rest remains important, especially during flares. But doing nothing results in weak muscles, stiff joints, reduced mobility, and lost vitality. Now, rheumatologists routinely advise arthritis patients to get a balance of physical activity and rest. Exercise offers physical and psychological benefits that include improved overall fitness and well-being, increased mobility, and better sleep.

For example, twice a week for three years, Elsie Sequeira, 81, of Concord, Calif., has attended a water-based exercise class sponsored by the Arthritis Foundation. "It's helped me a lot," she says. Sequeira has rheumatoid arthritis in her shoulders and legs. She had also had a mild stroke and got to her first classes with the help of a walker and an attendant.

A few weeks passed before she saw any improvement in her arthritis, but within a few months she no longer needed either the walker or the attendant. "The warm water is very soothing and we can do things in the water that we couldn't do on land," Sequeira says. She enjoys the social contact, and feels better able to take care of herself. "I don't feel so hamstrung," she says.

Joints require motion to stay healthy. That's why doctors advise arthritis patients to do range-of-motion, or flexibility, exercises every day--even during flares. Painful or swollen arthritic joints should be moved gently, however.

Strengthening and endurance activities are also recommended, but should be limited or avoided during arthritis flares. Arthritis patients should consult their doctors before starting an exercise program, and begin gradually. Exercises must be individualized to work the right muscles while avoiding overstressing affected joints. Doctors or physical therapists can teach proper ways to move.

Muscle strength is especially important because strong muscles better support and protect arthritic joints. "Several studies show that if you improve muscle strength, you decrease pain," Boulware says. Arthritic joints will probably hurt during exercise, but shouldn't still hurt several hours later.

"There's a fine line between doing too much and too little," says rheumatologist William Ginsburg, M.D., of the Mayo Clinic, Jacksonville, Fla. "Sometimes people have to be reminded to slow down and listen to their disease."

Support groups and arthritis education can help people learn how to listen to their disease, and cope with it. "The psychological aspects are very important because that's what changes people's lives," Ginsburg says.

Participants learn practical things, such as how to: get up off the floor after a fall, protect arthritic joints with careful use and assistive devices, drive a car, get comfortable sleep, use heat and cold treatments, talk with their doctors, and cope with emotional aspects of arthritis pain and disability. They may also learn to acquire and maintain what health experts have long touted--a positive attitude.

Health education not only improves quality of life, but also lowers health-care costs, and the benefits are lasting, according to studies at Stanford University, Palo Alto, Calif. Four years after a short Arthritis Self-Management Program, participants still reported significantly less pain and made fewer physician visits, even though disability increased. The benefits came, not from the specifics taught, but from improved ability to cope with the consequences of arthritis--in other words, confidence. "It's the same thing that any good coach tries to instill," says Halsted R. Holman, M.D., Stanford University.

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Avoiding Fraud
Learning to understand arthritis can also help make people less likely to fall victim to fraud. Because they have a painful, incurable condition, people with arthritis are among the prime targets for fraud and spend nearly a billion dollars annually on unproved remedies, largely diets and supplements.

A claim describing the relationship between a nutrient or dietary ingredient and a disease, such as arthritis, cannot be made on the label or in labeling of a food or dietary supplement unless the claim is authorized by FDA. In order for FDA to consider authorizing the use of a health claim, there must be significant agreement among qualified experts that the health claim is scientifically valid. As of December 1996, FDA had not authorized any health claims for a relationship between any food or dietary supplement ingredient and arthritis. Sometimes, however, food or dietary supplement products are found on the market with unauthorized claims.

"If the claim sounds too good to be true, it probably is. Talk to your doctor or other health professional," says Peggy Binzer, a consumer safety officer in FDA's Center for Food Safety and Applied Nutrition.

Consumers who have questions or wish to report a company for falsely labeling its products should call FDA's Office of Consumer Affairs at (301) 443-3170 from 1 p.m. to 3:30 p.m. Eastern time. Consumers who have suffered from a serious adverse effect associated with the use of a dietary supplement should report the effect to their health-care professional or to MedWatch at (1-800) FDA-1088.

Some arthritis remedies, such as vinegar and honey or copper bracelets, seem harmless. But they can become harmful if they cause people to abandon conventional therapy. Others, such as the solvent dimethyl sulfoxide (DMSO), can be outright dangerous. (See "An FDA Guide to Choosing Medical Treatments," FDA Consumer, June 1995.

It's tempting to conclude that arthritis pain gets better or worse because of what was added or eliminated from the diet the day or week before. However, gout is the only rheumatic disease known to be helped by avoiding certain foods. The unpredictable ups and downs of arthritis make it hard to establish a relationship between diet and disease. Scientists have only recently begun to study nutritional therapy for arthritis, and the American College of Rheumatology (ACR) urges continued research.

The ACR Position Statement on Diet and Arthritis advises, "Until more data are available, patients should continue to follow balanced and healthy diets, be skeptical of 'miraculous' claims and avoid elimination diets and fad nutritional practices."

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Research Under Way
New treatments are likely to stem from better understanding of the underlying causes and destructive processes of arthritis. Overuse, injury and obesity are contributing factors in osteoarthritis, and researchers have implicated a faulty gene in the breakdown of cartilage. Heredity plays a role in other forms of arthritis, too, increasing susceptibility in some people. Potential genetic therapy approaches are still far off, however.

Increased knowledge of immunology and the inflammatory process offers more immediate promise. Researchers have developed a drug that blocks the effects of TNF-alpha, an inflammatory protein responsible for reactions resulting in joint damage. In short-term preliminary trials, the drug significantly reduced symptoms in rheumatoid arthritis patients.

Such results are encouraging, but the ultimate goal is to understand what start s the immune response in the first place. "Until you know the real cause, you're not going to have the right drug," Ginsburg says.

That quest continues and offers hope. But short of a cure, enlightened coping may be the most promising avenue to a less taxing life for people with arthritis.

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Common Types of Arthritis
Of more than 100 different kinds of arthritis, these are the most common:

  • Osteoarthritis
    Also called degenerative arthritis. Occurs when the cushioning cartilage in a joint breaks down. Commonly affects feet, knees, hips, and fingers. Affects 16 million Americans, mostly 45 and older. About half of those 65 and older have this form.

  • Rheumatoid Arthritis
    Immune system attacks the lining, or synovial membrane, of the joints. Joint damage can become severe and deforming. Involves the whole body, and may also cause fatigue, weight loss and anemia, and affect the lungs, heart and eyes. Affects about 2.1 million Americans, three times more women than men.

  • Gout
    Causes sudden, severe attacks, usually in the big toe, but any joint can be affected. A metabolic disorder in which uric acid builds up in the blood and crystals form in joints and other places. Drugs and attention to diet can control gout. Affects about 1 million Americans (70 to 80 percent men), with first attack starting between 40 and 50 years of age. (See "Getting to Know Gout," FDA Consumer, March 1995.)

  • Ankylosing Spondylitis
    A chronic inflammatory disease of the spine that can result in fused vertebrae and rigid spine. It is often milder and harder to diagnose in women. Most people with the disease also have a genetic marker known as HLA-B27. Affects about 318,000 Americans, usually men between the ages of 16 and 35.

  • Juvenile Arthritis
    The most common form is juvenile rheumatoid arthritis. Arthritis diagnosis, treatment, and disease characteristics are different in children and adults. Some children recover completely; others remain affected throughout their lives. Affects about 200,000 Americans.

  • Psoriatic Arthritis
    Bone and other joint tissues become inflamed, and, like rheumatoid arthritis, it can affect the whole body. Affects about 5 percent of people with psoriasis, a chronic skin disease. Likely to affect fingers or spine. Symptoms are mild in most people but can be quite severe. Affects about 160,000 Americans.

  • Systemic Lupus Erythematosus
    Involves skin, joints, muscles, and sometimes internal organs. Symptoms usually appear in women of childbearing age but can occur in anyone at any age. Also called lupus or SLE, it can be mild or life threatening. Affects at least 131,000 Americans, nine to ten times as many women as men.

  • Other forms
    Arthritis can develop as a result of an infection. For example, bacteria that cause gonorrhea or Lyme disease can cause arthritis. Infectious arthritis can cause serious damage, but usually clears up completely with antibiotics. Scleroderma is a systemic disease that involves the skin, but may include problems with blood vessels, joints, and internal organs. Fibromyalgia syndrome is a soft-tissue rheumatism that doesn't lead to joint deformity, but affects an estimated 5 million Americans, mostly women.

References
Strange, CJ. Coping with Arthritis in Its Many Forms
Carolyn J. Strange is a science and medical writer in Saratoga, Calif.

Reprinted with permission from U. S. Food and Drug Administration: FDA Consumer; March 1996; Revised December 1996 and June 1997.

  1. Jacob, Stanley W. M.D., Lawrence, Ronald M. M.D., Ph.D., Zucker, Martin. The Miracle of MSM; The Natural Solution for Pain. New York: Berkley Books, 1999.
  2. An Update on Cetyl Myristoleate (CMO)   Chuck Cochran, D.C. 2000
  3. Barefoot RR, Reich CJ. The Calcium Factor 1992; Bokar Consultants; Wickenburg, AZ

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