GLOSSARY OF TERMS
Arthritis: This term loosely describes a group of disorders affecting the joints of the body. There are over 100 types of "Arthritis". Many parts of a joint can be affected, including the cartilage, the bones that meet to form a joint, the tendons and ligaments that support a joint. Arthritis can be roughly categorized into non-inflammatory and inflammatory. Non-inflammatory types of arthritis include those caused by trauma (torn cartilage in a knee, for example) or wear and tear (Osteoarthritis). Inflammatory types of arthritis include those caused by Autoimmunity (Rheumatoid Arthritis), crystal deposition in the joint (Gout), and infection (Lyme Arthritis). Arthritis can also be looked at as systemic or non-systemic. When it is systemic, a person will feel generally ill, fatigued, and sometimes feverish along with having joint pain. When non-systemic, the joint(s) are the only thing causing discomfort.
Autoimmunity: When a person's immune system malfunctions and instead of only attacking bacteria and viruses, begins to attack one's own body parts. By way of antibodies, immune cells, and certain proteins, the immune system can attack the joints, skin, hair follicles, salivary glands, nerves, blood vessels, and internal organs. We define Autoimmune Diseases or Connective Tissue Diseases based on which method of attack the immune system uses and which body parts or organs are involved. Two of the more common autoimmune diseases that can have joint involvement are Rheumatoid Arthritis and Systemic Lupus Erythematosus.
ANA (Anti-Nuclear Antibody): This is a screening test for the presence of antibodies against one's own body (auto-antibodies) in the blood. One can find auto-antibodies (and thus a + ANA) in normal, healthy individuals as well as in those with Autoimmune Disease. Therefore, it is important to carefully examine a person and confirm the presence of disease by performing more blood testing for specific antibodies that are known to cause autoimmune disease before jumping to conclusions. The immune system can produce many auto-antibodies that never produce disease. A positive ANA can be found in siblings and children of patients with Autoimmune Disease without them ever developing disease. Certain medications and viruses can induce a +ANA without causing disease.
Ankylosing Spondylitis: An autoimmune disease causing inflammation and progressive fusion of the joints of the spine. It leads to increasing stiffness and loss of neck and back flexibility. Patients will often feel the most stiffness and discomfort at night and early morning. They will find that stretching exercises relieve their pain and stiffness. The joints adjacent to the spine, such as the costochondral joints (where the ribs attach to the spine and breast bone), sacroiliac joints (where the spine attaches to the pelvic bones), and temporomandibular joints will often be inflamed as well. 95% of patients with Ankylosing Spondylitis will have a gene marker present in their blood called the HLA-B27 Antigen. Ankylosing Spondylitis is also categorized as a Spondyloarthropathy.
Bursitis: Inflammation of a soft tissue structure called a bursa. This is a small sac that overlies tendons and bones in many locations in our body. Its job is to produce lubrication for the structures it is adjacent to. It can become inflamed by trauma, infection, or by picking up inflammation from adjacent inflamed and injured tendons. One can have Bursitis of the shoulder, elbow, hip, and heel, just to name a few.
Carpal Tunnel Syndrome: A condition caused by swelling in the wrist resulting in pinching of one specific nerve, the Median Nerve. Anything that causes swelling of a wrist can cause this syndrome, including trauma, arthritis, tendonitis, pregnancy, hypothyroidism, tendonitis, obesity, alchohol abuse, etc. About 50% of the time, the underlying cause of Carpal Tunnel Syndrome is never determined. The Median Nerve has branches that go to the thumb, index, middle, and part of the ring finger. Symptoms include a sensation of swelling or numbness of the entire hand (even though only 4 of the 5 fingers are involved). Occasionally these nerve sensation can be very uncomfortable and will awaken a person from sleep at night. It is during the night and early morning that people tend to feel the symptoms most.
Connective Tissue Diseases: A term used to describe over 25 different types of Autoimmune Diseases that can affect the joints, tendons, bones and skin.
Fibromyalgia: A condition that is characterized by widespread pain, hypersensitivity to pain, fatigue, and "tender points" in specific locations of the body (near muscle attachments to bone). The cause of this condition is not fully understood, but it is often associated with disturbed sleep, more specifically, inadequate deep, Stage IV sleep. The central nervous system appears to be involved because it is also frequently associated with depression and chronic stress. Other conditions often seen in association with Fibromyalgia include Irritable Bowel Syndrome, TMJ Syndrome, and Interstitial Cystitis.
Gonococcal Arthritis: A very inflammatory arthritis that is caused by infection with the sexually-transmitted Neisseria Gonorrhea bacteria. It can affect one or more joints and is often associated with a few scattered skin pustules. Once recognized, it responds to IV antibiotic therapy fairly quickly. Men usually have other symptoms associated with Gonorrhea infection, such as burning when they urinate and a penile discharge. Women are often unaware that they are infected.
Gout: An inflammatory type of arthritis caused by the build up of a natural waste product, uric acid, in the blood and deposited in the joints. When the concentration of uric acid becomes high enough in a joint, it can crystallize in the joint fluid causing very painful inflammation. The big toe joints are most frequently involved, but the ankles, knees, wrists, and most other joints in the body can also be affected. This uric acid build-up in the blood is due to a genetic defect of the kidneys in 90% of those with gout. The kidneys are not able to clear the uric acid from the blood efficiently enough. The other 10% of individuals with gout produce too much uric acid, either due to a genetic defect in their metabolism or due to some other underlying illness. Alchohol and certain medications (Aspirin and diuretics, eg.) interfere with the kidneys' ability to excrete uric acid. Certain foods (shellfish and organ meats, eg.) cause more production of uric acid. High uric acid levels can also cause formation of kidney stones.
Immune System: A very complex network of organs, glands, and cells that the defend the body against bacteria, viruses, and other foreign substances. The cells of the immune system can produce enzymes that dissolve tissues and cause inflammation. They also produce a variety of proteins, including cytokines (TNF and IL-1 for example) that allow immune cells to communicate with one another and antibodies that can cause direct damage to bacteria and one's own organs.
Inflammation: The body's reaction to injury caused by trauma, infection, chemical irritation or attack by the immune system's cells and proteins. Inflammation in a joint produces swelling, heat, redness, and pain.
Myofascial Pain Syndrome: This is a painful condition involving a specific group of muscles, tendons, and ligaments. It follows an episode of strain or injury to the structures adjacent to the muscles involved. The muscles tighten in response and eventually take on a state of constant spasm. There is usually a focus of pain and spasm within the group of muscles called a "trigger point". Pressure here will usually reproduce pain radiating throughout the involved area. This condition can become relatively chronic and can persist even after the site of original injury has healed. It often requires a combination of Physical Therapy, anti-inflammatory medication, and trigger point injection with cortisone and/or lidocaine to resolve. The most commonly involved areas are the upper back (between the neck and shoulder) and the buttock and hip muscles.
Lyme Arthropathy: Arthritis can occur as a result of infection with an organism by the name of Borrelia Burgdorferi. This infection is transmitted by a bite from a particular type of deer tick. Within the first few weeks of infection, a person can develop aches and pains in multiple joints, usually without swelling. This pain accompanies other non-specific symptoms such as fatigue, fever, muscle aches and malaise. There is a characteristic skin rash that develops at the site of the tick bite. These musculoskeletal pains usually resolve within several days, but years later, a person can then develop chronic arthritis in one or more joints. One knee is most commonly involved, but there have been rare cases where multiple joints have been involved, mimicking Rheumatoid Arthritis. This arthropathy is usually treated with a course of IV antibiotics. Occasionally it will be come chronic and we think that this is most likely due to a person's own immune system prolonging the inflammation even though the infection has cleared. When it becomes a chronic condition, we treat it the same way as we do other autoimmune arthropathies, using anti-inflammatory and sometimes immuno-suppressive medications. When only one joint, such as a knee, is involved, it will often respond to cortisone injection and, when necessary, surgical synovectomy.
Osteoarthritis: The most common type of arthritis. It is caused by degeneration of the cartilage between bones. It is a consequence of aging, wear and tear. It can occur prematurely in joints that have been significantly injured or that have been chronically stressed by excessive weight. As cartilage degenerates, it becomes thin and increasingly fragile. Although technically not considered an inflammatory arthritis, a joint with Osteoarthritis can episodically flare and become inflamed with swelling, warmth, and increased pain. The symptoms of Osteoarthritis in any given joint can wax and wane in severity over time. We have no way to regrow cartilage (despite the claims of certain non-FDA approved "supplement" manufacturers). Osteoarthritis affecting the hands presents with enlargement (sometimes painless) of the finger joints. When it affects the spine, we refer to it as Spondylosis because of the characteristic bone spurs that grow between the vertebrae.
Osteoporosis: A disease that causes bone to become thin and brittle. It makes one more susceptible to fractures of the wrists, hips, and vertebrae most commonly. Compression fractures of the vertebrae can occur without falling or trauma and can lead to a "rounding" or hump-like appearance of the upper spine. Women are especially at risk for developing Osteoporosis after menopause. Men who are treated with steroids or with drugs like LUPRON for prostate cancer are also at great risk for developing this condition. Screening tests that measure bone density to determine whether Osteoporosis is present include DEXA Scans and QCT Scans (for the spine only).
Polymyalgia Rheumatica (PMR): An autoimmune disease that affects the muscles and joints causing very characteristic symptoms. A person feels intense stiffness and discomfort in the neck, shoulders, upper arms, buttocks and hips, primarily in the mornings. The pain and stiffness can be so severe that a person has difficulty getting out of bed. It can be associated with fatigue, feverishness, weight loss, and anemia. It can be preceded by Bursitis of the shoulders. It only occurs in individuals over the age of 50 and is almost always associated with an elevated sedimentation rate (a blood test). About 10-15% of people with PMR also develop Temporal Arteritis (Giant Cell Arteritis).
Polymyositis and Dermatomyositis: An autoimmune disease causing chronic inflammation and eventual atrophy of muscle. It is usually a painless condition that usually first presents with increasing weakness of the upper arm and leg muscles. It can also affect the muscles that control swallowing. When associated with a typical rash around the eyes, upper back, and extremities, it is called Dermatomyositis. Its diagnosis requires blood testing for elevated muscle enzymes, muscle biopsy, and sometimes, an Electromyographic study or MRI Scan.
Psoriatic Arthritis: An inflammatory, autoimmune arthritis that occurs in 5-10% of individuals with a skin disorder called Psoriasis. It can develop long before Psoriasis develops, however. At times, Psoriasis never develops or it is so minor that it is not noticed. The inflammatory nature of this arthritis causes chronic pain, swelling and stiffness in the large and small joints alike - often affecting all of the joints of one finger or toe and causing a "sausage digit" (dactylitis). The joints of the spine and the costochondral joints of the rib cage (where the ribs meet the breast bone or spine) can also be involved. Tendonitis occurs with greater frequency in this condition. Psoriatic Arthritis is also categorized as a Spondyloarthropathy. Psoriatic Arthritis is capable of causing erosion of bone around joints leading to permanent destruction.
Raynaud's Phenomenon: A condition that causes episodic narrowing and clotting of the small blood vessels in the fingers and toes temporarily obstructing blood flow. By definition, there has to be significant color change in the fingertips ranging from blanching to blueness (cyanosis). It can be very painful and is triggered by minor cold or stress. When severe, it cause enough loss of circulation to the fingertips to cause small painful sores and ulcers around the fingernails. This condition is often seen in association with Connective Tissue Diseases such as Systemic Lupus Erythematosus, Scleroderma, and CREST Syndrome. More often, however, it is seen in healthy individuals without any autoimmune disease.
Reactive Arthritis (Reiter's Syndrome): An autoimmune disease usually involving the joints of the legs that is triggered by an infection, either a gastroenteritis or a urethritis. Certain bacteria have been identified as more often causing this arthritis in genetically susceptible individuals, Yersinia, Shigella, Campylobacter, Salmonella, Chlamydia, Borrelia Burgdorferi (the Lyme disease bacteria). It is often associated with conjunctivitis, oral ulcers, circinate balanitis (a skin lesion on the penis), Keratoderma Blenorrhagicum (a scaly rash on the soles of the feet), plantar fasciitis (also called "heel spurs") or Achilles tendonitis. 90% of patients with Reactive Arthritis will have a gene marker called the HLA-B27 Antigen. Some individuals will continue to have a chronic arthritis even after triggering infection has long since passed. Reactive Arthritis is also categorized as a Spondyloarthropathy.
Rheumatism: An outdated, obsolete term that was used to describe a variety of types of arthritis before we knew how to better categorize them.
Rheumatoid Arthritis: A systemic, autoimmune disease that causes chronic inflammation in multiple joints. Involvement of the joints tends to be symmetric, affecting the same joints on both sides of the body. It is characterized by significant and prolonged morning stiffness of the joints, lasting for more than an hour. Inflammation of the joints causes synovitis, a swelling of the joint lining. This leads to bone destruction beginning around the margins of a joint called erosion. This "erosive disease" of the joints leads to permanent loss of joint flexibility and function. Treatment of this disease is aimed at not only decreasing the symptoms, but also stopping the erosive disease. Rheumatoid Arthritis causes fatigue and often anemia. Infrequently, inflammation can develop in the eyes, lungs, and blood vessels with this disease. Sjogren's Syndrome, causing chronic dryness of the mouth and eyes can be associated with Rheumatoid Arthritis.
Scleroderma (Systemic Sclerosis): An autoimmune disease that causes inflammation and gradual thickening of the skin. It usually begins in the skin of the hands and feet, but often involves the face, neck, chest and abdomen as well. It is associated with Raynaud's Phenomenon, lung inflammation and scarring (fibrosis), bowel disorders, and a kidney disease that can cause severe Hypertension.
Sjogren's Syndrome: An autoimmune disease that causes inflammation and eventual atrophy of the salivary glands of the mouth and lacrimal (tear) glands of the eyes. This results in chronic dryness of the mouth and eyes. This syndrome can be associated with Rheumatoid Arthritis and Systemic Lupus Erythematosus. A definitive diagnosis is made by biopsying the small salivary glands on the inside of the lower lip.
Spondyloarthropathy: A group of autoimmune diseases that can affect the spine as well as the "peripheral" joints of the arms and legs. These include Ankylosing Spondylitis, Psoriatic Arthritis, Reactive Arthritis (Reiter's Syndrome), Arthritis associated with Inflammatory Bowel Disease (Ulcerative Colitis or Crohn's Disease), and Undifferentiated Spondyloarthropathy. When the spine is involved in this group of arthritis, there is significant stiffness and discomfort in the spine at night and in the morning, in particularly. The costochondral joints of the rib cage (where the ribs attach to the spine and breast bone) and the sacroiliac joints (where the spine attaches to the pelvic bones) can be inflamed and painful. Progressive loss of flexibility of the neck, lower back and rib cage develops over many years. Patients notice that stretching exercises help to relieve the pain and stiffness. When the joints of the extremities are involved, often only one or two joints will be inflamed at a time.
Systemic Lupus Erythematosus (SLE): A systemic, autoimmune disease that can cause inflammation in many different parts of the body, including multiple internal organs. SLE has a wide spectrum of severity, ranging from limited skin rashes and joint pains in some to life-threatening disease of the kidneys or brain in others. When SLE is active or flaring, a person will generally feel ill with severe fatigue, fevers, and weight loss. Sun exposure can trigger the typical rash of SLE (a red rash over the cheeks and bridge of the nose) and the more systemic form causing internal organ inflammation. Hair loss, Raynaud's Phenomenon, and Sjogren's Syndrome are often associated with SLE. This disease often first develops during pregnancy or after pregnancy in a genetically susceptible woman. Women with SLE who are contemplating pregnancy or who become pregnant, should be tested for certain antibodies that can interfere with pregnancy and the health of their baby (anti-Cardiolipin, SS-A, SS-B, Lupus Anticoagulant). Women with less severe SLE usually have uncomplicated pregnancies and normal babies, but need to be aware of the risks and may require treatment with Corticosteroids (Prednisone) or anti-coagulants (Aspirin or Heparin) during the pregnancy. Lupus can cause blood cell problems such as anemia (a low red cell count), leukopenia (a low white cell count), or thrombocytopenia (a low platelet count). There forms of "lupus" that only affect the skin, Discoid Lupus and Subacute Cutaneous Lupus. These conditions do not have the systemic or internal organ problems associated with them. Protection from the sun is very important in these conditions as well.
Temporal Arteritis (Giant Cell Arteritis): An autoimmune disease causing inflammation of the blood vessels in the scalp (the Temporal Arteries, eg.) and rarely, those of the eyes, neck and chest. It occurs in the elderly, causes a severe headache with scalp tenderness, and can cause permanent blindness if it affects the ophthalmic artery of the eye. Blindness can be prevented if this disease is recognized and treated early enough. A person will feel generally ill with this disease and experiences fevers, fatigue, and loss of appetite. 50% of individuals with Temporal Arteritis will also have Polymyalgia Rheumatica (see above).
Undifferentiated Connective Tissue Disease (CTD): There are people who experience symptoms and have physical findings that strongly suggest the presence of an autoimmune disease. They will also have some of the antibodies associated with one or more Connective Tissue Disease. However, when the pattern of symptoms or blood test abnormalities does not fit one of the specific autoimmune diseases that we know, we will categorize their disease as an Undifferentiated CTD. This can occur at the early stages of a CTD and as the disease progresses, more "differentiating" features develop that then allow more accurate diagnosis. Often, a persons Undifferentiated CTD remains just that, and never develops into something else. The prognosis is generally better for those that remain in the "undifferentiated" category.
Vasculitis: An autoimmune disease causing inflammation of the small, medium, or large blood vessels of the body. The severity of this condition ranges from mild Hypersensitivity Vasculitis, causing only a rash, to Polyarteritis Nodosa, where life-threatening inflammation of the blood vessels of the internal organs can occur. The blood vessels supplying large nerves of the body can also be involved, leading to numbness or weakness of an arm or leg. People with this condition feel generally ill with fatigue, fevers, and weight loss.
Antibiotics: A theory exists that many types of chronic arthritis are caused by bacterial infection. Certainly that is the case with Lyme Arthritis and Gonococcal Arthritis. There is good evidence that Reactive Arthritis (Reiter's Syndrome) is triggered by bacterial infection. There is no convincing scientific evidence that Rheumatoid Arthritis is the result of on-going bacterial infection. Nevertheless, there are physicians (and a few of these are rheumatologists) that treat their Rheumatoid Arthritis with a variety of antibiotics. There are some with very strong opinions on the subject and they have anecdotal examples to give of patients who have responded to this therapy. In recent years, a few well-designed and credible clinical trials have shown that a tetracycline-based antibiotic, MINOCYCLINE, is effective in decreasing the symptoms of patients with mild Rheumatoid Arthritis in its early stages. I have used it with mixed success in this setting. There is also a place for antibiotic therapy in the first few months of Reactive Arthritis. It should be noted that antibiotics are not without potential side effects. MINOCYCLINE, for example, has been found to induce an illness similar to Systemic Lupus Erythematosus (see above) in rare cases. Prolonged courses of antibiotics can cause gastrointestinal problems and create resistant bacteria.
ALLOPURINOL (ZYLOPRIM): A medication used to lower uric acid levels. Uric acid is a natural waste product that reaches excessive levels in patients with Gout and causes arthritis and kidney stones. ALLOPURINOL lowers the uric acid level in the blood by inhibiting the production of this waste product by a person's metabolism. It is the preferred medication for lowering uric acid levels in Gout patients who: 1) overproduce uric acid due to a genetic defect of metabolism, 2) have a history of kidney stones, 3) have deposits of uric acid in their soft tissues called tophi, 4) are allergic to PROBENECID. This medication is generally very well-tolerated and can be taken daily for a person's lifetime to essentially "cure" Gout. Rarely, ALLOPURINOL can cause liver irritation, especially if a person has impaired kidney function. Kidney and liver function blood testing should be performed once or twice a year. Extremely rare, is an allergic skin reaction to this drug called "Stevens Johnson Syndrome" This can be fatal.
ARAVA (LEFLUNOMIDE):A slow-acting, immunosuppressive medication used in the treatment of autoimmune forms of arthritis (specifically designed for Rheumatoid Arthritis). It interferes with the metabolism of certain cells of the immune system, rendering them less capable of causing inflammation and cartilage destruction. It can begin to have effect as soon as 2 weeks, but more often is effective within 3 months. Potential side effects are stomach upset and diarrhea. If diarrhea develops, it will sometimes subside with time or by decreasing the dose. Adding a fiber supplement can help. Very infrequently, ARAVA can cause some hair loss. Rarely, it can irritate the liver and cause anemia and that is why it is important to perform blood testing on a regular basis, because these side effects are reversible if detected early. This drug is to be avoided in men and women contemplating conceiving a pregnancy because it can be very harmful to a fetus.
ASPIRIN: This is the first "non-steroidal" anti-inflammatory medication ever prescribed. In high doses, it can be very effective in treating arthritis symptoms. Unfortunately, it can be very irritating to the stomach, rapidly inducing gastritis and ulcer formation. This, combined with its ability to interfere with clotting of the blood, produces a dangerous combination that can lead to life-threatening, bleeding ulcers. Most physicians believe that if Aspirin were required to undergo the rigorous testing now required of modern medications, it would never be approved by the FDA because of its potential for dangerous side effects. Fortunately, safer anti-inflammatory medications are now available.
AZULFIDINE: (See SULFASALAZINE.)
CELEBREX: A "new generation", COX2 Inhibitor, non-steroidal, anti-inflammatory drug that is less likely to irritate the stomach and cause ulcers than older anti-inflammatory medications. It is also safer because it does not inhibit platelet function like the older anti-inflammatories, thereby not interfering with your ability to clot. If you have been advised to take ASPIRIN daily to "thin" your blood and reduce the chance of coronary artery disease and stroke, you should continue the ASPIRIN while taking CELEBREX. Like all non-steroidal anti-inflammatory medications, it has a less than 1% chance of causing reversible kidney or liver irritation. Therefore blood testing should be performed 4 to 6 weeks after starting it, then every 6 months if you continue taking it. CELEBREX has an active Sulfa component and, therefore, can cause an allergic reaction (usually a rash) in those that are allergic to Sulfa drugs. In my opinion, media reports about an increased risk of heart attack or stroke associated with CELEBREX use have been exaggerated. There has been no convincing evidence that use of CELEBREX at a dose of less than 400mg per day imparts any increased risk of myocardial infarction or stroke. There is evidence of very slightly increased risk of these events in elderly patients taking 400mg or more of CELEBREX per day for a year or longer.
COLCRYS (COLCHICINE): This is a medication that has been used for decades to treat Gout. It has a mild anti-inflammatory effect when used in low doses (0.6 mg once or twice a day). Daily low doses of COLCHICINE are used to help prevent Gout attacks from developing, especially when taking PROBENECID or ALLOPURINOL to lower uric acid. Years ago, COLCHICINE was used in high doses to treat acute attacks of Gout. At those high doses it inevitably caused vomiting and diarrhea, making one wonder whether the cure was worse than the disease! COLCHICINE is rarely used in high doses anymore. However, even at low doses, it can occasionally cause diarrhea or loose stools. If that happens, the dose is lowered until this side effect resolves. In general, it is a very well tolerated medication and can be taken for many years without toxicity. A very rare complication of long-term therapy is a muscle disorder or "myopathy" that results in increasing weakness and atrophy.
CORTISONE: A natural hormone (a type of "steroid") that is vital to maintaining one's organ function, metabolism and blood pressure. It is secreted into the circulation every morning by the adrenal glands which sit atop each kidney. When given in pharmacologic doses, it is the most potent anti-inflammatory "medication" we have. It can be administered by injection or by mouth. The most common oral forms of this steroid are PREDNISONE, MEDROL. When taken by mouth, CORTISONE causes a general, systemic, anti-inflammatory effect. Potency and risk of side effects are very dependent on dose. Taking the oral CORTISONE in the mornings, mimicking the bodies natural secretion cycle, reduces the chance of side effects. A low dose (up to 7.5mg of PREDNISONE) can be very effective for certain types of arthritis and the risk for side effects is very small. However, many months to years of treatment at this dose can still thin one's bones and measures can be taken to prevent this. Appetite can increase at this low dose. Moderate doses (7.5 to 20mg of PREDNISONE) are more likely to suppress the immune system and can interfere with wound healing. At these doses, the appetite is almost always increased and fat tends to be distributed more around the trunk and face. Other potential side effects at moderate doses are nervousness, insomnia, increased blood sugar levels, high blood pressure, and fluid retention. Thinning of bone can occur more rapidly. At doses higher than the equivalent of 20mg PREDNISONE per day, all of the aforementioned side effects are more likely to occur, especially when used for prolonged periods of time (weeks to months). In addition, when used for long periods of time, there is an increased risk of small areas of bone losing their blood supply, inducing a painful condition called Osteonecrosis. That is why it is important to start decreasing doses of systemic CORTISONE (PREDNISONE) as soon as possible. The dose needs to be reduced gradually to give the adrenal glands of the body time to "wake up" and start producing your own CORTISONE again. This secretion stops when CORTISONE is given by mouth (systemically) and once the glands lie "dormant" for several weeks (or years in some cases) it can take weeks to months for them to re-activate. That's why missing more than a couple of days of CORTISONE, once you have been taking it for more than a month, can lead to a dangerous state of "steroid withdrawal".
CORTISONE Injection: When CORTISONE is injected into or around an inflamed joint, bursa, tendon, or other soft tissue structure, it can stop inflammation and allow healing to take place. It can take effect as soon as within 24 hrs., but often takes 10-14 days to take full effect. When injected into a joint, bursa, or tendon sheath, relatively little "leaks" out into the circulation for a systemic effect. When injected into the muscle in the form of DEPOMEDROL or KENOLOG, it is slowly absorbed into the bloodstream and has a systemic effect over a 2 to 3 week period. Too many injections of CORTISONE into the same place (more than 3 per year) can result in weakening and atrophy or the involved tissue. This is where "CORTISONE injections" get their bad name. They have been abused and taken too frequently by athletes, leading to tendon and ligament ruptures. Infrequently, even one injection can leave a small area of fat and skin atrophy with loss of pigment at the site of injection. This usually fills in with time. There is a small risk of infection associated with cortisone injection - about 1 in 500,000. That is why the skin at the site of injection needs to be carefully sterilized with Betadine and Alchohol before injection. Sometimes, in the first 24 hrs. after injection, there may be increased pain, redness and swelling at the site of injection. This can occur because of the crystalline solution the CORTISONE comes in, causing transient soft tissue irritation. Putting ice on the site of injection for approximately 20 min. within 8 hrs. of the injection, helps prevent this reaction from occurring. If there is an associated fever or if swelling and redness persist beyond 24 hrs., be sure to call me.
ENBREL (ETANERCEPT): A powerful "biologic response modifier" that suppresses the immune system by interfering with a very specific component, Tumor Necrosis Factor. TNF is a cytokine that induces joint inflammation and destruction. Therefore, ENBREL treats autoimmune arthritis by not only suppressing inflammation, but also inhibiting potential structural damage (i.e.- joint erosion). This drug has also been shown to significantly decrease the fatigue associated with rheumatic arthritis. It has been shown to work best in combination with another immunosuppressive, anti-rheumatic medication called METHOTREXATE. ENBREL is administered by subcutaneous injection (similar to injecting insulin for diabetics) once weekly. Potential side effects from this medication are relatively few. Because there have been a few cases reported of Tuberculosis re-activating in patients receiving ENBREL, a tuberculin skin test (PPD) or chest x-ray needs to be done prior to starting therapy. It does suppress the immune system and, therefore, any infection that occurs, whether it be respiratory or skin, should be watched closely and probably treated sooner rather than later. There have been a few reports of serious anemia in patients using ENBREL and, therefore, I check a CBC every few months. Rare cases of a "Lupus-like" reaction (rash, arthritis, fever) and exacerbation of a nerve disease, Multiple Sclerosis", have been reported as well. Medications that work in a similar fashion to ENBREL are HUMIRA (Adalimumab) and REMICADE (Infliximab).
FOSAMAX (ALENDRONATE): This medication was one of the first in a class of compounds called bisphosphonates used to treat and prevent Osteoporosis. Other bisphosphonates include ACTONEL, BONIVA, and RECLAST. FOSAMAX works to maintain bone density by inhibiting osteoclasts, the cells that dissolve bone. This allows osteoblasts, the cells that build bone, to dominate. Over time, this can result in an increase in bone density and a decrease in osteoporosis or osteopenia. Within months of starting FOSAMAX, a person's risk for fracture decreases significantly. It is a medication that is not easily absorbed by the GI tract, so it needs to be taken on a completely empty stomach with nothing but a full glass of water. It is necessary to wait 30 min. before eating or taking any other medication. FOSAMAX is taken on a weekly basis and it is recommended that one take it first thing in the morning, 30 min. before eating breakfast or taking any other medication. One of its few potential side effects is esophageal irritation. Therefore, one should not lie flat for an hour after taking the medication - stay seated or standing. A rare side effect of FOSAMAX and other bisphosphonates is the development of weak or brittle bone in certain locations. This can result in spontaneous or atypical fractures of the femur (thigh bone). In hope of avoiding this complication, it is recommended that patients stop FOSAMAX (and other bisphosphonates) after approximately 5 years of treatment, stopping the inhibition of osteoclasts and allowing the bone to recycle normally for 1-2 years. FOSAMAX can then be restarted if necessary. Another rare side effect is the development of osteonecrosis (bone death) of the jaw. This results in open, non-healing,sores in the gingiva of the mouth. This is primarily seen in cancer patients taking bisphosphonates for bone metastases. These rare side effects must be kept in perspective. The risk of bone fracture, which can lead to serious health complications, is markedly higher than the risk of these side effects in a person with Osteoporosis.
GLUCOSAMINE: Sold as a "natural" food supplement, manufacturers of this compound have sponsored studies that show it can decrease pain in patients with Osteoarthritis They also claim that it can grow back cartilage that is thinned by Osteoarthritis when used in combination with CHONDROITIN SULFATE. Well designed studies sponsored by the NIH in the past several years have not substantiated these claims. Although these supplements have not been found to produce any serious side effects, I cannot recommend them.
HUMIRA (ADALIMUMAB): A "biologic response modifier" that suppresses the immune system by binding to one specific protein, Tumor Necrosis Factor (TNF). It is similar to SIMPONI in that it is a human monoclonal antibody against TNF. HUMIRA is administered by every other week subcutaneous injection (similar to injecting insulin for diabetics). Even though it is a purely human monoclonal antibody, there is potential for one's immune system to build up a tolerance to it by making antibodies against the monoclonal antibody. Using it together with METHOTREXATE reduces that possibility. Like all TNF Inhibitors (REMICADE, ENBREL, SIMPONI, and CIMZIA included), it has very few side effects and does not require frequent blood test monitoring. One needs to be vigilant for infections while immunosuppressed by HUMIRA. There have been rare reports of "lupus-like" autoimmune disease and nerve problems similar to multiple sclerosis developing in patients using TNF Inhibitors, including HUMIRA. Because there have been a few cases reported of Tuberculosis re-activating in patients receiving HUMIRA, a tuberculin skin test (PPD) or chest x-ray needs to be done prior to starting therapy. In treating Rheumatoid Arthritis, the combination of HUMIRA and METHOTREXATE has been shown to be more effective in decreasing joint inflammation and preventing joint destruction than using either drug alone.
HYDROXYCHLOROQUINE: (See PLAQUENIL.)
IMURAN (AZATHIOPRINE): A slow-acting immunosuppressive medication used in the treatment of a variety of autoimmune diseases, including Rheumatoid Arthritis and Systemic Lupus Erythematosus. It interferes with the metabolism of certain cells of the immune system, rendering them less capable of causing inflammation and cartilage destruction. It usually takes 2 to 3 months to have an effect and the dose is slowly increased as tolerated to maximize its effectiveness. Potential side effects include stomach upset and, very infrequently, reversible liver irritation or bone marrow suppression that causes anemia and a drop in white blood cells. Therefore regular blood test monitoring is important. When this drug has been used in high doses for long periods of time in organ transplant patients, it has been rarely associated with the development of lymphomas. This drug has been useful in allowing patients who require corticosteroids (PREDNISONE) to control their autoimmune disease, to decrease their dose of the steroids.
KINERET (ANAKINRA): A "biologic response modifier" that suppresses the immune system by interfering with a very specific component, Interleukin-1 (IL-1). IL-1 is an inflammatory cytokine that plays a role in joint destruction (erosion). KINERET is approved by the FDA for the treatment of Rheumatoid Arthritis. It is administered by daily subcutaneous injection (similar to injecting Insulin for diabetics). Potential side effects from this medication are relatively few and no blood test monitoring is necessary. It does suppress the immune system and, therefore, any infection that occurs, whether it be respiratory or skin, should be watched closely and probably treated sooner rather than later. Irritation at the site of injection can occur and there are a variety of topical therapies for this.
METHOTREXATE: A slow-acting, immunosuppressive medication used in the treatment of autoimmune forms of arthritis. It interferes with the metabolism of certain cells of the immune system, rendering them less capable of causing inflammation and cartilage destruction. METHOTREXATE has been used to treat arthritis for over 20 years and is, therefore, a medication that rheumatologists have the most confidence in using. It has potential for side effects, but we have great deal of experience in monitoring for them and treating them should they occur. It can begin to have effect in a month, but more often is effective within 2 to 3 months. It is taken by mouth on a weekly basis and the dose is gradually increased to where it has the greatest effect without significant side effects. Potential side effects are stomach upset and oral ulcers (like "canker sores"). These side effects are very dose-dependent. Very infrequently, METHOTREXATE can irritate the liver and cause anemia and that is why it is important to perform blood testing on a regular basis, because these side effects are reversible if detected early. For unexplained reasons, there have been a few patients with Psoriatic Arthritis that have developed liver cirrhosis despite normal blood test results. Therefore, the manufacturer recommends a thin-needle liver biopsy in patients with Psoriatic Arthritis after a total of 2.0 grams of METHOTREXATE have been taken (approximately every 2 years). Very rarely, an allergic reaction can occur in the lungs secondary to this medication. This can result in permanent scarring of the lungs. Vitamin B6 (FOLIC ACID) is taken daily when taking METHOTREXATE to help prevent oral ulcers and anemia. This drug is to be avoided in men and women contemplating conceiving a pregnancy because it can interfere with fertility and be very harmful to a fetus.
ORENCIA (ABATACEPT): A biologic agent effective for the treatment of Rheumatoid Arthritis with or without METHOTREXATE. It blocks the stimulation of immune system cells called T cells. These cells regulate the function of the immune system by secreting specific cytokines. It is administered by weekly subcutaneous injection or monthly intravenous infusion. It has a slightly slower onset of action than some of the other biologic agents, but is usually effective within 3 to 6 months. Although there is potential for serious infection associated with ORENCIA use, the incidence of infection appears to be less than with other biologic agents. Transient headaches can occur after administration of ORENCIA.
PLAQUENIL (HYDROXYCHLOROQUINE): This is a medication that has been used for many years to treat a variety of autoimmune, Connective Tissue Diseases. It modulates the autoimmune effects of the immune system in a way that we do not understand well, despite extensive experience with using it. It was originally used to treat malaria, but was incidentally found to be effective in treating autoimmune disease. It is taken by mouth once or twice a day and is generally very well tolerated with the most common side effect being mild nausea. A feared, but rarely occurring side effect at the doses used for autoimmune disease is damage to the retina of the eye. This can be detected by ophthalmologic examination and testing. I recommend seeing an ophthalmologist while on this drug every 6 months. Patients who are genetically deficient in one particular enzyme (G6PD), can also develop an anemia from PLAQUENIL. Levels of G6PD are tested in the blood before starting the medication.
PROBENECID: This is a medication used to lower uric acid levels in most patients with Gout. Uric acid is a natural waste product that builds up in the bodies of patients with Gout, usually because of a genetic defect in the kidneys. PROBENECID helps the kidneys excrete more uric acid into the urine and out of the body. It is important to drink adequate amounts of fluid every day when taking PROBENECID to help prevent the formation of kidney stones from the increased uric acid in the urine. The recommended quantity is 6 to 8 glasses of water per day. Except for rare allergic reactions that usually manifest with a skin rash, PROBENECID is very well tolerated. No specific blood test monitoring is required to rule out toxicity from this medication. It cannot be used in Gout patients with impaired kidney function (it doesn't work), history of kidney stones, or that 10% of patients who have Gout because of overproduction of uric acid (rather than underexcretion).
REMICADE (INFLIXIMAB): A powerful "biologic response modifier" that suppresses the immune system by interfering with a very specific component, Tumor Necrosis Factor. TNF is a cytokine that induces joint inflammation and destruction. Therefore, REMICADE treats autoimmune arthritis by not only suppressing inflammation, but also inhibiting potential structural damage (i.e.- joint erosion). This drug has also been shown to significantly decrease the fatigue associated with rheumatic arthritis. It should be used in combination with another immunosuppressive, anti-rheumatic medication called METHOTREXATE. METHOTREXATE not only enhances the effect of REMICADE, but prevents the body from forming antibodies against it that can neutralize it. REMICADE is administered by intravenous infusion every 6 to 8 weeks. The infusion usually takes a little over 2 hrs. and is performed at private or hospital-based infusion centers. It certain cases, it can be arranged to be infused at home. Potential side effects from this medication are relatively few. It does suppress the immune system and, therefore, any infection that occurs whether it be respiratory or skin, should be watched closely and probably treated sooner rather than later. Because there have been a few cases reported of Tuberculosis re-activating in patients receiving REMICADE, a Tuberculin skin test (PPD) or chest x-ray needs to be done prior to starting treatment. Allergic reactions at the time of infusion can occur and are usually easy to treat. Medications that work in a similar fashion to REMICADE are ENBREL (Etanercept), HUMIRA (Adalimumab), SIMPONI (Golimumab), and CIMZIA (Certolizumab).
RITUXAN (RITUXIMAB): A potent biologic agent that suppresses the immune system by destroying B cells. These cells produce antibodies and other proteins that regulate the immune system. RITUXAN was first used to treat Lymphoma and was later discovered to be very effective against Rheumatoid Arthritis. It is administered intravenously with 2 infusions, 2 weeks apart. The infusions are then repeated every 6 months or when the Rheumatoid Arthritis begins to flare again. It is not necessary to take METHOTREXATE in conjunction with RITUXAN. As with other immune suppressing medications, there is an increased potential for infection associated with this biologic agent. Allergic reactions can occur during infusion of RITUXAN. Therefore, a bolus of IV Cortisone is given preceding each infusion. A very rare side effect that has been reported with RITUXAN is Progressive Multifocal Leukoencephalopathy (PML) - a fatal viral infection of the brain. RITUXAN can be a very effective therapy in Rheumatoid Arthritis, even when many other treatments have failed.
SULFASALAZINE (AZULFIDINE): A slow-acting, anti-rheumatic medication that is most commonly used to treat Psoriatic Arthritis, other Spondyloarthropathies, and mild forms of Rheumatoid Arthritis. It is more popular in Europe than in the U.S. for this purpose. It appears to function by interfering with the metabolism of certain cells of the immune system, thereby decreasing inflammation. It is not significantly "immuno-suppressive". SULFASALAZINE is taken by mouth 2 to 3 times daily and usually takes 2 to 3 months to take effect. The most common side effect is stomach upset and I find that the enteric-coated brand AZULFIDINE ENTABS are generally better tolerated. Rarely, this medication can cause irritation of the liver, anemia, and a low white blood cell count. Patients with a genetic deficiency of a particular enzyme (G6PD) are more susceptible to anemia from this drug and a blood test is performed to check for this before starting. Blood test monitoring is performed every 3 months while taking SULFASALAZINE. This medication is contraindicated in patients who are allergic to SULFA drugs.