 | Non-steriodal anti-inflammatory drugs |
| Disease-modifying anti-rheumatic drugs |
Up until very recently, conventional medical treatment for arthritic
conditions relied on two categories of medications: nonsteriodal
anti-inflammatory drugs (NSAIDs) that work to reduce inflammation and relieve
pain, and disease-modifying drugs that work to slow the disease process in
auto-immune diseases. In most cases, more than one type of medication is
needed to control the symptoms over the life of the disorder.
The most common side-effect associated with NSAIDs is stomach upset.
Sometimes, stomach problems can be minimized if the medications are taken with
meals, milk, or antacids. However, because these medications are most often
taken regularly at high dosages, it is hard to avoid intermittent stomach
irritation. These drugs can cause bleeding ulcers and the tendency to retain
fluids. Moreover, because aspirin has an anti-coagulant effect, that is, it
inhibits the blood's ability to clot, people who take a lot of aspirin can
develop a reactive bleeding disorder, bleeding excessively both in response to
injury or trauma and randomly under the skin. These side-effects associated with NSAIDs range from troublesome to
serious. In fact, one nonsteroidal anti-inflammatory analgesic, Duract (bromfenac
sodium capsules), has been taken off the market recently because of reports of
serious liver failure. The strongest group of anti-inflammatory agents is corticosteriods. These
are synthetic versions of the body's hormone, cortisone that are produced in
small quantities by the adrenal gland. Synthetically produced corticosteroids
are used to reduce inflammation and suppress activity of the immune system.
The most commonly prescribed are prednisone and dexamthasone. Usually
prescribed for short periods of time when symptoms have not responded to other
medications or during times of intense flare-ups, they may also be used when
inflammation is severe and localized, especially at weight-bearing joints,
such as the knee or ankle. Taken orally or administered by injection, corticosteriods can produce
dramatic results. However, they have little lasting benefit and tend to become
less effective overtime. In addition, overuse of these drugs can damage the
joint and produce troubling side-effects such as weight gain, rounding of the
face, high blood pressure, acne, easy bruising, cataracts, thinning of the
skin and bone, and an increased risk of diabetes, infection and stomach
ulcers.
Doctors generally prescribe a short course of corticosteroids to relieve
acute symptoms, and then gradually decrease the dosage. In all cases, the
possible benefits are weighed against the possible side-effects. And since
side-effects occur more frequently when steroids are taken over long periods
of time at high doses, they are typically prescribed at the lowest effective
dosage.
However, it can take months before these drugs produce any beneficial
effect. During the time it takes for these drugs to work, your doctor will
likely recommend that you use NSAIDs or steroid as well. Like NSAIDs, DMARDs too can have problematic side-effects. Various drugs in
this category can cause diarrhea, rashes, anemia (decrease in red blood
cells), leukopenia (low white blood cell count), and increased risk of
infection. In fact, whenever a drug works to suppress the immune system, there
is an increased risk of infection. Methotrexate can cause serious liver and
lung problems. Some anti-malarial drugs can affect the eyes. It is therefore
necessary that use of these drugs be carefully monitored. Gold salts, another disease-modifying anti-rheumatic drug, have been used
to treat arthritis for over half a century; however, the way in which they
work is not entirely clear. One common form of arthritis, osteoarthritis, does not involve significant
inflammation. As a result, managing pain may be the primary focus of medical
therapy. Pain relievers such as acetaminophen (Tylenol) may then be
sufficient to control the pain. In addition, when the cartilage at the joint
has eroded, a fluid called Synvisc can be injected into the joint. This agent
works to supplement and restore the lubricating, protecting and
shock-absorbing properties of synovial fluid, functions that are compromised
in osteoarthritis. In most cases, it can relieve pain and improve mobility in
osteoarthritic joints as well as Tylenol.
Recent advances in research and technology have yielded promising new
anti-arthritis therapies. A new class of arthritis drugs is currently being
developed that works to inhibit inflammation and pain without producing
significant side effects. Called COX-2 inhibitors or “super-aspirin,”Non-steriodal anti-inflammatory drugs (NSAIDs)
NSAIDs are a class of drugs that relieves the symptoms associated with many
forms of arthritis by slowing the body's production of prostaglandins.
Prostaglandins are responsible for the characteristics of inflammation -
swelling, pain, stiffness, redness and warmth. Aspirin is the most
well-known anti-inflammatory. Other forms of anti-inflammatory agents include ibuprofen
(Motrin, Nuprin, or Advil, for example), naproxen (Naprosyn), indomethacin
(Indocin), sulindac (Clinoril), and tolmetin (Tolectin). Many of
these agents also have an analgesic, or painkilling, effect at low doses.
However, in order for these medications to reduce swelling, they must be taken
regularly at higher dosages.
Disease-modifying anti-rheumatic drugs (DMARDs)
When a person does not respond to anti-inflammatories (NSAIDs), or when the
arthritis appears to be a result of an autoimmune response, such as in
systemic lupus erythematosus or rheumatoid arthritis, disease-modifying
anti-rheumatic drugs (DMARDs) may be used. Many of these medications are
actually borrowed from other disease, specifically cancer and malaria. Anti-malarials
include chloroquine (Aralen) and hydroxychloroquine (Plaquenil).
Cytotoxic drugs, a group anticancer agents, include methotrexate (Rheumatrex),
azathioprine (Imuran) and cyclophosphamide (Cytoxan). Both act to suppress
inflammation and the immune system.
Another category of arthritis drugs is evolving out of the 20 year-old
biotechnology industry. Anti-TNF drugs seem to slow, if not halt altogether,
the destruction of the joints by disrupting the activity of tumor necrosis
factor (TNF), a substance involved in the body's immune response. An
autoimmune response - a process by which the body's defense system
malfunctions and begins to attack itself - appears to account for many types
of arthritis including rheumatoid arthritis, lupus, myositis, and scleroderma.
By blocking TNF, these agents act to pre-empt the autoimmune response.
Already, some doctors administer anti-TNF injections during severe flares of
autoimmune arthritis. Other forms of the drug are at different stages of the
approval process. One such agent,Etanercept (Enbrel), is has been approved by
the FDA. Another, Avakine, has just been approved by an FDA panel.
Medical research is also looking into ways of restraining the body's autoimmune response before it is triggered. One company is in the process of testing a vaccine against arthritis.
Although much of conventional anti-arthritis medications are palliative, that is, they treat the symptoms, much of the newer research, and the therapies that will inevitably emerge, seem to be heading in the direction of much more substantial relief and perhaps even cure.