"Winning the War Against Rheumatoid Arthritis"

RA is a condition that forces half of patients to become disabled from the work force within five to ten years? and reduces life expectancy by as much as 18 years. RA affects about one per cent of the world?s adult population, most commonly women between the ages of 30 and 50.

The good news is that a tremendous amount of progress has been made within the last ten years in identifying patients earlier and treating the disease more aggressively. Patients with RA, if treated appropriately, can lead a relatively normal life. This is in stark contrast to the wheel-chair bound existence common as recently as 20 years ago!

Experts in the field consider early rheumatoid arthritis to be a medical emergency with mortality and morbidity equal to that for diabetes, asthma, heart disease, and other life-threatening conditions.

Rheumatoid arthritis attacks the joints in a symmetric fashion (both sides of the body affected equally) with the most common areas being the hands, wrists, ankles, knees, and feet. In addition to the swelling and pain, patients with RA often have profound fatigue and stiffness.

Rheumatoid arthritis is an autoimmune disease that attacks not only joints, but internal organs such as the blood vessels, lungs, heart, and eyes. Patients with RA are at increased risk for heart attack, stroke, and lymphoma.

Since many other types of arthritis such as gout, lupus, and osteoarthritis can look like RA a careful diagnostic approach is needed.

Laboratory testing has its pitfalls. The rheumatoid factor, a blood test found to be positive in about 80 per cent of individuals with RA, may also be positive in other disease conditions. Couple that with the fact that 20 per cent of patients with RA will be rheumatoid factor negative, then it becomes clear a diagnosis should not hinge on the results of blood tests alone.

Imaging procedures can also be misleading. Conventional x-rays often miss the erosions found with early disease. Newer imaging technologies such as magnetic resonance imaging (MRI) and ultrasound are much more sensitive.

After the diagnosis is made, there is even more hope for a patient today. In the past, non steroidal anti-inflammatory drugs (NSAIDS) used to be considered a cornerstone of therapy. That is no longer true.

Disease-modifying anti-rheumatic drugs (DMARDS) are being used earlier. Among the DMARDS currently being used are methotrexate, leflunomide (Arava), azathioprine (Imuran), sulfasalazine (Azulfidine), cyclosporine, and hydroxychloroquine (Plaquenil). These drugs attack the immune cells responsible for chronic inflammation. While DMARDS alone in combination are effective, they are relatively non-specific. Often, combinations of DMARDS are required.

Biologic Response Modifiers (BRMS) can target the disease more specifically than DMARDS. RA is a disease that is dependent on the signaling that occurs between immune cells. The signaling takes place through the use of special chemical messengers called cytokines. BRMS act at both the cytokine (chemical messenger) as well as the cellular level allowing the disease to be better controlled and in some instances put into remission.

Biologic response modifiers, which include drugs that suppress tumor necrosis factor (TNF), appear to be particularly effective.

Tumor necrosis factor is a protein that is produced by the immune cells. TNF is the major culprit responsible for inflammation-inducing damage. By block the effects of TNF, better control of RA can be achieved.

Three anti-TNF drugs are currently available: etanercept (Enbrel), adalimumab (Humira), and infliximab (Remicade). Another biologic drug, anakinra (Kineret) blocks interleukin, a different cytokine.

These drugs allow patients to have their disease controlled to such an extent that most are able to enjoy a normal work and leisure existence.

On the horizon are other biologic drugs that work at different points in the immune system- on different cytokines and on different pathways- to allow even greater as well as more specific control of disease. Since rheumatoid arthritis is a disease with many different cytokine and cellular mechanisms responsible for damage, attacking the disease at different points makes sense. In the future it may be possible to identify patients through specific tissue signals (called ?biomarkers?). These biomarkers will allow physicians to type patients and give patients the specific therapy that will work best for them. Once that is achieved, the possibility of a cure becomes a reality.

Everything, though, starts with early accurate diagnosis. If damage is allowed to occur the chances for remission drop dramatically!

Dr. Wei (pronounced ?way?) is a board-certified rheumatologist and Clinical Director of the nationally respected Arthritis and Osteoporosis Center of Maryland. He is a Clinical Assistant Professor of Medicine at the University of Maryland School of Medicine and has served as a consultant to the Arthritis Branch of the National Institutes of Health. He is a Fellow of the American College of Rheumatology and the American College of Physicians. For more information on arthritis and related conditions, go to: http://www.arthritis-treatment-and-relief.com

Preventing Headaches and Reducing Their Impact

Whether speaking of migraines, tension-type headaches or other recurring head pains, it's safe to say that the best headache attack is the one you don't have. Even if you have found an effective treatment for resolving a headache that is already underway, there is nothing about today's as-needed treatment that will keep next week's attack from occurring.

Headache treatments come in two forms?abortive and preventive. The abortive form is familiar to most people. It means something you do to get rid of a headache that has already started. Usually it consists of an over-the-counter or prescription medication, but in some cases, a non-drug approach works. By contrast, a preventive treatment is something you do every day with the goal of keeping some future attacks from even starting. These, too, can involve drug and non-drug strategies.

Billions of dollars are spent each year on abortive remedies. For the most part, they are dollars well spent. And for people who have infrequent headaches that are rapidly and reliably resolved by an abortive treatment, a preventive treatment might be needless.

But if attacks are frequent, hard to resolve, interfere with usual activities?or side-effects from the abortive treatment interfere with usual activities?then a preventive treatment should be considered. Employing a preventive remedy does not preclude also using an abortive measure: each can be part of an integrated plan.

Before discussing specific treatments for specific headache types, let's consider the impacts of recurring headaches. The more obvious impact is the sheer unpleasantness and suffering involved in an attack. However, another impact?though less obvious?is in its own way just as important. And that is the associated disability or loss of function that comes with an attack.

If a headache attack is severe, then whatever else was planned for that day goes out the window?it's just not going to happen. If an attack is moderate in intensity, then usual activities might be possible, but occur more slowly, less efficiently, or require more effort to produce. This, too, represents headache-associated disability.

An increasing trend in the field of headache management is for practitioners to address their patients' loss of function as well as their pain and suffering. Drs. Richard Lipton and Walter Stewart designed a questionnaire to estimate headache-associated disability, called the MIDAS (Migraine Disability Assessment) scale which can also be used for non-migraine headaches.

Measuring and then re-measuring MIDAS is one method for judging if a preventive treatment is effective. But to accurately detect the effectiveness (or lack of effectiveness) of a preventive headache treatment there should also be some sort of day-by-day recording system.

It might be as minimal as a check-mark on the calendar for each day with any symptoms. Another system is to summarize at the end of each day that one day's headache-impact by selecting one of the following four descriptions?none, mild, moderate or severe. Numerically inclined people can assign scores of 0-3 to these choices and then run averages and other statistics for each calendar month.

For people with recurring or continuous pain there is a tendency to live moment-to-moment without a view of the longer-term pattern. A recording system helps capture the big picture. It would be a mistake to judge the effectiveness of any treatment by what happened with symptoms in just the last few days. Generally, a month or longer is required to judge fairly and accurately.

So now that we have decided to consider a preventive treatment for our headaches and have put in place a system for measuring the treatment's outcome, what specific remedies are available?

It depends, of course, on the kind of headaches being treated. Let's discuss two of the most common types?migraine and tension-type headaches.

For prevention of migraine, the best-studied and most effective drug treatments are available by prescription only in the U.S. These include propranolol (brand name Inderal), amitriptyline (Elavil), divalproex (Depakote) and topirimate (Topamax).

Riboflavin (vitamin B2) at 400 milligrams per day was shown in one controlled study to have migraine-preventing actions. (At this dose?far higher than what is needed to treat vitamin deficiency?riboflavin should be considered a drug rather than a vitamin.) The herb feverfew has also shown benefit in controlled trials, but it is important to remember that this, too, is a drug and can have side-effects. As is the case with other drugs, it should not be used during pregnancy.

Non-drug strategies of proven effectiveness in migraine prevention include therapist-supervised programs of stress management, relaxation, biofeedback and cognitive-behavioral therapy. Studies of acupuncture have shown mixed results. Avoiding individually determined triggers for attacks carries no risk and can reduce the attack rate.

For tension-type headaches amitripyline is the best-studied drug for prevention of attacks. Note that this drug is also a leading treatment for migraine, so people unlucky enough to have both kinds of headaches can obtain benefit from just one drug. Unfortunately, even at the low doses used for headache prevention, amitriptyline can cause daytime drowsiness (even when administered at bedtime) or annoying oral dryness. Because of this, substitution of a better-tolerated, though less-studied drug in amitriptyline's family (tricyclic antidepressants) is sometimes required. Tizanidine (Zanaflex) has also shown benefit in controlled trials.

Non-drug strategies for tension-type headache have also been proved effective. These include similar behavioral interventions to those mentioned for migraine?stress management, relaxation, biofeedback and cognitive-behavioral therapy.

It would be wonderful if preventive treatments stopped headaches entirely. If they did, a measurement system would not be necessary. But a more realistic goal for preventive treatment is to reduce overall headache symptoms by at least half, or to an extent that an individual patient finds meaningful. When this occurs, a preventive approach can be a valuable addition to a program of headache management.

(C) 2005 by Gary Cordingley

Gary Cordingley, MD, PhD, is a clinical neurologist, teacher and researcher. For more health-related articles, see his website at: http://www.cordingleyneurology.com

A Healthy Way to be Sick

A person who deals with a physical condition that is beyond their control has to accept an inner depth, which is uncommon in society. If all we do is try to fit into society, we ignore the unique opportunity our illness offers. Our illness forces us beyond the socially accepted depth and allows us an inner exploration most people ignore.

I am partially blind, so it is hard for me to see my outer world. This forces me to look within and explore parts of myself that are not a normal part of society. I am legally blind looking outside of myself, but most people are legally blind looking within. If I had to choose which was worst, inner blindness would be my choice. I believe it is the cause of most of our suffering.

I have had multiple sclerosis since 1981 and I have tried every possible cure that came my way. I am on a weekly shot medication today, but I have tried several diets. I do acupuncture and massage treatments regularly and I have done several alternative treatments including Bee venom and purification methods. I benefited from these treatments; but I am still legally blind with several other symptoms of multiple sclerosis.

Looking Within

Over the decades of making serious efforts to heal myself using everything that held promise, I learned a beautiful lesson. No matter who you are or what condition you are in, the silence beyond our thinking mind is an amazing resource for fulfillment. Becoming aware of that resource is what I call a healthy way to be sick.

That silence is free from disturbing thoughts and fears, giving you a shelter where you are free from your illness and the struggle you are in. It is at that depth the Wisdom of your Body responds to your medication without the distractions from your thinking mind. Even when you are dealing with a chronic illness, like multiple sclerosis, there is an inner peace at that depth. In my condition, if I was to limit my focus to my superficial thinking mind, I would easily become depressed. I am forced to go deeper.

Once I was asked how do we create the ideal state of mind? My answer was: Take away everything that isn't the Ideal State of Mind. When imperfection is removed, we have what existed before we were messed up. In other words, deep within all of us is a wisdom that may not be perfect, but is free to change and evolve. The real task we all face is to learn how can we return to that ideal state of mind.

When we rely on the wisdom of the body, we learn to accept the beauty of life. Our illness or disability may limit us as we adapt to society, but that same situation has the power to force us into a wonderful self-acceptance and that is what I think is a healthy way to be sick. From that state of mind you create an inner healing environment, where you become an active partner with your doctor.

Use your thinking mind to uplift your spirits and work with your doctor and medical team. Your thoughts were not created to depress you or limit you in any way. Thinking, like the clothes you wear can be put on or taken off. Dress up to meet the incredible challenge where you consciously participate in healing. Don't go shabby to an event that is so significant.

Copyright ? 2005 Marc A. Lerner

Marc Lerner is the President of Life Skills Inc. and the author of The Life Skills Approach. He lectures frequently to patients in a health crisis and those undergoing emotional trauma, to help them harness inner resources to overcome these obstacles. For more information and a free e-book, please visit http://www.lifeskillsinc.com