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What's New in Arthritis Treatment

Online Health Chat with Dr. Bjoern Buehring

January 27, 2011


Introduction

Cleveland_Clinic_Host: The two most common forms of arthritis - osteoarthritis and rheumatoid arthritis - both cause joint pain and limit movement. Osteoarthritis results from wear-and-tear on the cartilage that cushions the joints, typically after an injury or with advancing age. Rheumatoid arthritis is less common and is an autoimmune disease. Learn what’s new in the treatment of arthritis, tips to avoid surgery, and what’s best for you.

Dr. Bjoern Buerhing was born in Duesseldorf, Germany. He attended the Charite – University medicine Berlin and received his medical degree from that institution in 2005.He completed his internal medicine residency at the University of Wisconsin Hospital and Clinics in 2009. He is now in the second year of his rheumatology fellowship, currently serving as chief fellow. Dr. Buerhing has presented at several national meetings and has been published in a number of peer-reviewed journals, including the Journal of Clinical Densitometry, Clinical Geriatrics, the European Journal of Applied Physiology, and Bone.

To make an appointment with any of the specialists in the Arthritis and Musculoskeletal Center at Cleveland Clinic, please call 216.445.3330 or call toll-free at 800.223.2273, ext. 53330. You can also visit us online at www.clevelandclinic.org/arthritis.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Bjoern Buehring. We are thrilled to have him here today for this chat. Thank you, Dr. Buehring, for joining us today. Let’s begin with the questions!


Rheumatoid Arthritis (RA) and Osteoarthritis (OA)

Sammy: Is there any test that is the absolute for diagnosing rheumatoid arthritis?

Dr__Bjoern_Buehring: Unfortunately, there is not. The diagnosis is made based on clinical symptoms (such as joint swelling and pain), lab work (such as rheumatoid factor, CCP antibodies, elevated inflammatory markers) and imaging studies.

changeisgood: What actually causes osteoarthritis? Is it due to inflammation caused in part by our bodies being too acidic?

Dr__Bjoern_Buehring: We unfortunately don't know what causes osteoarthritis. There are risk factors that have been established (trauma, family history, obesity,and older age), but we don't know what actually causes it. There is much research in this field. Inflammation may play a role in osteoarthritis.

Intrepid: I recently had a hip replacement. What can I do to reduce the possibility of having more problems in the future with other joints? My surgeon indicated that I had years left on the other hip. I would like to avoid further issues with my knees, too. What suggestions would you have?

Dr__Bjoern_Buehring: The current recommendations for osteoarthritis (OA) of the knees and hips include:

  1. Participate in self-management educational programs, such as those conducted by the Arthritis Foundation, and incorporate activity modifications (e.g., walking instead of running, alternative activities) into your lifestyle.
  2. Patients with symptomatic OA of the knee, who are overweight (as defined by a BMI greater than 25), should be encouraged to lose weight (a minimum of five percent of body weight) and maintain their weight at a lower level with an appropriate program of dietary modification and exercise.
  3. Patients with symptomatic OA of the knee should be encouraged to participate in low-impact aerobic fitness exercises.
  4. Range of motion/flexibility exercises are an option for patients with symptomatic OA of the knee. We suggest quadriceps strengthening for patients with symptomatic OA of the knee.

Toms: Can cartilage be 'rebuilt' or rejuvenated?

Dr__Bjoern_Buehring: I am hopeful that one day in the future we will have medication and/or procedures that can rebuild or rejuvenate cartilage. At this point, there is active research in this field but currently nothing that is routinely available.

BW: I am 90 years old and under the care of a rheumatologist. At this point, I have severe pain when I have to step up or down or even bend my knees to sit on the commode. I am OK walking on a flat surface. In the past, my physician has drained liquid from my knee and given me cortisone injections, which provided some short-term relief. He does not feel he can give me any additional injections of this type. He wants me to consider knee replacement surgery. I do not want to do this. Two years ago I fell and broke my wrist. Despite physical therapy and doing my exercises regularly, I still have pain every day. I cannot imagine a good result at my age from knee surgery. What other options beside surgery might be available to me?

Dr__Bjoern_Buehring: The first important question to ask is whether your knee symptoms are from osteoarthritis (OA) only, or if you might have a different type of arthritis in addition to the OA. I am particularly thinking of a disease called gout or pseudogout. This can develop in older folks and the knees are a common location. One can see evidence of pseudogout on an X-ray (a condition called chondrocalcinosis). However, the best test for gout or pseudogout is to look for crystals in the synovial fluid. If you have a different type of arthritis than OA, you might need medication that reduces inflammation. I encourage you to talk to your primary care physician and a rheumatologist about this.

In terms of OA alone, there unfortunately is no medication approved that can reverse or even stop the degenerative changes in joints. The only pharmacological options available are:

  • Medications to reduce pain, including over-the-counter drugs such as acetaminophen (Tylenol) or stronger medications such as tramadol
  • Injection therapy with steroids or hyaluronic acid.

Non-surgical, non-pharmacological treatments that are effective include:

  • Exercise - both aerobic and stretching exercises, as well as thigh muscle strengthening exercises
  • Weight loss, if overweight.
  • Evaluation by a physical therapist- use of assistive devices such as a knee brace may be helpful in certain patients.

Surgery often is necessary in severe cases. It often comes down to the degree of your suffering versus the surgical risks. Sometimes arthroscopic surgery can also relieve symptoms (using scope to look inside your knee and clean it out if needed.)If you are in a lot of pain, are very disabled, have decreased quality of life due to your OA, you might be more willing to accept the risk of surgery.

Additionally, if you are otherwise healthy; you do not have any heart or lung problems, diabetes, cancer or high blood pressure, and you have normal liver and kidney function, the surgical risk will be low. These are not easy decisions, and they should be made after you talk in great detail with your family and with physicians who know you very well.


Shoulder

changeisgood: What is the difference in symptoms between osteoarthritis of the shoulder and rotator cuff issues?

Dr__Bjoern_Buehring: The truth is that they can go hand in hand. The rotator cuff is a group of muscles that surround the shoulder joint. They help to keep the ball placed in the socket of the shoulder joint. If the rotator cuff gets injured (through trauma or degeneration), it can cause pain and an inability to move the arm (particularly lift the arm). Rotator cuff problems can lead to osteoarthritis. Osteoarthritis of the shoulder is the bony degenerative changes that happen to the shoulder joint. You can get osteoarthritis of the shoulder without having rotator cuff problems. Physical therapy can help both.


Hand

changeisgood: I am a 54-year-old woman who was diagnosed with osteoarthritis in my finger joints nine years ago. It hasn't bothered me until recently. The Heberden's nodes in the pinky finger of my right hand have become painful. Recently, an orthopaedic surgeon told me the joints were almost 100 percent fused in that finger. The only treatment would be either pain medications or joint fusion surgery. Is there anything else I can do, especially for my pinky finger? I've tried Capsaicin cream and Aspercreme®. They didn't help much. I've increased my Omega 3s and D3, which have helped. Is there anything else I can try? Surgery is the last resort in my opinion.

Dr__Bjoern_Buehring: I agree that surgery often is the last resort. Unfortunately, there are no medical treatments approved that can help reverse osteoarthritis. If your pinky finger is bothering you this much and is not helped by pain medication and physical therapy/occupational therapy, you might need to discuss surgery with your primary care provider, Rheumatologist, and your orthopaedic surgeon.

changeisgood: If distal finger joints are almost fused in one finger, would steroid injections still be helpful for the pain caused by Heberden's nodes?

Dr__Bjoern_Buehring: I think cortisone injection therapy in these joints is generally difficult. If there is active swelling, redness, and pain, it might be useful to try an injection. Often, however, it is hard to get into the joint and - sometimes - the injections don't work.


Knee

CMB: I have osteoarthritis of the knee that causes me to limp. Is there anything other than a knee replacement that might help?

Dr__Bjoern_Buehring: It is hard to answer this question without knowing how severely your knee is damaged and what you have tried so far.

Non-surgical options include pain medicine, injection therapy, exercise (particularly strengthening the thigh muscles), and weight loss. There are also other surgical procedures apart from total knee replacement available such as arthroscopic surgery if you are a candidate for this.

Harley: I have osteoarthritis and have been trying to lose some weight to help my knees feel better. When I exercise or walk a lot, the next day my knees are very swollen. What kind of exercise would you recommend to help lessen the swelling? Also, is there anything I can do to decrease the swelling? I already ice after exercise, but it doesn't help much.

Dr__Bjoern_Buehring: Exercises that do not produce high impact on the knee joints are preferred. In this case, stationary bikes are better than treadmills. Water exercises can be very helpful. Doing exercises to strengthen the thigh muscles - under the supervision of a physical therapist or trainer in a gym - are recommended.

In terms of reducing the swelling, changing the exercise regimen might be enough. Additionally, the RICE method (R rest, I ice, C compression, E elevation) is helpful. Make sure you do not overdo the ice and compression part.

BKrause440: How do you determine whether to recommend steroid or hyaluronic injections for osteoarthritis of the knee? Is this a treatment of last resort before replacement surgery?

Dr__Bjoern_Buehring: There are a few studies that have compared steroids and hyaluronic acid. There was a lot of variation between the studies, however, and it is hard to come to good conclusions. A lot depends on physician preference and patient experience. Steroids might work a little faster, and hyaluronic acid might last a little longer. You are right that injections are often tried before surgery is considered.


Foot and Ankle

feethurt: I have recently been diagnosed with inflammatory arthritis in my ankles. Is this the same as rheumatoid arthritis? Also, the lateral edges of my feet (one more than the other) are experiencing pain that is most severe upon waking and walking. How is this connected with the joints?

Dr__Bjoern_Buehring: There are different types of inflammatory arthritis. Rheumatoid arthritis is one of them. From the brief message you sent, it is hard to tell what type of arthritis you have. The inflammation can involve structures around the joints. That is particularly true for inflammatory arthritis that we group in the class of spondyloarthritis (meaning arthritis involving the back and peripheral joints). These include reactive arthritis, psoriatic arthritis, inflammatory bowel disease related-arthritis, and ankylosing spondylitis. You should see a rheumatologist to see which type of arthritis you have.

annamaryandallen: I have arthritis in the big toe joint, hallux rigidus I believe it's called. I am at the point of having surgery on this in March. It has gotten so bad I have much pain and cannot wear regular shoes anymore. Have I gone too far for any new treatment other than surgery? Is there any prevention for future joints that might be affected? I walked three miles a day until six months ago....walked that far for 30+ years. Exercise is great, but repetitive motion probably did this to my joint. Thank you.

Dr__Bjoern_Buehring: Deformities of the big toes can be very painful. Unfortunately once the damage is done, surgery is often the only option left. You can help prevent the development of these deformities by wearing comfortable (wide) shoes rather than high-heels. Weight loss is also helpful. Certain orthotics can also be custom made to help with the pain when walking.

Toms: I understand hyaluronic acid injections are approved for knee “use.” Is this treatment approved and effective for foot/ankle joint and arthritis issues?

Dr__Bjoern_Buehring: You are right that hyaluronic acid is approved for knee osteoarthritis. It is the only joint, however. There are no medications that are specifically approved for the ankle or foot. Cortisone injections can be used in the ankle.

33117485: Has the FDA approved viscosupplementation injections for the ankle? I know it is really effective for relieving knee pain. I wanted to pursue other treatment options for secondary osteoarthritis in my left ankle. I have tried many different types of NSAIDs, and nothing seems to be helping with the pain and swelling. I am a very young and active person, but being on the ankle after a short period of time seems to be slowing me down with regard to my daily activities. I tried a support brace but found that it was not very helpful. The physical therapy I tried didn’t seem to help either. Thanks

Dr__Bjoern_Buehring: The FDA has approved hyaluronic acid only for osteoarthritis of the knee. Studies have been done for ankle osteoarthritis. Some of them were promising, others were not. In a recent review of these studies, the authors only found 200 to 300 participants that they could include in their analysis. They could not recommend against or for the use of these injections for the ankle, and concluded that larger trials are necessary.

Treating ankle osteoarthritis can be very difficult. As with other locations (knee, hip, shoulder, elbow, hands), there are no medications approved that can reverse or even stop the degenerative changes in joints. Unfortunately, surgical options are often necessary to relieve pain. Have you considered being evaluated by a foot and ankle specialist?


Medications and Treatment Options

pfinnegan18: When would you use the steroids and when would you use the hyaluronic injection?

Dr__Bjoern_Buehring: Personally (no evidence behind it!) I often try a steroid injection first and see what happens. I know, however, that other physicians often use hyaluronic acid. The indications for HA may differ from cortisone (steroid) as HA is best used in moderate to advanced OA.  Thus, you will need to discuss with your physician to see which one is best for your degree of knee OA.  Sometimes physicians can use one type of injection first followed by another type of injection.

CMB: I have rheumatoid arthritis. Is there anything safer/better to use than methotrexate?

Dr__Bjoern_Buehring: Methotrexate really has been the "workhorse" for rheumatoid arthritis (RA) in the last years. It is very safe and effective when used properly (with regular lab monitoring, no alcohol use, etc.). Some patients need additional medication if methotrexate does not control their RA or if they have side-effects from the medication. It is the drug of choice to start with in the current guidelines.

Toms: To help alleviate joint/arthritis pain resulting from a traumatic foot injury, I recently started taking oral supplements that include MSM, chicken collagen type II, and hyaluronic acid. Can you help me understand the potential benefits from taking these supplements? Are there any long-term use considerations I should be aware of? Thanks.

Dr__Bjoern_Buehring: There is great debate whether these supplements work or not. Some guidelines (2010) recommend against them. I usually don't prescribe them, but if they help patients, I tend not to stop them either. However, if you spend a lot of money on them and they don't help, there is no need to continue them.

kbtennislaser: I had a serious infusion reaction during my second session with Rituxan®. I am now very sensitive to steroid shots or prednisone. It makes my blood pressure rise quickly and I never had that problem before. The infusion was almost four months ago. I am now on Cimzia®. I strongly feel like I am feeling an improvement for the first time in two years. My question is: will I ever be able to use steroids again, if needed for a flare? Could I take blood pressure medication at the same time to even out the reaction?

Dr__Bjoern_Buehring: I am sharing your concern for future reactions to medicine. However, as the body itself produces steroids, true adverse reactions to the drug itself (and not other medications you received with the drug) are very rare. I think you will be able to tolerate steroids in the future, but you will need to be closely monitored with the first dose. You should discuss this with your rheumatologist.

kbtennislaser: I just began Cimzia® injections for rheumatoid arthritis. I will be getting my third set soon. When will I feel a difference?

Dr__Bjoern_Buehring: It can take a few doses to feel the effects of treatment. However it varies between individuals. I hope you will feel better soon.

handshurt: So, it really doesn't matter whether you take acetaminophen or etodolac - either will help control pain - but neither will slow the progression of the osteoarthritis.

Dr__Bjoern_Buehring: That is correct. We often recommend acetaminophen (Tylenol) to older folks because NSAIDs have a higher risk of damaging the kidneys and causing bleeding in the stomach. Acetaminophen carries the risk of liver damage if taken in too high doses.

kbtennislaser: I have severe tinnitus from sulfasalazine. Does that mean I am allergic to sulfa drugs?

Dr__Bjoern_Buehring: That is a good question that I am unfortunately not able to answer. I suggest you contact an ear, nose and throat physician since they are specialists in tinnitus. It will be important to be examined for all reasons of tinnitus.

handshurt: Do NSAIDs actually slow the progression of arthritis?

Dr__Bjoern_Buehring: They unfortunately do not. Although there is much research in this area, there are no medications currently approved that are known to stop or reverse osteoarthritis.

five: Do you recommend glucosamine and chondroitin supplements to promote joint health in the elderly?

Dr__Bjoern_Buehring: I do not generally recommend these supplements because of a recent NIH study demonstrating that these supplements do not reduce the pain associated with knee OA. However, as these are generally safe and well-tolerated, I do not stop them if they help patients. If they don't help you, you do not need to spend the money.

handshurt: Does Cleveland Clinic use prolotherapy or done any trials testing its efficacy? Are there significant risks?

Dr_Bjoern_Buehring: Hello handshurt. The Cleveland Clinic Arthritis Center does not provide this service. I briefly reviewed the evidence and found a Cochrane Review (high-quality reviews) from 2004 that stated the following: “There is conflicting evidence regarding the efficacy of prolotherapy injections in reducing pain and disability in patients with chronic low-back pain. Conclusions are confounded by clinical heterogeneity amongst studies and by the presence of co-interventions. There was no evidence that prolotherapy injections alone were more effective than control injections alone. However, in the presence of co-interventions, prolotherapy injections were more effective than control injections, more so when both injections and co-interventions were controlled concurrently.”

This was for back pain. There is not much evidence for joints. I agree more research is needed

JSBNews: What about acupuncture? Is it an effective supplement to traditional treatment?

Dr__Bjoern_Buehring: The evidence for acupuncture in osteoarthritis is also a field of great debate. The guidelines currently don't recommend for or against it. If it works for you, I think you should continue it. If it does not help, you don't necessarily need to continue.


The Autoimmune Connection

JBmedic: I was diagnosed with rheumatoid arthritis (RA) about eight years ago. For the last two years I have been battling with alopecia totalis. Are there connections with the diseases? Do you have any suggestions? My RA has been well-controlled.

Dr__Bjoern_Buehring: Autoimmune diseases can occur together. I would recommend you see a dermatologist who specializes in alopecia to see whether there are other treatments available. If your RA is well-controlled and there is no evidence of inflammation in your body, systemic immunosuppressants might cause more risks than benefits. Could it be due to medication side- effects? This should be decided by you rheumatologist together with dermatology input.

tryhard: In patients with both rheumatoid arthritis and Sjogren’s syndrome, can you determine which came first? Does it matter?

Dr__Bjoern_Buehring: Often it is impossible to determine which came first - the rheumatoid arthritis or the Sjogren's. You are right that often it does not matter which came first. It is important, however, to diagnose both diseases, as the treatment can differ between them (treatment for dry eyes, dry mouth).


Gout

golden: When you have more than five attacks of gout in a five to six month period, what would be the proper treatment? Is there any specific diet? Medications?

Dr__Bjoern_Buehring: We generally recommend medical treatment if patients get more than two gout flares per year. Diet changes can decrease uric acid to a certain degree, but if you get this many attacks, I think you will need additional treatment. Drugs like allopurinol or febuxostat help decrease uric acid and prevent future flares, but you will need additional treatment (colchicine, steroids, NSAIDs) in the acute flare. I recommend you make an appointment with a rheumatologist to discuss this.  


Juvenile Rheumatoid Arthritis (JIA)

salsol56: What is the best treatment for systemic juvenile idiopathic arthritis (JIA)?

Dr__Bjoern_Buehring: Hello salsol56, I will not be able to answer that question. There are different medications available. Your pediatric rheumatologist will need to assess how severe and how active the systemic JIA is at a given point, and then decide which drug is best. However, there have been very exciting discoveries in the last years, and the treatment options have improved greatly. One of these is the blockade of IL-1.


Closing

Dr__Bjoern_Buehring: Thank you everybody for joining our chat. I hope we were able to answer most of your questions. I encourage you to keep interested in the field of arthritis because much more research is necessary. The Cleveland Clinic Arthritis Center has a multi-disciplinary approach to all types of arthritis and is looking forward to seeing you in a personal consultation if you are interested. Thanks again for all your interest!


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