Arthritis: How Far Have We Come?

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By Melvin Churchill, M.D.

Arthritis, for many individuals, remains a mysterious diagnosis that belongs to a few unfortunate individuals. The diagnosis of a rheumatic disease or some form of arthritis is actually quite common. One out of three households has a member with significant disability, based on the diagnosis of arthritis. In fact, 46 million people have doctor-diagnosed arthritis, and it’s estimated, by the year 2030, 67 million or 25 percent of the U.S. population will suffer from conditions known as arthritis. Arthritis is the number one cause of disability, and costs in the United States are estimated to be more than $130 billion dollars annually. In actuality, one out of every five adults with doctor-diagnosed arthritis is a reality. An estimated 300,000 children have arthritis in this country.

The aging population, the growing epidemic of obesity and the ongoing use of tobacco all promote the incidence of rheumatic disease, and the prevalence of arthritis is increasing steadily. This is a reality that cannot be ignored by the public health model. Prevention needs to be proactive, and early treatment requires awareness and early diagnosis.

The diagnostic tools are in the hands of physicians and other health professionals trained in the diagnosis and management of rheumatic disease. The public seems to be learning the fact that measures can be put in place that will reduce the symptoms and preserve the functional capacity of individuals who suffer from arthritis.

It’s interesting that, for many years, the notion that “nothing can be done” has been promoted at many levels of society. In fact, a number of years ago, as chairman of Government of Affairs Committee of the Nebraska Chapter of the Arthritis Foundation, I had the opportunity of presenting the topic of arthritis and its impact on society to some members of the Nebraska state Legislature. After my presentation was completed, it became clear that my words had little impact on those attending, when one of the state senators stood up and simply said, “My wife has arthritis, and I know there’s nothing that can be done to alleviate her pain or cure her arthritis.” Unfortunately, his comments were actually a testament of the stark reality in the early 1980s.

Certainly as a rheumatologist who has practiced for many years in this state, it has become obvious that the treatment of rheumatic disease has improved by leaps and bounds. The number of rheumatologists has expanded, and health professionals are more aware of the need for early and aggressive treatment of many rheumatic diseases.

For many years, our treatments consisted of salicylates, otherwise known as aspirin, combined with agents that were borrowed from other disciplines, including the antimalarials (Plaquenil), chelating agents (D-penicillamine), heavy metal therapy (gold salts), sulfa and cancer chemotherapy agents (methotrexate) derivatives. Probably the most significant discovery in the 20th century, which provided significant change in the treatment of arthritis, was the development of cortisone by Dr. Edward Kendall and Dr. Philip Hench at the Mayo Clinic, leading to the Nobel Prize in medicine in the year 1950. For many years subsequently, many clinical studies attempted to produce new treatment options but failed. In the early 1980s immunosuppressive therapies designed to slow down the joint damage began with products including methotrexate, azathioprine and cyclophosphamide, all of which were chemotherapy agents used to treat malignancies—again, a number of borrowed medications put to use in the field of rheumatic disease.

In the mid-1990s the technological advances in medicine allowed researchers to develop what are known as “biological” disease-modifying agents to rheumatologists. These products were developed in living cell cultures, producing antibody-like structures, which have the ability to target the specific proteins that cause inflammation in the setting of many rheumatic diseases. These antibody-like structures neutralize proteins that signal cells in the body to attack the joint tissue, as well as other organs, such as the skin, eyes, heart, lungs, kidneys, etc. These so-called proinflammatory proteins, known as cytokines, can be targeted with these monoclonal antibody-like structures, neutralize their function and allow reduction and provide significant reduction in the inflammatory process. We now have commercial products available that impact this disease dramatically, when standard disease-modifying agents, such as methotrexate, Azulfidine and Plaquenil, are not adequately controlling the disease process.

The team surrounding the patient with rheumatic disease requires an early diagnosis by a trained rheumatologist, adequate instruction in nutrition, physical exercise, adaptive aids for daily activity, as well as education, which will provide insight into the disease process and the need for treatment.

Social responsibility in rheumatic disease on the part of the patient is key. Adequate nutrition with efforts to control weight gain and to reduce the impact of alcohol and tobacco all have significant impact on this set of diseases. The degenerative diseases, as well as the inflammatory forms of arthritis, are impacted greatly by weight gain and obesity. The risk of developing rheumatoid arthritis is more than 60 times greater in smokers as compared to nonsmokers. Individuals who continue to smoke while being treated fare poorly and do not respond as well to treatment. Using anti-rheumatic medications require healthy liver tissue, so excessive alcohol, which promotes weight gain and liver disease, needs to be restricted.

Certainly the impact of total joint replacement has produced viable individuals when joints need to be replaced; however, the long-term consequences of joint replacement do not replace early treatment and control of the disease process. From a public health standpoint the continued escalation of joint replacement and subsequent joint replacement failures will have significant impact on the “boomer” population.

In retrospect the honorable state senator was probably more right than wrong when he said there was little to do to help his wife with her arthritis pain. At that time lots of aspirin, some borrowed medications, lots of bed rest, physical therapy, etc., were probably not enough. Fortunately the advances in clinical research, promoted by the Arthritis Foundation and the American College of Rheumatology and funded by the pharmaceutical industry and taxpayer dollars, have, in fact, made a difference. With the help of my colleagues at the Arthritis Center of Nebraska it has been my good fortune to have the opportunity to help develop many new and exciting treatment options for diseases such as rheumatoid arthritis, systemic lupus erythematosus, gouty arthritis, ankylosing spondylitis, psoriatic arthritis, as well as osteoarthritis. As one of the rheumatologists in Nebraska, it has been my pleasure to see these changes happen for the benefit of all those patients who suffer from arthritis.

For over 60 years the Arthritis Foundation has helped bring change and relief to millions of Americans through supporting cutting-edge research and providing scientifically proven programs at the local level. For information on arthritis programs, events or how you can take action in your arthritis community, visit www.arthritis.org/nebraska/ or email Carey Collingham at ccollingham[at]arthritis[dot]org. Upcoming events in Nebraska include a Halloween Bone Bash party in Lincoln on Oct. 20, the Lincoln Jingle Bell Run 5K on Nov. 24 and the Omaha and Council Bluffs Jingle Bell Run 5K on Dec. 8.

 

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