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Joint Dilemma

New Data Suggest One-Third of U.S. Adults Have Arthritis. Unfortunately, Treatments Aren't Keeping Pace



By Brian Reid

Special to The Washington Post

Tuesday, November 5, 2002; Page HE01


With last week's announcement that almost 70 million American adults -- one out of three -- are affected by arthritis, it's a good time to face the unpleasant realities about the chronic joint inflammation disease. For most people, there's no preventing it, no curing it and no treating it effectively except by managing pain. Seeking pain relief carries risks of its own, and the best strategy for keeping the disease contained -- a healthy diet and regular exercise -- is not generally heeded by the afflicted.


"We are dealing with conditions that are very common, and that will be more common and more of a burden as the years go on," said Eric Matteson, a professor of rheumatology and internal medicine at the Mayo Clinic in Rochester, Minn. "We baby boomers are getting old."


The U.S. Centers for Disease Control and Prevention (CDC) reported late last month that 69.9 million adults have arthritis or chronic joint pain symptoms. That figure is more than 60 percent higher than past estimates, and experts said the number will grow as Americans get older and heavier, two of the most powerful risk factors for the disease.


But even as the numbers affected by arthritis mount, doctors have few tools to stop or reverse the most common form of the disease, osteoarthritis, which is generally linked to wear on the joints and the breakdown of cartilage that cushions those joints from years of use, or trauma. Rheumatoid arthritis, which can affect people at any age and is caused by an autoimmune reaction, is estimated to affect more than 2 million people.


Physicians have evidence that lifestyle changes may slow osteoarthritis and reduce pain. But doctors say wonder drugs to prevent the condition or retard its progression are still years away.


"The largest group, the group that has the osteoarthritis or degenerative arthritis that's part of aging, that's the group that we still don't have perfect solutions for," said Lenore Buckley, a rheumatologist at Virginia Commonwealth University in Richmond. "We can't currently prevent most of the cases. We need new therapies."


That limits drug treatment largely to pain relief.


Last week a study out of Harvard flagged shortcomings with that approach, too, showing that regular, frequent use of acetaminophen (the active ingredient in Tylenol) and nonsteroidal anti-inflammatory drugs, or NSAIDS (such as ibuprofen, found in Advil and Motrin) appeared to dramatically increase women's risk of high blood pressure. Women who used either type of painkiller more than 22 days a month had about twice the risk of nonusers. Less-regular users also saw their risk elevated, though not by as much. And while that study showed no association between hypertension risk and aspirin, it carries other drawbacks. Regular use of the analgesic can put some patients at risk of bleeding ulcers, a shortcoming shared by NSAIDs.


New, more expensive pain relievers -- such as Vioxx and Celebrex -- have been designed to reduce the problem with bleeding, but doctors are still unsure whether they actually do. Concerns about higher-than-expected rates of heart attack in users of Vioxx and Celebrex also continue to dog the drugs.


About Those Numbers


The new government survey, conducted last year, asked more than 200,000 people two basic questions: Had they ever been diagnosed with arthritis? And had they experienced joint pain in the last year that lasted more than a month? Those who answered yes to the second question were included in the updated arthritis count, even though the CDC conceded that some of those individuals may have had joint pain that was unrelated to arthritis.


Chad Helmick, a CDC researcher who helped compile the survey results, said that about one-third of the respondents answered yes to at least one of the questions, with about 10 percent reporting both a diagnosis and recent episodes of joint pain.


The survey findings reaffirmed the basic tenets about arthritis risk. Those 65 and older are most affected, with nearly 60 percent reporting arthritis or chronic joint pain.


Individuals who are overweight, obese or inactive were also more likely to report joint problems than their normal-weight or active peers. Women were more likely to suffer symptoms than men, with roughly 37 percent of women affected compared with about 28 percent of men. Whites and blacks had higher rates of arthritis -- with both groups above 30 percent -- than Hispanics -- 23 percent.


The lack of good medical options for osteoarthritis stands in contrast to the treatment of rheumatoid arthritis. Though rheumatoid arthritis doesn't look different than osteoarthritis, it develops in a different way and can affect a broader spectrum of joints. Advances over the past two decades in our understanding of how the immune system goes awry have led to a few new drugs, notably Enbrel and Remicade, that can delay the disease and restore quality of life in both its early and late stages. The drugs have revolutionized treatment of the disease, experts said.


"No one should really have the kinds of deformities and disabilities that they had 10 years ago or 20 years ago, because the medication [for rheumatoid arthritis] is there," said Tino Mantella, president of the Arthritis Foundation, a nonprofit group that funds arthritis research and advocacy.


Looking Ahead


Now researchers are turning their attention to how osteoarthritis may begin, a first step in understanding that disease and fashioning treatments that may curb its impact on the millions with the disease -- and the millions more likely to develop it as they age.


"There's just beginning to be research about the causes and genetics and treatments for osteoarthritis," said Buckley. "We're really getting for the first time some insights into the mechanism. What's yet to be seen is if that understanding will parlay into better treatments."


Scientists are also taking a harder look at whether dietary supplements can make a difference. Glucosamine and chondroitin, substances naturally found around cartilage cells, are widely used as a self-care treatment, although reports of their effectiveness have been largely anecdotal. Makers claim the supplements can slow the effects of arthritis and may even repair battered joints.


The National Institutes of Health has funded a study of glucosamine and chondroitin that is designed to follow more than 1,000 patients. A smaller study, recently in The Lancet, a British medical journal, suggested the supplements may alleviate symptoms and slow the progression of the disease.


"There does appear to be an increasing science base" to claims of the substances' effectiveness, said John Klippel, the Arthritis Foundation's medical director. "You're seeing more patients use and more doctor recommending glucosamine."


But even future breakthroughs may not address one of the obstacles to arthritis care: patients who don't see their pain as arthritis or as treatable. Mantella says that he often deals with people who endure old sports injuries or a bad back, not realizing that those pains could signal arthritis.


"People tend to minimize these symptoms too often, and this loses valuable time in terms of treating and preventing worse outcomes," said Helmick.


And those with osteoarthritis are not completely without options. In addition to drugs for pain management, research has suggested that diet and exercise choices, while not able to rebuild deteriorating joints, can help reduce pain and improve mobility and daily life.


At the top of the list is exercise. Mantella says there was a time when treatment called for patients' immobilization within a body cast to give the joints time to heal. Those days are over. "Now," he says, "they would all say that's the worst thing in the world to do."


Ravaged joints benefit from strong muscle support, making muscle-building activities important. The evidence is strongest in arthritis of the knee. "Even in late knee osteoarthritis, if you can get people strengthening their quadriceps, you'll improve pain and improve function," Buckley said.


Regular exercise also helps shed pounds, one of the biggest contributors to osteoarthritis. That underscores the importance of proper diet, too, doctors said. Research has suggested that losing 11 pounds cuts osteoarthritis risk in half, and doctors said losing weight should help even patients who have already begun to show symptoms of arthritis.


That means public health efforts to stem arthritis dovetail with efforts to stem obesity. The bad news is that this effort is failing. Nationwide, a majority of people in every state but Colorado is either overweight or obese, and the CDC survey confirmed that more than 62 percent of adults contacted were above their ideal weight.


"Once you have the disease, if you lose weight, that should help," said Helmick.


Still, those interventions can't reverse the disease, and those with severe arthritis may never be able to regain even reasonable function if the condition is left unaddressed for too long, Buckley said. In a graying America, that group -- and the larger group of arthritis sufferers -- is growing, making new medical breakthroughs vital.


"We're all going to be joining that group. It's just a matter of time. The question is, when we get there, will there be better solutions?" Buckley paused. "I think there will, but it will take a significant investment by society."?


Brian Reid is a regular contributor to the Health section




? 2002 The Washington Post Company

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