New treatments for old joints

Aching knees. Tender knuckles. Stiff joints. For 10 million Filipinos suffering from arthritis, these are part of their day-to-day lives. And along with other bone and joint disorders, it is the most common cause of severe long-term pain and physical disability in the Philippines today.

The term "arthritis" actually covers several diseases. Osteoarthritis (OA), sometimes called the "wear and tear" disease, is the most common of these disorders and is a chronic degenerative joint disease that usually affects older people. It is marked by a breakdown of cartilage, the tissue that cushions the joints. Think of it as a losing battle between the forces that destroy cartilage and those that repair it. Loss of cartilage means more friction between bones at the joint. This can cause pain, stiffness and loss of mobility. Hands, especially the finger joints, knees, hips, neck and lumbar spine are most often affected. OA cannot be cured (it will get better and then get worse, for no apparent reason), but it can be managed. You can reduce pain and impairment, and you can improve your quality of life.

"Since we haven’t yet determined how to stop the progress of osteoarthritis, we focus on treating the pain and, to some degree, slowing the speed of cartilage deterioration," says Robert Dimeff, M.D., Medical Director of Sports Medicines of the Cleveland Clinic. There is a variety of methods used to provide pain relief – physical therapy; weight reduction; anti-inflammatory drugs; steroid injections; and, in more severe cases, surgery. Progress in treatments is being made on nearly all fronts. And several other high-tech approaches in the research pipeline may even help some people delay the onset of osteoarthritis or prevent it altogether. Here are some of the new, promising treatments for this age-old condition.

Improved Medicines

Until recently, non-steroidal anti-inflammatory drugs (NSAIDs), such as Voltaren and Naprosyn, were the mainstays of medical therapy for arthritis. But when taken in large doses, they often caused gastric irritation. Now, newer drugs are available that are kinder to the stomach. These are the COX-2 inhibitors, such as Celebrex and Vioxx, whose introduction have changed the arthritis treatment landscape significantly.

The COX-2 inhibitors block only the "bad" form of an enzyme (cyclooxygenase) involved in pain and inflammation. They do not interfere with the "good" form of the enzyme, the one which protects your stomach lining from irritation. Aspirin, ibuprofen and other NSAIDs block both forms, causing gastric irritation in as many as 20-30 percent of those who take them.

The COX-2 inhibitors do not necessarily work better than other anti-arthritic agents. They work, however, with less risk of gastrointestinal side effects, liver enzyme elevation, bleeding complications and drug interactions.

Chondroitin And Glucosamine

Chemically, the nutritional supplements glucosamine and chondroitin sulfate are precursors to the production of proteogylcans, an important component of joint cartilage. For years, reports on the benefits of these substances were largely anecdotal or the results of small pilot studies.

However, a recent review in the Journal of the American Medical Association took a collective look at 15 such studies and came up with some larger-scale conclusions. The most important finding is that these two supplements are as effective as aspirin or ibuprofen in providing pain relief for arthritis, and with fewer side effects. A new three-year study published in the Jan. 27, 2001 issue of the medical journal Lancet suggests that glucosamine may actually slow the progression of this joint-degenerating ailment.

"If a patient is interested in trying supplements and other treatments haven’t worked, I recommend a two-month trial using 500 mg of glucosamine and 400 mg of chondroitin three times a day," Dr. Dimeff says. Higher doses may cause gastrointestinal problems including nausea, indigestion, gas or diarrhea, he notes.

The US National Institute of Health (NIH) has begun a four-year, 1,000-patient, multi-center study of glucosamine and chondroitin sulfate. The results will be available in 2004.

Viscosupplementation

A newer treatment for arthritic knees involves injecting a man-made substitute for synovial fluid, the thick glutinous substance resembling egg whites that cushions the joints. Viscosupplementation, as they are called, are injected directly into the joint. The fluid replaces or adds to existing synovial fluid, helping to lubricate the joint and improve the shock absorption.

These injections, sold under the brand names Hyalgan and Synvisc, are derivatives of hyaluronic acid, a gooey fluid that normally lubricates the joint. They were approved by the US Food and Drug Administration in 1997 but they are, however, not yet available in the Philippines. Several injections over a two-to-four week period are needed. When arthritis sets in, hyaluronic acid starts to deteriorate. The injections "put back in what the joint loses," says Tufts University arthritis expert Ronenn Roubenoff, M.D. That not only helps to relieve pain and restore mobility but also has the potential to suppress inflammation and even helps "turn on" the joint’s own production of new fluid.

Alternative Therapies

Even some forms of alternative – or complementary – therapies are becoming more widely accepted as clinical studies prove their effectiveness. For example, a clinical trial done last year and sponsored by the US Institutes of Health (NIH) found that acupuncture relieved arthritis-related knee pain and stiffness while increasing physical functioning when used in addition to conventional therapies. The NIG is launching a larger trial to confirm the findings.

Because there are still many bogus treatments promoted for arthritis, talk to your doctor before beginning any form of alternative therapy.

Therapies To Prevent Arthritis?

There are a few therapies designed to treat small cartilage defects, that hold promise for preventing osteoarthritis in the young adult who is experiencing debilitating joint pain from sports injury or accident. These include:

Cartilage cell transplant. The hallmark of osteoarthritis is the breakdown of cartilage in joints. But transplanting cartilage cells can help reduce pain – and perhaps, even keep arthritis from gaining a foothold – in someone who has sustained a small tear or hole in the cartilage from an accident or sports injury (for example, twisting a knee while playing basketball). Even one such "defect," if left untreated, can cause pain and swelling, not to mention predispose a joint to become osteoarthritic over time.

The transplant treatment, so far approved for use in repairing knee cartilage, employs a cell solution called Carticel. Several steps are involved. First, a surgeon performs an operation to "harvest" a raisin-sized chunk of healthy knee cartilage cells. The cells are then shipped to a lab, cultured, or grown, for several weeks. When they number in the millions, the culture cells (now called Carticel) are returned for another operation. In this second procedure, the surgeon cleans out the damaged cartilage in the knee and then injects Carticel into the injured area, leaving the cells to multiply and knit themselves into a new framework of protective tissue.

The patch of tissue that protects the implanted cells, while a major treatment advance, can cover only a small area (half-an-inch to an inch wide). That’s why cartilage cell transplantation can’t as of yet, help people with full-blown osteoarthritis involving the whole joint.

Stem cell transplant. Some people with painful cartilage damage that hasn’t progressed to arthritis might benefit from transplants of stem cells – primitive cells found in the bone marrow that haven’t matured into specific types of cells. The surgical process isn’t much different from a cartilage cell transplant: the stem cells are harvested, grown in a lab, and implanted in defects where cartilage has been torn or worn away.

In theory, replacement cartilage produced from younger, healthier stem cells might be more likely to take hold than replacement tissue produced from older, mature cartilage cells, which are "not as viable." But the transplant, which is already being done in Europe, is still in the animal research stage. In the United States, human studies are expected to begin soon.

Mosaicplasty. In this therapy, doctors take a cylindrical plug of cartilage and bone from a healthy area within a knee joint, drill a matching hole in the damaged cartilage in the same joint, and fit the plug into the hole, much like a carpenter would fit a dowel. About one inch worth of damage can be covered with a number of plugs which are used like puzzle pieces – hence the name ("plasty" – the medical term for repair.)

Striving For Prevention

Doctors continue to refine and improve their methods for relieving the pain, inflammation and limited joint mobility that are the hallmarks of this "wear and tear" disorder. There is still no proven method to halt or reverse it, although experimental studies continue to push in that direction. For now, treating arthritis means focusing on pain relief. In the future, it will be striving for prevention. Meanwhile, the new treatments are already helping improve the quality of life of many old Filipinos with osteoarthritis.