Arthritis requires solutions on multiple fronts, depending on the causes and types of arthritis.
The management options encompass medicines and supplements, as well as revisiting one’s diet and lifestyle.
Quick read- Dietary tips for arthritis
NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)
These medicines decrease the pain as well as the joint inflammation, therefore giving good symptomatic relief. They are the first-line and most commonly prescribed medication in arthritis. Examples include ibuprofen, naproxen, diclofenac, aceclofenac, piroxicam, lornoxicam, ketorolac, etodolac, etoricoxib, and niflumic acid.
However, long-term or regular usage can increase the risk of developing stomach/duodenal ulcers, so these drugs are commonly prescribed along with drugs (called Proton Pump Inhibitors- PPIs like rabeprazole or pantoprazole), which reduce acid release in our gut.
These drugs provide only pain relief and do not have anti-inflammatory action. They are sometimes prescribed in combination with the NSAID class to enhance the pain-relieving effect during painful phases or episodes.
Paracetamol is one such medicine often added to NSAIDs. Others include stronger analgesics like those of the opioid group like tramadol and tapentadol, and others like flupirtine, and newer ones like nefopam.
The latest area of research for arthritis pain management that is attracting both medical and public attention is cannabinoids which are substances found naturally in our body (endocannabinoids) as well as derived from plants (phytocannabinoids). Cannabinoids have multi-pronged action through decreasing sensitization of pain receptors and decreasing pain transmission and perception. Phytocannabinoids are derived from the leaf of the Hemp plant (cannabis sativa), and are available as oils (Cannabidiol- CBD oil, etc.).
Another substance that has multiple actions on different pain channels is PEA (palmitoylethanolamide), which is also being included in arthritis treatment as an analgesic.
SYSADOA (Symptomatic Slow Acting Drugs for Osteoarthritis)
These are agents that act slowly on the underlying disease process either by enhancing and strengthening the cartilage (glucosamine, chondroitin, hyaluronate – strengthen cartilage matrix), or modulating the inflammatory mediators (diacerein). These are initially prescribed in combination with NSAIDs as they take time to exert their effect and improve the symptoms.
These medicines mainly have a place in rheumatoid arthritis and other immune-mediated, primarily inflammatory arthritis. They act by suppressing and modulating the abnormal immune response of the body by which it attacks the joint cartilage.
These drugs include steroid medicines like prednisolone and a group of medications called DMARDs (Disease Modifying Anti Rheumatoid Drugs). Methotrexate is one of the most common conventional DMARD prescribed (others include azathioprine, gold, cyclosporine, leflunomide, sulphasalazine, penicillamine, cyclophosphamide, chloroquine, and hydroxychloroquine).
A new class of immunomodulators are JAK inhibitors (tofacitinib and baricitinib) that are targeted DMARDs. JAK inhibitors should be taken cautiously and under strict medical supervision in patients who are elderly and have risk factors for cardiovascular disease (CVD). Recent studies have shown a higher rate of heart attack, stroke, cancer (of lung in smokers, lymphomas), blood clots, and death as compared to the TNF blockers drugs (see below).
Another new drug iguratimod acts via both anti-inflammatory actions (like NSAIDs) and immune modulation.
Supportive medicines for Pain
Depression has been strongly linked with arthritis, and both anxiety and depression can increase pain perception and decrease pain thresholds.
Antianxiety-antidepressant drugs may be combined in certain phases of disease management to improve the quality of pain relief. These act by increasing a chemical messenger called serotonin, which reduces anxiety, elevates mood and decreases pain perception. These include drugs like pregabalin which reduces anxiety and pain, and antidepressants like duloxetine and venlafaxine.
Anti Gout drugs
Two drugs febuxostat and allopurinol act by reducing production and deposition of uric acid in the joints, so these are used in arthritis caused due to gout.
Collagen type II
This is the flexible and robust protein present in the cartilage of the joints and is available as two kinds of supplements.
The first type consists of collagen type II in large dosages (>1gram) in a broken up (hydrolyzed) form available alone in sachets/capsules or in combination with SYSADOAs. The primary purpose is to provide the cartilage components to improve the synthesis and regeneration of cartilage, as well as to enhance the strength of the cartilage.
The second type of collagen type II supplement consists of tiny doses (40mg) in its native (undenatured) form. It acts on the part of our immune system present in the gut to gradually get familiar and ‘tolerant’ to this type of collagen so that the body’s immune system reduces and ceases to attack the joint cartilage.
Many herbs have shown inherent anti-inflammatory properties and have also been part of traditional medicine in various countries for treating arthritis. Even though the scientific evidence via clinical trials may not be as robust as it is for the drug/medicine groups, the herbal supplements score by being devoid of side effects and, therefore, suitable for long-term use.
Some of the herbs which are now gaining acceptance and popularity for usage in arthritis include extracts of rosehip, Boswellia serrata (Indian frankincense, Sallaki or Salai guggul), curcumin (turmeric), devil’s claw, cat’s claw, Acacia catechu (catechins) + Scuttuleria biacalensis (biacalins), Morus alba, soy, willow bark, ginger, and green tea. These are generally available in combinations and should be used along with drug therapy.
These are often prescribed as supportive therapy as their role in the body is to strengthen bone and cartilage. These include vitamin D, vitamin C, calcium, magnesium, zinc, boron, and phosphorus. Sometimes these may be combined with amino acids, which are the building blocks for proteins.
Sulphur has known anti-inflammatory properties, and that may be the rationale behind arthritis patients seeking relief at hot springs.
Methyl Sulphonyl Methane (MSM) is a source of sulphur commonly used in supplements, or in combination with the SYSADOAs.
S-Adenosyl Methionine (SAMe) is another supplement sometimes used for its anti-inflammatory and cartilage regeneration properties.
Supplements as the name suggest work best along with appropriate medicines for better symptomatic relief as their effects may be variable and take time to set in.
CREAMS, OINTMENTS, GELS
The NSAID class of medicines are available as creams, ointments, and gels (or even sprays) for application on the skin over the involved joint. The drugs are taken up by the blood vessels of the skin and thereby enter the circulation to reach the affected site. They also have the advantage of avoiding the side effects seen in the gut caused when given orally.
Some of the oral SYSADOAs, herbs, and immunomodulators are also available as preparations for local application.
Phytocannabinoids like CBD are available as gels and oils for application. PEA creams are also available in some countries.
Agents called counter irritants are often added to these preparations, as they produce a sensation of heat, burning, or coolness, which decreases the underlying pain perception from that site. Such agents include methylsalicylate (oil of wintergreen), linseed oil, menthol, capsaicin, camphor, and eucalyptus oil.
NOTE: It is important to check with your doctor about the clinical evidence, effectiveness, and safety of over-the-counter and online arthritis oral and local application products, before using them. Products for arthritis should be used in the right dosage and duration under medical guidance.
Sometimes, medicines may be injected directly into the affected joint for stronger action. Such injections are called intra-articular needles. Steroid medicines (methylprednisolone, triamcinolone) can be given as Intra-articular injections to effectively control severe inflammation, with the effect after that maintained with oral medication.
Hyaluronate, when injected in the joint space, provides lubrication and temporary symptomatic improvement.
However, the action of injectable agents, though useful, is short-lived, along with associated pain, need for the hospital setting, and repeat injections. Therefore, they are used less commonly and for severely symptomatic cases.
Newer therapies include intra-articular injections of a part of the patient’s blood (called platelet-rich plasma – PRP obtained by centrifugation of patient’s blood) as evidence suggests that it contains growth factors that increase regeneration of cartilage.
Some of the DMARDs like methotrexate or cyclophosphamide may not be well absorbed from the gut in certain people when given orally, thereby limiting their effectiveness. In such cases, they are given as regular intramuscular or intravenous once-weekly injections.
Biologicals are the class of injectable targeted DMARDs for rheumatoid and other immune-mediated inflammatory arthritis. These act by targeting specific immune mediators (like inflammatory cytokine TNF-A blockers etanercept, infliximab, adalimumab, and IL-6 blocker tocilizumab). They are given intravenously or through subcutaneous injections every few weeks (each having a particular frequency and regimen). They are used for severe Inflammatory arthritis unresponsive to other treatments and are far more expensive than other medicines.
DIET IN ARTHRITIS
The diet for arthritis is based on two principles. The first is reducing inflammation, and the second is reducing or maintaining optimal weight, as increasing weight puts more pressure and wear-tear on the lower limb joints most affected by osteoarthritis.
A favorable diet for arthritis should be rich in fruits (especially including berries and grapes), green vegetables (especially including broccoli and spinach), yogurts, omega-3 fats (fish, fish oils, canola oil, walnuts, flaxseeds), Olive oil, whole grain items, beans, ginger, garlic, and turmeric. These substances help watch weight as well as reduce inflammation.
Salt intake should be kept to around 6g/day (daily 1 teaspoon per person) as salt can increase joint swelling and also trigger a flare of rheumatoid arthritis. Restrict and avoid fried foods, fast and processed food, and high-sugar foods. Make sure to have at least 2 liters of daily water intake.
It is important to note here that diets designed to reduce BP, weight, BMI, blood lipids and cardiovascular risk, are also highly appropriate for arthritis, and are now being recommended and seen to improve overall disease management. (Read more on the DASH diet, Fat control diets)
Certain substances are known to be inflammatory triggers in sensitive individuals who should preferably avoid these to prevent the worsening of arthritis symptoms like gluten products, aspartame-low calorie sweetener, and MSG– Mono Sodium Glutamate.
EXERCISE AND PHYSICAL ACTIVITY
Regular exercise helps to strengthen the muscles of the joint, which reduces wear-tear, as well as strengthens bones. It acts as a stimulus for the production of cartilage and joint fluid. Regular exercise has a preventive role in the development of osteoarthritis. If arthritis (or spondylitis) has already set in, daily guided physical activity and exercise can help slow disease progression and improve everyday quality of life.
Ideal exercises include simple stretching and holding, water aerobics, cycling or swimming, moderate to brisk walking, guided yoga, and individual joint flexing routines. A daily half to one hour schedule should be planned without overexertion and straining. One should gradually increase the duration of sessions, and each session should have an initial gradual warm-up.
Physiotherapy sessions can be beneficial especially in spondylitis to maximize the decrease in pain and improve muscle strength, reduce stiffness and improve functioning.
Massage of the joint area with moderate pressure can decrease pain perception by stimulating pressure receptors in the deeper skin, as well as increasing the level of serotonin. Massage can also help to reduce joint stiffness, stimulate local circulation, and reduce inflammation.
Heat and cold application through pads, wraps, or bags both have their benefits. Heat improves joint lubrication and reduces stiffness. It works best when applied in the mornings or before physical activity/exercise. Cold reduces swelling, pain, and inflammation, and is best suited for application later in the day or after physical activity/exercise.
Vibration therapy is also available, which decreases pain and stiffness, and improves mobility. It needs to be used carefully under guidance.
Collars/braces or belts may be recommended to be worn for support and maintaining posture, especially for spondylitis.
This is usually done for knee or hip joints in osteoarthritis patients when pain is nonresponsive to medicines and supplements, mobility becomes restricted, and joint destruction on imaging tests is significant. Joint replacement surgery is called arthroplasty, where the joint is replaced surgically with a ‘prosthesis’ or implant, which could be made up of silicones, ceramics, metals, polyethylene, or their combinations. Newer techniques with bio-prosthesis and cartilage regeneration are being researched further and are available selectively.
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