Inflammatory Arthritis Center

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Inflammatory Arthritis Center
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Drug Treatment

Arthritis Treatment is Disappointing
A 1997 survey of 1,000 Canadian Arthritis sufferers showed that 60% developed the disease after age 40; 62% of those dissatisfied with the care they received cited "not getting better" as their chief complaint. Arthritis was one of the most reasons for visiting the family doctor in Canada and is the third most common reason for prescription drug use. The annual cost of Arthritis health care in Canada is $14.3 billion.

Overview of Standard Medical Treatment

Arthritis is usually treated with drugs and physiotherapy. Drug treatment of arthritis is often unsatisfactory. If you critically examine treatment regimens, there has been little progress beyond the basic drugs, aspirin and prednisone that have been in uses for several decades.

Aspirin (ASA) has been imitated by many other agents that have similar benefits, side effects and similar toxicity. There are two groups of ASA substitutes:

1. Non-steroidal anti-inflammatory drugs (NSAIDs)

2. Selective COX-2 inhibitors.

The mechanism of ASA and the other drugs is the inhibition of the enzyme, cyclooxygenase (COX), responsible for the production of pro-inflammatory prostaglandins. NSAIDs were once considered controlled drugs, available only on prescription, but many NSAIDs have been removed from the prescription list and are available as over-the-counter drugs: Advil and Motrin are examples.

COX 2 Inhibitors, Expensive and Not Safe
The newest class of pain–relieving drugs, the selective COX-2 inhibitors were marketed aggressively and outsold older less expensive drugs. All these drugs alleviate the pain of active arthritis but do not favorably affect the outcome of the disease. Advertising for the newer “selective COX-2 inhibitors” led the casual reader to believe that these drugs were the newest and best drugs for arthritis. Because they are prescription drugs and more expensive, patients may be tempted to believe they are better than ASA, ibuprofen, diclofenac or naproxen but this is not true. The claimed advantage of the newer COX-2 inhibitors, slightly lower incidence of gastrointestinal irritation is supported by some but not all studies Cox-2 inhibitors have no advantage in terms of pain relief and anti-inflammatory effects.

A growing controversy surrounds the use of Cox-2 inhibitors. The drug companies involved competed to secure a large share of the multi-billion-dollar-a-year market for pain-relieving anti-inflammatory drugs. A news report in 2002, for example, warned people that: "Elderly patients taking Vioxx, the most popular arthritis drug in Canada, are twice as likely to be hospitalized with major gastrointestinal bleeding than those taking its pharmaceutical competitor, Celebrex. In 2002, 3.4 million prescriptions for Vioxx were filled across Canada; 3.1 million for Celebrex.[i]” What is surprising about this expensive and unproven class of drugs is that physicians prescribed them so quickly and frequently. They and their patients have been obedient consumers responding to clever advertising campaigns.

Immune Suppression
The steroids, represented by cortisone and prednisone, are potent anti-inflammatory drugs and can have dramatic benefits in short-term use. In long-term use, there are penalties for the benefits offered. The other drugs are mixed bag of oddities - accidental discoveries such as gold and anti-malarials that may have benefits but also have toxic penalties. No one knows exactly how they work, and they do not work very well.

Increasingly, drugs that inhibit or kill immune cells are used as anti-inflammatory drugs (methotrexate and cyclosporin are examples). All the new therapies that receive headline attention involve disabling the immune system one way or another. While immune inhibition may be helpful, none of these strategies cures the disease by removing the cause. All immune inhibition strategies are expensive to buy and carry serious risk of developing secondary disease that can be worse than arthritis.

A Better Approach

Part of the problem with arthritis therapy has been complacency attached to dogma. No one understands the cause of arthritis and the mechanisms that initiate and then maintain inflammation remain obscure. The treatments are inadequate and the suffering is great. Apparently, it has been easy for institutions to focus on coping with the ravages of arthritis - you have resources to help people cope with pain and loss of function. Pain control is seldom adequate and loss of function is often progressive and disabling. No resources are applied to prevention or emergency care of the arthritis attack.

Our attitude is different. What if you took the point of view that any an all inflammatory attacks on joints is a medical emergency. You got into the ambulance and were rushed to the joint ICU. Hours count. The onset of joint swelling and pain should be treated as an urgent problem to be solved. Inflammation damages joints and they cannot be repaired. Some can be replaced but this is hardly a satisfactory strategy.

What if the attitude was - there has to be an immediate investigation into the cause so that the problem can be stopped at its source. You ask important questions about the possible cause, even if you are not sure. Is the cause in the Food? In the Air? Water?

What if the attitude was - in the face of uncertainty, why not make some simple assumptions and try simple, safe experiments to see if the problem can be avoided? We propose diet revision as the experiment - not casual, haphazard, silly diet revision, but complete, thorough, thoughtful, disciplined diet revision.Drugs may play a role in controlling the disease, but again the casual use of drugs without understanding, without a clearly-defined strategy, without goal and end-points to measure efficacy, drug use can be a great disappointment and a source of further suffering and disease.

Quick Action to stop inflammation:

Our preference is to try to stop the inflammatory activity as soon as possible. All inflammation is likened to a fire. You get out the fire extinguishers and go to work. Drugs are used as short-term tools. Diet revision is used to control the disease long-term. No matter what pattern the immune attack assumes, our standard defense can be tried:

Food Holiday on Alpha ENF - 10 days minimum
With or without prednisone until the fire is out.
Pain-relievers, as required
Rest; free movement, non-weight bearing ( warm pool is best)
Prednisone is often a magic drug that relieves terrible pain and suffering often in the first 48-72 hours of therapy. The problems with prednisone arise with long-term use. The secret of success is to use this drug for brief periods and attempt to control the disease with diet revision in the long-term. A medium to high dose of prednisone (20 - 60 mg per day) may be required for several days and then is reduced to an effective short-term maintenance level between 5 and 20 mg/day.

After pain and swelling have subsided, slow food reintroduction follows the Alpha Nutrition Program. Each food is carefully screened for arthritis-triggering effects. You hope that food allergy caused the problem and that food control can be successful controlling the disease in the long-term. Unfortunately, we do not have good data on how many un-selected patients would respond to this approach, but nothing is lost by taking this approach and complete control of the disease has been obtained. If strict food control proves to be inadequate, then other drug treatments - step 1 and 2 can be instituted to replace prednisone in the longer term.

Tom Arnold. Study Links Arthritis Drugs To Bleeding: Vioxx And Nsaids: (A2) Competing Medication Results In Less Hospitalization. National Post, Friday, September 20, 2002

The Therapeutics Initiative Newsletter in BC. Do journal publications tell the full story? January 31, 2002. http://www.ti.ubc.ca/pages/letter43.htm

US FDA News, FDA Issues Public Health Advisory on Vioxx as its Manufacturer Voluntarily Withdraws the Product. Sept 30 2004. Online http://www.fda.gov/bbs/topics/news/2004/NEW01122.html

Topol, E.J. Failing the Public Health — Rofecoxib, Merck, and the FDA. n engl j med. 351;17 October 21, 2004. 1708

Barclay, L. Vioxx Withdrawal Prompts Reevaluation of COX-2 Inhibitor Safety. Medscape Medical News Oct. 2004. http://www.medscape.com/viewarticle/490979?src=mp

Jeffrey M. Drazen, M.D. COX-2 Inhibitors -- A Lesson in Unexpected Problems. Published at www.nejm.org February 15, 2005 (10.1056/NEJMe058038)