Rheumatoid Arthritis and drugs by Dr Mercola

Safest Anti-Inflammatories to Use for Pain

Clearly the safest prescription drugs to use for pain are the non-acetylated salicylates such as:

  • Salsalate
  • Sodium salicylate
  • Magnesium salicylate (i.e., Salflex, Disalcid, or Trilisate)

They are the drugs of choice if there is renal insufficiency, as they minimally interfere with anticyclooxygenase and other prostaglandins. Additionally, they will not impair platelet inhibition in those patients who are on an every-other-day aspirin regimen to decrease their risk for stroke or heart disease.

Unlike aspirin, they do not increase the formation of products of lipoxygenase-mediated metabolism of arachidonic acid. For this reason, they may be less likely to cause hypersensitivity reactions. These drugs have been safely used in patients with reversible obstructive airway disease and a history of aspirin sensitivity.

They are also much gentler on your stomach than the other NSAIDs and are the drug of choice if you have problems with peptic ulcer disease. Unfortunately, all these benefits are balanced by the fact that they may not be as effective as the other agents and are less convenient to take. You need to take 1.5-2 grams twice a day, and tinnitus, or ringing in your ear, is a frequent side effect.

You need to be aware of this complication and know that if tinnitus does develop, you need to stop the drugs for a day and restart with a dose that is half a pill per day lower. You can repeat this until you find a dose that relieves your pain and doesn’t cause any ringing in your ears.

If the Safer Anti-Inflammatories Aren’t Helping, Try This Next…

If the non-acetylated salicylates aren’t helping, there are many different NSAIDs to try. Relafen, Daypro, Voltaren, Motrin, Naprosyn. Meclomen, Indocin, Orudis, and Tolectin are among the most toxic or likely to cause complications. You can experiment with them, and see which one works best for you. If cost is a concern, generic ibuprofen can be used at up to 800 mg per dose. Unfortunately, recent studies suggest this drug is more damaging to your kidneys. If you use any of the above drugs, though, it is really important to make sure you take them with your largest meal as this will somewhat moderate their GI toxicity and the likelihood of causing an ulcer.

Please beware that they are much more dangerous than the antibiotics or non-acetylated salicylates. You should have an SMA blood test performed at least once a year if you are on these medications. In addition, you must monitor your serum potassium levels if you are on an ACE inhibitor as these medications can cause high potassium levels. You should also monitor your kidney function. The SMA will show any liver impairment the drugs might be causing.

These medications can also impair prostaglandin metabolism and cause papillary necrosis and chronic interstitial nephritis. Your kidney needs vasodilatory prostaglandins (PGE2 and prostacyclin) to counterbalance the effects of potent vasoconstrictor hormones such as angiotensin II and catecholamines. NSAIDs decrease prostaglandin synthesis by inhibiting cyclooxygenase, leading to unopposed constriction of the renal arterioles supplying your kidney.

Warning: These Drugs Massively Increase Your Risk for Ulcers

The first non-aspirin NSAID, indomethacin, was introduced in 1963. Now more than 30 are available. Relafen is one of the better alternatives as it seems to cause less of an intestinal dysbiosis. You must be especially careful to monitor renal function periodically. It is important to understand and accept the risks associated with these more toxic drugs. Every year, they do enough damage to the GI tract to kill 2,000 to 4,000 people with rheumatoid arthritis alone. That is 10 people EVERY DAY. At any given time, 10 to 20 percent of all those receiving NSAID therapy have gastric ulcers.

If you are taking an NSAID, you are at approximately three times greater risk for developing serious gastrointestinal side effects than those who don’t. Approximately 1.2 percent of patients taking NSAIDs are hospitalized for upper GI problems, per year of exposure. One study of patients taking NSAIDs showed that a life-threatening complication was the first sign of ulcer in more than half of the subjects. Researchers found that the drugs suppress production of prostacyclin, which is needed to dilate blood vessels and inhibit clotting. Earlier studies had found that mice genetically engineered to be unable to use prostacyclin properly were prone to clotting disorders.

Anyone who is at increased risk of cardiovascular disease should steer clear of these medications. Ulcer complications are certainly potentially life-threatening, but heart attacks are a much more common and likely risk, especially in older individuals.

How You Can Tell if You Are at Risk for NSAID Side Effects

Risk factor analysis can help determine if you will face an increased danger of developing these complications. If you have any of the following, you will likely to have a higher risk of side effects from these drugs:

  1. Old age
  2. Peptic ulcer history
  3. Alcohol dependency
  4. Cigarette smoking
  5. Concurrent prednisone or corticosteroid use
  6. Disability
  7. Taking a high dose of the NSAID
  8. Using an NSAID known to be more toxic

Prednisone

The above drug class are called non steroidal anti inflammatories (NSAIDs). If they are unable to control the pain, then prednisone is nearly universally used. This is a steroid drug that is loaded with side effects. If you are on large doses of prednisone for extended periods of time, you can be virtually assured that you will develop the following problems:

  • Osteoporosis
  • Cataracts
  • Diabetes
  • Ulcers
  • Herpes reactivation
  • Insomnia
  • Hypertension
  • Kidney stones

You can be virtually assured that every time you take a dose of prednisone your bones are becoming weaker. The higher the dose and the longer you are on prednisone, the more likely you are to develop the problems. However, if you are able to keep your dose to 5 mg or below, this is not typically a major issue. Typically this is one of the first medicines you should try to stop as soon as your symptoms permit.

Beware that blood levels of cortisol peak between 3 and 9am. It would, therefore, be safest to administer the prednisone in the morning. This will minimize the suppression on your hypothalamic-pituitary-adrenal axis. You also need to be concerned about the increased risk of peptic ulcer disease when using this medicine with conventional non-steroidal anti-inflammatories. If you are taking both of these medicines, you have a 15 times greater risk of developing an ulcer!

If you are already on prednisone, it is helpful to get a prescription for 1 mg tablets so you can wean yourself off the prednisone as soon as possible. Usually you can lower your dose by about 1 mg per week. If a relapse of your symptoms occurs, then further reduction of the prednisone is not indicated.

How Do You Know When to Stop the Drugs?

Unlike conventional approaches to RA, my protocol is designed to treat the underlying cause of the problem. So eventually the drugs that you are going to use during the program will be weaned off. The following criteria can help determine when you are in remission and can consider weaning off your medications:

  • A decrease in duration of morning stiffness to no more than 15 minutes
  • No pain at rest
  • Little or no pain or tenderness on motion
  • Absence of joint swelling
  • A normal energy level
  • A decrease in your ESR to no more than 30
  • A normalization of your CBC. Generally your HGB, HCT, & MCV will increase to normal and your “pseudo”-iron deficiency will disappear
  • ANA, RF, & ASO titers returning to normal

If you discontinue your medications before all of the above criteria are met, there is a greater risk that the disease will recur. If you meet the above criteria, you can try to wean off your anti-inflammatory medication and monitor for flare-ups. If no flare-ups occur for six months, then discontinue the clindamycin. If the improvements are maintained for the next six months, you can then discontinue your Minocin and monitor for recurrences. If symptoms should recur, it would be wise to restart the previous antibiotic regimen.

Evaluation to Determine and Follow Rheumatoid Arthritis

If you have received evaluations and treatment by one or more board certified rheumatologists, you can be very confident that the appropriate evaluation was done. Although conventional treatments fail miserably in the long run, the conventional diagnostic approach is typically excellent, and you can start the treatment program discussed above. If you have not been evaluated by a specialist then it will be important to be properly evaluated to determine if indeed you have rheumatoid arthritis. Please be sure and carefully review Appendix Two, as you will want to confirm that fibromyalgia is not present.

Beware that arthritic pain can be an early manifestation of 20-30 different clinical problems. These include not only rheumatic disease, but also metabolic, infectious and malignant disorders. Rheumatoid arthritis is a clinical diagnosis for which there is not a single test or group of laboratory tests that can be considered confirmatory.

Criteria for Classification of Rheumatoid Arthritis

  • Morning Stiffness – Morning stiffness in and around joints lasting at least one hour before maximal improvement is noted.
  • Arthritis of three or more joint areas – At least three joint areas have simultaneously had soft-tissue swelling or fluid (not bony overgrowth) observed by a physician. There are 14 possible joints: right or left PIP, MCP, wrist, elbow, knee, ankle, and MTP joints.
  • Arthritis of hand joints – At least one joint area swollen as above in a wrist, MCP, or PIP joint.
  • Symmetric arthritis – Simultaneous involvement of the same joint areas (as in criterion 2) on both sides of your body (bilateral involvement of PIPs, MCPs, or MTPs) is acceptable without absolute symmetry. Lack of symmetry is not sufficient to rule out the diagnosis of rheumatoid arthritis.
  • Rheumatoid Nodules – Subcutaneous nodules over bony prominences, or extensor surfaces, or in juxta-articular regions, observed by a physician. Only about 25 percent of patients with rheumatoid arthritis develop nodules, and usually as a later manifestation.
  • Serum Rheumatoid Factor – Demonstration of abnormal amounts of serum rheumatoid factor by any method that has been positive in less than 5 percent of normal control subjects. This test is positive only 30-40 percent of the time in the early months of rheumatoid arthritis.

You must also make certain that the first four symptoms listed in the table above are present for six or more weeks. These criteria have a 91-94 percent sensitivity and 89 percent specificity for the diagnosis of rheumatoid arthritis.

However, these criteria were designed for classification and not for diagnosis. The diagnosis must be made on clinical grounds. It is important to note that many patients with negative serologic tests can have a strong clinical picture for rheumatoid arthritis.

Your Hands Are the KEY to the Diagnosis of Rheumatoid Arthritis

In a way, the hands are the calling card of rheumatoid arthritis. If you completely lack hand and wrist involvement, even by history, the diagnosis of rheumatoid arthritis is doubtful. Rheumatoid arthritis rarely affects your hips and ankles early in its course.

The metacarpophalangeal joints, proximal interphalangeal and wrist joints are the first joints to become symptomatic. Osteoarthritis typically affects the joints that are closest to your fingertips (DIP joints) while RA typically affects the joints closest to your wrist (PIP), like your knuckles.

Fatigue may be present before your joint symptoms begin, and morning stiffness is a sensitive indicator of rheumatoid arthritis. An increase in fluid in and around your joint probably causes the stiffness. Your joints are warm, but your skin is rarely red. When your joints develop effusions, hold them flexed at 5 to 20 degrees as it is likely going to be too painful to extend them fully.

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