Are NSAIDs Enough?
Q: I was recently diagnosed with arthritis by my family doctor, who prescribed an NSAID for me. I have heard that there are all kinds of new arthritis treatments, including something called biologics. Do you think NSAIDs are enough to help me?
A: I wonder if your doctor told you which form of arthritis you have. Although we casually use the term arthritis to refer to one of many different conditions, arthritis (literally meaning "joint inflammation") is really more a symptom than a disease itself.
Joint involvement can occur in more than 100 different diseases, including osteoarthritis (OA), rheumatoid arthritis (RA), lupus, ankylosing spondylitis and gout, just to name a few. Treatment depends on the form of arthritis or related disease, and the sooner you discover which form you have and begin appropriate treatment, the better you will do in the long run.
The drug your doctor prescribed is just one of many of a class called nonsteroidal anti-inflammatory drugs (NSAIDs). These drugs work by limiting the body's production of hormone-like substances called prostaglandins, which are involved in causing inflammation (which, over time, can lead to joint destruction) and pain.
For many arthritis-related diseases NSAIDs provide some symptomatic relief and therefore can be an important part of a treatment plan. But for many types of arthritis, NSAIDs should not be the sole medical treatment. Some doctors, unfortunately, don't realize this.
If you have RA, for example, you will benefit from more powerful drugs early on. Not too many years ago, most doctors – even those highly experienced in treating arthritis – used NSAIDs as the first line of treatment against RA. They might have used a number of different NSAIDs over several years. When it became obvious that the disease was progressing and causing joint damage, the doctor would then start a disease-modifying drug such as gold.
Now we know that most of the joint damage of RA occurs within the first two to three years. So it's important to control the inflammation affecting the joints before they are damaged. NSAIDs won't do that.
A class of drugs called disease- modifying anti-rheumatic drugs (DMARDs) on the other hand, have the potential to control inflammation and limit joint damage. The most frequently used DMARD is methotrexate. Others include gold, sulfasalazine, cyclosporine and hydroxychloroquine. More potent cytotoxic (cell-killing) drugs such as cyclophosphamide also can control inflammation and limit joint damage, but they carry a greater risk of serious side effects.
If you have another disease such as lupus or ankylosing spondylitis, disease-modifying drugs may be just as important. In lupus, for example, a disease that can affect the joints as well as other organ systems, second-line drugs can help prevent life-threatening complications. For that reason, prompt and proper treatment for lupus can improve quality of life and life span.
Increasingly, doctors are also turning to the newest class of arthritis drugs, called biologic response modifiers, biologic agents, or simply, biologics. Biologics are genetically engineered medications made from a living organism.
The biologics used in arthritis treatment – abatacept (Orencia), adalimumab (Humira), anakinra (Kineret), etanercept (Enbrel), infliximab (Remicade) and rituximab (Rituxan) – block triggers of inflammation. Biologics may be used alone or in combination with a traditional DMARD to treat autoimmune forms of arthritis, such as RA juvenile idiopathic arthritis (JIA), ankylosing spondylitis or psoriasis/psoriatic arthritis.
Treating the disease more aggressively with second-line drugs early on can slow disease progression and limit joint damage – before it occurs. In fact, studies have shown that the joint inflammation of RA may be reversible if properly treated in the first several months. The problem is that few people are diagnosed that early.
Despite the usefulness and effectiveness of medication, treatment of joint disease should not be limited to NSAIDs, biologics, or any type of drug therapy. There are other measures you can pursue (along with your drug treatment) that can make a difference in the way you feel and can have a beneficial effect on your disease, no matter which particular disease you have.
These measures include physical therapy, exercise and education about your disease and its management. Your physical therapy and exercise program will have to be tailored for you and will be dependent on the type and extent of your arthritis. There are educational, self-help and coping materials offered through the Arthritis Foundation and other organizations that will help you manage your disease.
If you are continuing to have joint pain and swelling, consult your doctor again soon. Ask which form of arthritis you have and if there are other treatments you should be pursuing. If your doctor doesn't know what form you have, puts you off, or is unwilling to discuss any treatment other than NSAIDs, I would recommend that you consider seeing a rheumatologist. Pinpointing the problem and beginning appropriate treatment promptly could make a difference in your quality of life in years to come.
Doyt Conn, MD, Rheumatologist
