“Musculoskeletal disability is the most prevalent of the major health problems of our aging population. Rheumatoid arthritis and osteoarthritis, compared with other chronic diseases, appear to make the greatest contribution to subsequent disability among the elderly. Disease outcomes evolve over years, even decades” (ARAMIS -the national chronic disease data bank Arthritis, Rheumatism, and Aging Medical Information System from diverse U.S. / Canadian locations, managed by Stanford University Department of Medicine, California, 2003 ):
Thus (major trauma aside) it is a huge relief that in aging adults, both osteoporosis spinal/limb collapse, and rheumatoid and osteo-arthritis can now be reversed in most cases by early amd probably permanent prevention and treatment with relatively lowcost and safe combination of multiple proven drugs, most of them natural and nutritional supplements.
It is obvious from observation in daily practice that the nonspecific musculoarthritic stiffening of older people -including polymyalgia rheumatica- is usually easily reversed by early replacement with antioxidants including fish oil and appropriate steroid hormone replacement HRT according to bloodlevels – vitamin D3 and testosterone in both sexes, plus estradiol-progesterone in deficient women, +- lowdose prednisone.
Obviously, collapsing spine and hips incur increasing immobility osteoarthritis and frailty;
increasing arthrits incurs increasing immobility osteoporosis; and frailty;
and increasing vascular disease (including rheumatoid/ lupus arthritis) with worse microcirculation incurs increasing ostoporosis, frailty otheoarthritis, and tissue, cartilage, bone and disc ischemia. .
But, just as gouty tophi melt away with alkalis, allopurinol and probenecid, it is gratifying to see how osteoarthritic nodules and pain gradually regress and functionality return over months, with restoration of youthful bone density and articular cartilage on modest dose of anabolic glucosamine plus chondroitin, combined as always with the safe natural anti-inflammatories and antiosteoporotic agents – the vitamins nicotinamide, pantothenate, pyridoxine, folic acid and B12, C, D, K; the minerals calcium magnesium boron zinc and manganese; and the biologicals fish oil, proline, .MSM, cat’s claw, boswelia, bromelain, curcumin, and appropriate anabolic HRT including testosterone for both genders.
Since daily practice is clear proof, it does not need sophisticated randomized controlled trials to prove the obvious, that
provided prevention is started before spine, bones and joints are seriously damaged,
*osteoporosis is easily safely and cheaply preventible and curable;
*chondroglucosamine restores lost articular cartilage, as two controlled trials (Belgium; Czech) have shown .
And it does not take wild imagination that combining early and permanently the above anabolic bone-muscle- cartilage-restorative and anti-inflammatory supplements with remittive substances for inflammatory arthritis will permanently prevent disability.
So it is gratifying to find trials of both
* the benefit of chondroglucosamine on synovial retention in both humans and rats with inflammatory arthritis; and
* The full 4 year BeSt (Dutch) trial report of last month, that starting with methotrexte plus inflximab instead of methotrexte prednisone + sulfasalazine makes negligible difference to 4year outcome – without the farcical costs and potentially deadly adverse effects of infliximab.
It is instructive that the BeSt paper did not give P or confidence intervals in the abstract- and the full paper confirmed that the differences are not statistically significant.
The BeSt paper confirms that-: starting with methotrexate in all cases, adding one drug at a time for unresponsiveness gave much poorer result than combined therapy from the start. The endresult after 4 years was much better if infliximab , OR prednisone + sulfasalazine, was started ab initio;.
BUT infliximab gave 13% neurological adverse events AEs vs 2% with preds; and more infectious deaths and more non-melanoma skin cancers with infliximab.
In the end after 4 yrs, the overall risk:benefit in the respective groups favoured initial
*initial mtx + preds + SSA- 4yr totals of 4gm preds (174 pt yrs) (and with last resort where required) infliximab 39pt yrs; over
*initial mtx + infliximab -4yr totals 181pt yrs infliximab and (as last resort) 0.6gm preds 28pt yrs preds .
Since preds costs about 3c/mg & the total high dose preds averaged 1gm/yr , thats
Prednisone about R30/yr;
Chloroquine about R750/patient year;
Methotrexate perhaps R500/patient year;
SSA around R 6000 /patient year.
infliximab about R100 000/ patient year
so keeping infliximab as last resort rather than first makes major sense to both cost and survival.
David Gotlieb of the SA Arthritis group still recommends as primary therapy
“methotrexate – hydroxychloroquine
methotrexate – Sulphasalazine
Sulphasalazine – hydroxychloroquine
methotrexate – hydroxychloroquine – sulphasalazine.
plus for Articular RA, my usual regimen is to start at 7.5mg per day and maintain this dose until the DMARDS take effect. This is usually at approximately 2 months. Ithen start a slow reduction – to 5mg per day for a further month to 2 months, and then 2.5mg per day. Further reduction then depends on progress. If possible, the dose is then reduced to 2.5mg alternate day, an subsequently to 2.5mg every third day. Only then do I consider stopping the drug.
If at any step reduction, the patient becomes stiff or swollen, I maintain the previous level a further month before attempting a reduction again.
If a small maintenance dose is still required – it is almost invariably at 2.5 mg per day or less.”
The UK and USA guidelines do not recommend early anti-TNF tumour necrosis drugs like infliximab.
Indomethacid has been reported to accelerate articular loss, whereas other anti-inflammatories do not slow the loss; while in one 2005 USA trial, doxycycline merely slowed the progression of OA joint narrowing by 30%.
CONCLUSION: all cases of arthitis (and suspected fracture) should be seen early – within days- by a medical doctor; and osteoporosis risk also assessed; if only by ultrasound;
if symptoms do not settle rapidly on symptomatic therapy (eg for gout, sexually transmitted disease) and appropriate antimicrobials for possible micro-organism causes, and apprpriate HRT,
then appropriate baseline xrays and blood tests should be done, (including hormones, and to exclude tuberculosis, STDs) ,
and appropriate anti-inflammatories and anabolics should be started:
modest initial symptom-controlling prednisone+chloroquine+ methotrexate – R100pm.
+appropriate HRT(testosterone for all, + estradiol for women) about R40pm;
add 4gm cod liver oil /day R20pm;
+ modest natural anti-arthritic antiosteoporotic agents about R200pm