Created on: 06/04/07 - Email to friend - Print Page

General Medication Questions: Part 1

One of the most popular features in Arthritis Today, "On Call" finds answers to your most puzzling arthritis questions by asking a variety of healthcare experts. Just click on the question or title you'd like to see.

For more information on medications used to treat arthritis and related conditions, check out the Arthritis Today Drug Guide.

Stopping Narcotic Pain Medications

More questions

Stopping Narcotic Pain Medications

Q: I’d like to stop taking my pain medication, but I’m worried about going through withdrawal. What will it do to my body? How long does it take to go through, and what does it feel like?

A: Not all pain medications cause withdrawal symptoms, so I assume you’re talking about opioids (also called narcotics), such as OxyContin, Percoet, Tylenol #3 and Vicodin.

Opioids cause withdraw symptoms if you have been taking a high dose for a long period of time, and if you have been taking opioids regularly rather than intermittently.

Withdrawal from opioids most commonly leads to symptoms such as restlessness, sweating, runny nose or eyes, tremors, increased heart rate and increased blood pressure, but those effects stop within a few days.

Long-acting opioids, such as MS Contin and OxyContin, provide a steady level of medicine so that you don’t have peaks and valleys in the blood level. This means you can take a lower dose overall, so dependency on the medication is less likely to result. Therefore, long-acting opioids are better for functioning daily with chronic pain, such as that of arthritis or fibromyalgia. Withdrawal symptoms usually are much less of an issue for most people who want to stop using one these long-acting pain medications.

Withdrawal symptoms are far more pronounced and occur very quickly when short-acting opioids are stopped abruptly. Short-acting opioids make blood levels of the medication go up rapidly and come down rapidly. When the blood level of the acting medicine drops quickly, pain returns quickly, leading to the need for additional doses (and higher doses overall). Short-acting opioids, such as Percocet, Tylenol #3 or Vicodin, are used for acute pain.

When you are ready to stop taking pain medication, be sure to taper the dose under your doctor’s supervision.

Daniel Clauw, MD, Rheumatologist

Medication-Related Infections

Q: For the past seven months I have been taking Medrol, Feldene and Plaquenil for my RA. I have also been having a problem with recurrent vaginal yeast infections. Could there be a relationship between these medications and my infections? What can I do to prevent further infections?

A: Yes, fasting can cause gout - if fasting causes you to become dehydrated, which raises the level of uric acid in your blood. In fact, high blood levels of uric acid are the single most important factor in determining the risk of a gout attack. A form of arthritis that primarily affects middle aged men, gout is associated with obesity, heavy alcohol intake, hypertension, decreased kidney function and diuretic use. Acute gout is caused by uric acid crystals in the joint, which trigger inflammation and cause severe pain and swelling of the joint. If this condition is not treated effectively, inflammation can smolder in a number of joints and eventually cause joint damage.

Bernard Rubin, DO, Rheumatologist

Back to Top

Safer Pain Relief

Q: I have painful osteoarthritis in both knees and degenerative disk disease. Over the years I have used NSAIDs plus sufficient quantities of alcohol to ease the pain. To confound the problem, I have had two bouts of hepatitis during the past 30 years. I am concerned that my medications may be causing further liver damage. Are there any medications that would relieve my pain but be safer for my liver?

A: In addition to your question, you have some other issues here that need to be addressed. First, alcohol consumption is not safe for anyone with a history of liver disease. Second, it is not a good idea to combine alcohol with NSAIDs because the combination can increase the risk of the drugs' side effects, particularly stomach upset and ulcers.

Now, as for how to treat your pain without further compromising your liver, I urge you to see a physician. There are a number of treatments for your problems; NSAID therapy is just one of them -- and it may not be the best one for you. It's likely your physician will evaluate the status of your liver. If there is no evidence of liver abnormality, he may recommend acetaminophen to help ease the pain. In addition, a program of physical therapy designed to strengthen knee and back muscles will be important over the long haul. If you are experiencing swelling in both knees, your physician may want to remove the fluid, analyze it and consider injecting the joint spaces with glucocorticoid to help ease the pain. These are just a few options, and I am sure your physician can offer more insight into how to ease these painful problems.

Doyt Conn, MD, Rheumatologist

Back to Top

Bone-Damaging Medication?

Q: I recently started taking a medication called a "calcium channel blocker" for high blood pressure. The name makes me think that this drug is affecting my bones' ability to use calcium. Is it possible that this drug will increase my risk of osteoporosis?

A: Calcium channel blockers are a large group of medicines used to treat high blood pressure, angina (heart pain) and other conditions. They work by affecting the movement of calcium into certain cells, primarily in the heart and blood vessels. (Many people are surprised to learn that our bones and teeth aren't the only parts of our bodies that rely on calcium.) It would be logical to assume from their name that they would also affect calcium use by the bone; however, there is no evidence that these medications have a significant effect -- either positive or negative -- on bone cells. From what we know at this point, you should feel comfortable taking a calcium channel blocker without fear of osteoporosis.

Doyt Conn, MD, Rheumatologist

Back to Top

OK, I'm on Drugs. Now What?

Q: I've read that there are many things people can do to help manage their arthritis, yet every time I talk to my doctor about my rheumatoid arthritis, he mentions little more than the next medication -- or new dosage -- he is going to prescribe for me. What are some of the things I can do for myself and how can I get my doctor to involve me more in my own care?

A: The concern that doctors don't encourage patients to take a role in their own health care is, unfortunately, a common one. The problem, in part, is that the medical system itself arose in an era when acute disease predominated. Doctors traditionally have been trained to treat acute illness, which has a clear cause and cure in most cases. The doctor diagnoses the problem, determines the cause and administers the treatment. Then, if all goes well, the disease responds with little or no effort on the part of the patient.

For chronic conditions like the many types of arthritis, for which there may be no cures, managing the disease requires an ongoing, cooperative relationship between the doctor and patient. In this relationship, you -- the patient -- are actually the main caregiver. This is a new concept for most doctors.

Certainly your doctor must make the diagnosis, recommend a course of medical treatment, monitor your response to treatment, and adjust that treatment accordingly. But it is you who must follow your doctor's prescription, day in and day out. You are also the one who must monitor your symptoms and call your doctor between visits if you have a problem that needs to be addressed or a drug dose that perhaps needs to be changed. At office visits, you must honestly describe to your doctor how you are feeling and what you've been experiencing. Your personal accounts, along with lab tests and examination results, help your doctor make important treatment decisions.

Aside from medication-related issues, there is a lot more that you can and should do with the help and support of your physician. For one, you must maintain an overall healthy lifestyle. Proper nutrition and exercise are particularly important for people with arthritis. If pain is a problem, as it is for the majority of people with arthritis, there are measures -- other than medications -- that can help you feel better. Exercise can help relieve pain, so can applying heat or cold to affected joints and using relaxation techniques.

Making your home as accessible as possible and using assistive devices -- such as reachers to retrieve things from high shelves, or zipper pulls if your fingers are sore or no longer nimble -- can relieve frustration, protect joints and help you remain independent. Most importantly, you can learn more about your disease and its management. Just understanding your disease can help allay some of the anxiety you may be feeling. Learning about your disease and taking a more active role in managing it can give you an added sense of well-being and control.

Finally, there's one more thing you can do: Talk to your doctor about your concerns. Explain that you are interested in taking a role in your own care. Show your interest by bringing up medical issues you've seen in the news or by sharing articles from Arthritis Today or other magazines and newspapers. Ask your doctor for educational materials, schedules of exercise classes, support group information or referrals to a physical therapist or dietitian.

Just as there are doctors who are used to being the key players in their patients' health care, there are many patients who want -- and expect -- their doctors to assume the sole responsibility for disease management. If you haven't indicated otherwise, your doctor may assume you are one of them. Given the opportunity, most doctors are happy to give patients a greater role in their own health care. And studies show that you'll be better off taking that role.

Doyt L. Conn, MD, Rheumatologist

Back to Top

Acetaminophen vs. NSAIDs

Q: For osteoarthritis pain in my toes and neck, I have taken one NSAID or another. Recently I've seen medication ads that say only pain killers, not NSAIDs, are necessary for OA treatment. I'm confused because I've been told that the inflammation of OA must be treated. Can you explain to me what the best treatment is for osteoarthritis?

A: You raise an important point regarding the management of osteoarthritis (OA). The plan must be tailored to the individual and his particular problem.

Nonsteroidal anti-inflammatory drugs ( NSAIDs) are quite efficient at reducing both pain and inflammation, but they also can carry some significant side effects, including stomach irritation and gastric ulcers. Acetaminophen, on the other hand, does nothing for inflammation but if used correctly has few side effects. For that reason, doctors generally prescribe acetaminophen to help ease arthritis pain if inflammation is not a problem -- and, in OA of the neck and back, there is usually not evidence of inflammation.

If there is inflammation (recognized in the toe by the presence of redness, warmth and pain), your doctor will probably prescribe an NSAID. Any history of stomach problems or NSAID-related stomach distress, however, would contraindicate NSAID use in order to avoid further stomach damage. It's important to understand that the management of OA does not stop with pills. Probably the most important component of any plan is the non-pharmacologic approach, which you can often follow on your own at home. For neck pain, you should apply heat, do range-of-motion exercise and possibly modify work habits and activities that may be aggravating your neck. Later on, strengthening exercises may be important to help the muscles support joints in that area. A physical therapist can help guide you in the use of these methods. For painful toes, make sure that your shoes are not pinching or rubbing your toes. You may also have to limit any weight-bearing activities for a while to help reduce pain in your feet. If you are overweight, losing weight may help ease the pain as well. Your physician can help you with these issues.

Doyt Conn, MD, Rheumatologist

Back to Top

Try Glucosamine for OA

Q: I would like to know if the supplements glucosamine and chondroitin sulfate are worth trying for osteoarthritis. I've heard of many people who have been helped. Do these supplements really work? Are they safe?

A: Glucosamine is found in high concentrations in the joints and is believed to stimulate the formation of cartilage that is essential for joint repair. Chondroitin sulfate is also found in cartilage and draws fluid into the tissue, giving the cartilage resistance and elasticity. In test tubes, chondroitin sulfate stimulates the formation of components for new cartilage and slows cartilage breakdown.

Chondroitin and glucosamine supplements appear to be more effective in patients with osteoarthritis than in people with inflammatory diseases such as rheumatoid arthritis. The supplements might lessen pain in 30 to 50 percent of patients with osteoarthritis. European research has shown that people with OA who took 1,500 mg of glucosamine a day had the same level of pain relief as those who took painkilling drugs such as ibuprofen. There are a few studies that show people taking 1,200 mg of chondroitin a day had the same level of pain relief as those who took drugs such as ibuprofen and diclofenac (Voltaren). Right now there is no research that shows whether greater relief occurs when both glucosamine and chondroitin are taken together.

I believe it is worthwhile to take both high quality glucosamine and chondroitin sulfate. These products are safe, as far as I can tell, and can be continued for as long as they seem to work. But be warned: The quality and effectiveness of these products varies because right now there is no regulation in the manufacturing of them. Look for a product with the word "standardized" on the label and buy from a reputable source. If you experience no relief after four to six weeks of supplement use, stop spending your money on it.

James McKoy, MD, Rheumatologist

Back to Top

Mystery Medication

Q: Four years ago, a friend of mine who has fibromyalgia was referred to a physician in Mexicalli, Mexico. He gave her a prescription for capsules that she has taken every day since. Today, she is totally free of pain. Are you familiar with this Mexican "cure"?

A: I don't know what ingredients are in the medication your friend is taking. If the medication is a prescription that can be filled in
U.S. pharmacies, the ingredients should be appear on the package label or insert. If the ingredients aren't listed she should ask the pharmacist. Dispensing a medication without revealing its contents is unethical, and taking such a medication is unwise.

During my years at Mayo Clinic, I saw several patients who had received medications from Mexicalli with undisclosed ingredients. But the drugs' side effects (round face, obesity of the trunk, easy bruising) made it obvious to me what they contained -- large doses of cortisone or a cortisone derivative. Cortisone is a powerful medication that can be very useful in arthritis treatment, but its use and risk of side effects have to be evaluated carefully. Taking it unknowingly, particularly in doses larger than necessary, can lead to potentially dangerous side effects.

Another ingredient that has been found in some of these unlabeled capsules is Butazolidin, which is a potent anti-inflammatory and pain reliever. Because of its associated side effects, however, particularly aplastic anemia, Butazolidin is no longer available in this country.

Doyt Conn. MD, Rheumatologist

Back to Top

Combining medications

Q: I have rheumatoid arthritis (RA), for which I take both prednisone and methotrexate. Now my doctor wants to prescribe hydroxychloroquine (Plaquenil) for me. Have you ever heard of someone taking three drugs at once? Is this safe?

A: It is common for physicians to prescribe a combination of low doses of prednisone and drugs like methotrexate for patients with rheumatoid arthritis. In selected cases, as in your case, physicians are adding on additional drugs. These combinations of drugs are used for patients with RA whose disease has not responded well to a single drug or to two drugs. A number of clinical studies have shown that patients treated with certain drug combinations do better with no greater incidence of side effects than those taking individual drugs. In these situations, it's important to have your disease managed by a physician experienced in the arthritic diseases.

Doyt Conn, MD, Rheumatologist

Back to Top

NSAID Safety

Q: For some time I have been experiencing a sore tongue, which my doctor says is caused by the medications I take for RA. Is there anything I can take to relieve this problem?

Q: While taking Relafen for osteoarthritis, I developed nephrotic syndrome. It cleared up shortly after I stopped the drug. Is it safe for me to try other NSAIDs now, or should I avoid all of them from now on?

A: Certain NSAIDs have been reported to be associated with the nephrotic syndrome, a reversible degenerative condition of the kidney associated with the leakage of protein in the urine. These include indomethacin, naproxen, tolmetin and fenoprofen, but this syndrome can be caused by any NSAID. For osteoarthritis pain, acetaminophen would probably be a safer choice than these, or any other NSAID, for that matter. If you and your doctor feel that you need an NSAID, I would recommend using a nonacetylated salicylate preparation such as salsalate. To recognize or prevent problems in the future, your physician will need to monitor your kidney function.

Bernard Rubin, DO, Rheumatologist

Back to Top

Will Medication Cure Osteoporosis?

Q: I have osteoporosis and am currently taking alendronate. Will I have to take this drug indefinitely or will it eventually cure osteoporosis?

A: Osteoporosis is a medical challenge. It is a progressive, potentially debilitating disease characterized by low bone mass and deterioration of bone tissue, resulting in weak bones that are prone to fracture. Because the greatest bone loss occurs in the first six years after menopause, drug treatment and lifestyle changes can have the greatest impact during this time. The drug you're taking, alendronate, works by reducing the activity of the cells that cause bone loss. Its effects are seen as soon as three months after beginning drug treatment and continue as long as you take it. Both estrogen and alendronate have been shown to prevent osteoporosis. Long-term treatment is necessary because bone loss becomes rapid if the drug is stopped. Osteoporosis can be cured by an ongoing prevention program that includes drug treatment and lifestyle modifications. I hope your doctor has informed you of the important dietary and lifestyle changes you can make to strengthen your bones. These lifestyle practices include eating a diet rich in calcium and vitamin D and engaging in weight-bearing exercise.

James McKoy, MD, Rheumatologist

Back to Top

Blood Test Frequency

Q: I have been taking 15 mg of methotrexate weekly for the past seven years. I have had blood work done at least every other month during that time; however, my doctor wants me to have blood tests every month. Since none of my past blood tests have shown any problems, I am wondering why I need to have these tests so often. Wouldn't every few months suffice?

A: No, I wouldn't recommend having those tests any less frequently than your doctor recommends. In general, patients taking methotrexate should have the tests monthly. Just because you haven't had any problems for the past seven years doesn't mean you can't develop problems at any time in the future. Frequent blood tests may detect subtle abnormalities that could alert your doctor to modify your methotrexate dose before a serious problem occurs. If you still have concerns about the frequency of your lab tests, I would recommend bringing up the subject with your doctor at your next appointment. In the meantime, I know it's a hassle to have the tests monthly, but in doing so, you may save yourself serious problems down the road.

Bernard Rubin, DO, Rheumatologist

Back to Top

Medication and Pregnancy

Q: With my RA pretty well under control, I was able to completely stop taking Naprosyn and methotrexate while I was trying to become pregnant. Now that I am pregnant, my doctor has told me I can't even take an occasional aspirin. Can you tell me why this is? Does aspirin -- even in very small doses -- cause birth defects? Will the few tablets I've already taken harm my baby?

A: The use of medicines during pregnancy is a complex issue that requires careful discussion with your doctor and an individual balancing of the risks and benefits. Some medications like methotrexate clearly cause birth defects and should always be avoided during pregnancy. For most medicines, like aspirin, the risks are less clear.

The organs in a developing fetus are formed during the first three months (first trimester) of pregnancy, and the use of any medication during this period potentially may cause birth defects. Although high doses of aspirin and NSAIDs (Naprosyn is an NSAID) have caused birth defects in animals, the best studies in humans have not found an increase in birth defects when compared to women who never used these medications.

The second critical period for medication use is during the last few weeks before delivery. At this point we are not concerned about birth defects, but about physiological effects on the mother and child. There is good evidence that women who use aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) have a prolonged time to delivery, prolonged labor and experience greater blood loss at delivery than women who do not use these medications. In babies whose mothers use NSAIDs, the medications can occasionally cause internal bleeding or pulmonary hypertension, a condition that leads to breathing difficulty. Therefore, whenever possible, it is wise to avoid aspirin and NSAIDs in the week or two before delivery is expected.

Despite the risks associated with aspirin, sometimes its use may be necessary during pregnancy to control inflammation. Only you and your doctor working together can make this decision. Acetaminophen is a suitable alternative if pain control is the main concern.

Donald Miller, PharmD, Pharmacist

Back to Top

Methotrexate by Injection

Q: Is there any benefit to receiving methotrexate by injection as opposed to taking it orally? Is it metabolized differently? Are the side effects different?

A: Methotrexate is a disease-modifying antirheumatic drug (DMARD) used to slow the disease process and treat the pain and swelling of rheumatoid arthritis. The body's absorption of the drug, and therefore its effectiveness, varies among individual patients when the drug is taken orally. To improve methotrexate's effectiveness, physicians may increase the oral dosages or try intramuscular injections of the medication. Although the injections may help improve the medication's effectiveness, the potential side effects and benefits of methotrexate are virtually the same whether it is given orally or by injection. Liver damage remains the main concern, and is monitored by frequent blood tests. Taking 1 mg of folic acid per day can help reduce other side effects related to methotrexate use, such as mouth sores or gastrointestinal irritation.

David Pisetsky, MD, PhD, Rheumatologist

Back to Top

Cause of Nerve Damage

Q: I have been taking methotrexate for 15 years to treat rheumatoid arthritis. Recently I developed peripheral neuropathy in my left leg and foot, which my podiatrist believes is caused by the methotrexate. Is it true that using methotrexate can cause peripheral neuropathy?

A: Peripheral neuropathy refers to damage or dysfunction of the nerves outside the central nervous system (brain or spinal cord).

This condition is associated with weakness or abnormal sensation such as tingling or numbness. In rheumatoid arthritis, peripheral neuropathy can result from compression of a nerve from joint tissue that is inflamed and expanded; damage of blood vessels that supply a nerve can also cause neuropathy. While certain drugs and substances such as alcohol can cause neuropathy, methotrexate is not usually associated with this side effect. Evaluation, including assessment of nerve conduction by electrical recording techniques, may be needed to pinpoint the cause of the neuropathy.

David Pisetsky, MD, PhD, Rheumatologist

Back to Top

Are NSAIDs Enough?

Q: After several weeks of experiencing tiredness, achiness, swelling in my right knee, and pain and stiffness in my hands, I made an appointment with my family doctor who said I have arthritis and prescribed an NSAID. I have heard that there are all kinds of new arthritis treatments today. Do you think this drug is 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 varies depending 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 pain and inflammation. 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 antirheumatic drugs (DMARDs), on the other hand, do have the potential to control inflammation and limit joint damage. These drugs include gold, methotrexate, prednisone, 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.

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.

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.

Despite the usefulness and effectiveness of medication, treatment of joint disease, in whatever form, should not be limited to 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 what the problem is and beginning appropriate treatment promptly could make a difference in your quality of life in years to come.

Doyt Conn, MD, Rheumatologist

Back to Top

Cause of Fragile Skin

Q: My arthritis symptoms stay pretty much under control with the help of NSAIDs, Aristocort and methotrexate. My biggest problem is with my skin -- it bruises and tears so easily. The slightest rub against something leaves a dark-red bruise you wouldn't believe. I am ashamed to wear short-sleeve shirts. What can I do to help this situation?

A: The problem you described is common among people taking corticosteroids, including Aristicort (generic name: triamcinolone) and NSAIDs. Corticosteroid medications can cause weakening of the connective tissue of the skin, and NSAIDs impair blood's ability to clot, leading to easy bruising. I recommend that you talk about this with your physician, who can evaluate any abnormal bleeding tendencies and, if necessary, adjust the dosages of your medications. It is important that you be treated with the lowest effective dose of each drug, in order to minimize this and other side effects.

John Hardin, MD, Rheumatologist

Back to Top

"Super Aspirin" To The Rescue

Q: I have been hearing a lot about the new "super aspirin" lately. Is it really much better than regular aspirin or other pain medications? Should I switch?

A: A lot of people have been asking me about the so-called "super aspirins," a new class of anti-inflammatory drugs that technically are called COX-2 inhibitors. In 1999, celecoxib (Celebrex) and rofecoxib (Vioxx) received approval from the FDA. As I write this answer, a similar drug, meloxicam (Mobic), is awaiting FDA approval.

The term "super aspirin" was coined by writer Jerome Groopman in an article published in The New Yorker. The term has caught on, despite the fact these drugs are not aspirin, nor would I consider them "super." At best, they are as effective as current nonsteroidal anti-inflammatory drugs (NSAIDs) in helping control the pain and inflammation of arthritis. Their major advantage is that they are easier on the stomach. Studies show that patients who are taking COX-2 inhibitors experience fewer gastrointestinal side effects, including upset stomach and heartburn, than those taking the NSAIDs ibuprofen, naproxen or diclofenac. Studies thus far also show that patients on the new COX-2 inhibitors experience significantly fewer instances of stomach ulcers and major upper gastrointestinal (GI) problems such as bleeding, perforation and obstruction. As far as other side effects - such as water retention and aggravation of hypertension - the new COX-2s appear to be similar to traditional NSAIDs.

The two COX-2s currently available are also similar to one another, with a few exceptions. For one, Celebrex is FDA approved for rheumatoid arthritis (RA) and osteoarthritis; Vioxx is approved for osteoarthritis, acute pain and menstrual pain (however, doctors may choose to prescribe Vioxx for RA as well). Celebrex, unlike Vioxx, should be avoided by people who are allergic to sulfa drugs.

People with an allergy to aspirin or other NSAIDs should not take either Celebrex or Vioxx, and neither drug should be used along with prescription or over-the-counter NSAIDs, including therapeutic doses of aspirin. Either drug may be used for its anti-inflammatory properties along with low-dose (up to 325 milligrams daily) aspirin, which is used for the prevention of heart attacks. However, taking this combination may slightly increase the risk of GI bleeding and ulceration. (Incidentally, neither of the two COX-2 inhibitors provides aspirin's protection against heart attack or stroke when taken on its own.)

With regard to using a COX-2 instead of your current medication, that depends on what you are currently taking and for what disease. If you are on low doses of prednisone or a disease-modifying antirheumatic drug (DMARD) for rheumatoid arthritis, the answer is no. COX-2s, like other NSAIDs, do not control the disease process of rheumatoid arthritis. They are used as an adjunct to - rather than a replacement for - prednisone or DMARDs. If you are currently taking an NSAID for a musculoskeletal problem and you aren't having any stomach problems, again I would say no. Your current NSAID is probably doing the same thing a COX-2 would - maybe for less money. However, if your current NSAID is causing stomach upset or if you have a history of ulcers, a COX-2 might be the right choice for you. I would recommend asking your doctor, who is best suited to helping you sort through the options.

Doyt Conn, MD, Rheumatologist

Back to Top

Sore Tongue Relief

Q: For some time I have been experiencing a sore tongue, which my doctor says is caused by the medications I take for RA. Is there anything I can take to relieve this problem?

A: There are several reasons you may have developed a sore tongue or mouth, including - as your doctor told you - side effects from certain arthritis medications, such as methotrexate, gold salts and D-penicillamine. Less commonly, NSAIDs can cause mouth irritation. Dry mouth, from causes such as Sjögren's syndrome may also cause mouth soreness. To relieve the problem, try spraying your tongue with a topical anesthetic such as Chloraseptic or Cepastat. If your mouth is dry, frequently sipping water may help.

For more severe cases, your doctor may prescribe chlorhexidine gluconate 0.12 percent rinse to be swished in your mouth and spit out three times a day or a gel medication called lidocaine that will cause numbness of the tongue. If there are discrete sores in the mouth, a steroid medication in a sticky base called Orabase may be applied directly to the sores. If none of this helps, I would recommend asking your physician about other possible causes. Fungal infections or vitamin deficiencies can cause similar problems, and both of these can be corrected. If your pain persists or becomes severe, your only option might be to switch medications. Ask your physician about your options.

Timothy Lambert, MD, Family Physician

Back to Top

Glucosamine And Chondroitin

Q: Do glucosamine and chondroitin have harmful side effects?

A: So far, the two supplements appear to have few side effects at the dosages that are most commonly used - 1,500 milligrams (mg) glucosamine and 500 mg chondroitin sulfate per day. None of those amounts are dangerous. But that is not to say harmful side effects can't occur with their use. Human studies of the two supplements have involved only small numbers of patients (200 or less) - hardly enough people to uncover potential side effects. The most common side effect thus far for both supplements is mild gas. If the chondroitin sulfate is not extracted properly it may be contaminated by a protein that can cause allergic reactions such as hives.

Q: Because glucosamine is derived from crab, lobster or shrimp shells, should people with shellfish allergies avoid it?

A: Not necessarily. Glucosamine comes from chitin, a substance in these animals' shells. Allergic reactions to shellfish are usually to proteins unique to the fish part of shellfish. Because chitin contains no proteins, an allergic reaction to glucosamine in a person allergic to shellfish is unlikely. Of course, if you are allergic to shellfish and develop symptoms such as itching, hives or shortness of breath after taking glucosamine, stop taking it and call your doctor. Such reactions, if they do occur, can be dangerous or deadly.

Q: Do glucosamine and chondroitin provide any benefits besides pain relief?

A: Maybe, maybe not. Some scientific data suggests that glucosamine and chondroitin sulfate may slow down the degenerative process of osteoarthritis. Although this is an attractive theory, it is by no means proven. Longer-term studies are needed to document this effect if, in fact, it exists. Despite some advertising claims to the contrary, there is no data to suggest that either supplement - or both in conjunction - can help rebuild cartilage once it is lost.

Q: How long does it take glucosamine and chondroitin sulfate to produce noticeable effects?

A: Study results vary. Some say significant pain reduction and improvement in function can occur in as little as two weeks. Others suggest it may take as long as four months. It's important to realize that you may not get relief from these substances - no matter how long you use them. Some people don't. The general recommendation is that you take the supplements for two months. If you don't notice any improvement by then, you'd probably do better to try something different.

Back to Top

Steroid Safety

Q: I have both Ehlers-Danlos syndrome and osteoarthritis, and nothing eases my pain like steroids do. I have heard that steroids, particularly at high doses, have dangerous side effects. What is considered a high dose? Is it safe to take low doses of steroids daily or over a long period of time?

A: Taking high doses of steroid (more specifically, glucocorticoid) medications can cause serious side effects such as hypertension, diabetes, osteoporosis, cataracts, mood changes, weight gain and susceptibility to infection. Any dose of 10 milligrams (mg) or more is generally considered high, but even low doses (5 to 7.5 mg daily) aren't completely safe - particularly when taken for a number of months or years. As with any medication, when physicians prescribe glucocorticoids, they must weigh the benefits against the risks. For some people the benefits of glucocorticoids are great; even low doses can ease the inflammation of rheumatoid arthritis and very high doses (as high as 60 mg daily) can limit or prevent the damage of acute, serious conditions such as kidney disease in lupus. But these drugs are generally not prescribed for either Ehlers-Danlos syndrome or osteoarthritis, so I have to question why you are taking them. I would recommend a consultation with your doctor as well as a complete rheumatologic evaluation, if you're not already seeing a rheumatologist, to ensure you have been given the correct diagnoses.

David Pisetsky MD, PhD, Rheumatologist

Back to Top