In this issue:
Before You Order Drugs Online...
Does Fibromyalgia Drug Cause Weight Gain?
Cancer History and Drug Use
Enlarged Joint Spaces: What are they?
Pain Relief for Psoriatic Arthritis
Dressing and Styling with Sore Shoulders
 

Before You Order Drugs Online...

Q. With rheumatoid arthritis, fibromyalgia and several other health problems, I find getting to the drugstore to pick up my medications difficult. I have heard that ordering drugs on the Internet is easy and convenient, so I would like to give it a try. Before I do, is there anything I should know?

A. You can get just about anything over the Internet these days.

Certainly, drugs are no exception. While it is no doubt convenient to get drugs online — essentially all you have to do is point and click — I can think of at least five reasons the Internet isn't necessarily the best place to purchase your medications. Before you decide to place an order, consider these potential problems and consider some words of advice:

1) Questionable products. Online pharmacies may lure you with the opportunity to get drugs, such as narcotic pain relievers, that your own doctor refuses to prescribe. Foreign pharmacies may even offer drugs that aren't approved in this country. Resist the temptation to buy these drugs — there's a reason why they aren't approved in the United States or why your own doctor, who is aware of your medical history, won't prescribe them for you.

Even if you just order the same drugs you have used for years, there is no way to ensure that the products you get from non-U.S. Web sites are genuine, of the right strength and uncontaminated.

2) Faceless doctors and unethical prescribing practices. Although there are a number of reputable online drugstores that require a faxed prescription from your own physician, others ask only that you have a "consultation" with an anonymous online physician, who most likely is not licensed to practice in your state.

The consultation essentially amounts to a brief questionnaire, which can't take the place of a face-to-face meeting with your own doctor and a thorough physical exam. With your multiple health problems, you really need at least one doctor who knows you well and can coordinate your medical care and direct drug prescribing.

3) Excessive costs. When it comes to prescription drugs, online shopping may be convenient, but it isn't cheap. In a study published last December in the Annals of Internal Medicine, researchers at the University of Pennsylvania in Philadelphia searched the Internet extensively to identify sites that provided consultations by a doctor and sold prescription drugs.

Among other things, the researchers found that drugs purchased through those sites were more expensive (even when excluding the shipping costs of $8 to $25) than were the same medications in Philadelphia drugstores. Furthermore, online "consultations" with physicians cost, on average, $10 more than a physician visit in Philadelphia.

4) Inconsistency. If you buy all your medications from one pharmacy, there will be a central location for all your prescription records. It's common for a pharmacist to notice and alert a person to the fact that they are taking, or are about to take, two medications that have the potential to interact with one another. Switching some — but not all — prescriptions to an online pharmacy or ordering new prescriptions online can potentially lead to drug interactions, particularly if you take different medications for your various health problems.

5) Delivery Delays. If you need a medication for an acute problem or if you're down to your last day's supply of the medication you need for a chronic illness, the Internet isn't the place to shop – the soonest an Internet pharmacy can deliver is the next day. In those cases, you should always opt for a local pharmacy where you can get your medications the same day.

I understand your interest in the Internet. But remember that it's not your only option for convenience. Some local pharmacies still deliver. (Check the Yellow Pages for one near you.) If you have health insurance, your plan may have a contract with a mail order pharmacy. Some will deliver three months of medication to your home with a single co-payment. (As with Internet shopping, this isn't appropriate for an acute illness that requires medication immediately.)

Finally, if you do decide to order drugs online, please keep the following in mind: Use only a prescription from your own doctor, choose a U.S. Web site that requires a prescription from your physician, then compare prices — and be prepared to pay more for the convenience.

Doyt L. Conn, MD
Rheumatologist

Does Fibromyalgia Drug Cause Weight Gain?

Q. Two years ago, my doctor prescribed the drug Pamelor to ease the pain and sleep disturbances associated with my fibromyalgia. Although I exercise regularly and eat sensibly, I have gained 25 pounds since I started taking Pamelor. Could this drug be causing my weight gain and, if so, is there another drug I could take instead?

A. Yes, Pamelor (nortriptyline) very well could be responsible for the higher number you're seeing on your bathroom scale. A member of the tricyclic class of antidepressants, Pamelor is frequently used to treat fibromyalgia symptoms.

While people with fibromyalgia often find the tricyclics effective in promoting sleep, they may also discover the drugs promoting something they don't want — weight gain. The cause for this isn't clear, but tricyclics appear to increase appetite, especially for carbohydrates.

Fortunately, there are alternatives to taking Pamelor and the other tricyclics. Serotonin-selective reuptake inhibitors (SSRIs), a newer group of antidepressants that includes drugs such as fluoxetine (Prozac), sertraline (Zoloft) and paroxetine (Paxil), cause little weight gain and may even contribute to weight loss.

I recommend you speak to your doctor who might consider changing your medications.

Don Miller, PharmD
Pharmacist

Cancer History and Drug Use

Q. I have heard that malignancies can occur in people taking the drug Arava. Because I have a history of Hodgkin's disease (a cancer of the lymph nodes), as well as RA, do you think I should avoid this drug?

A. Leflunomide (Arava) is a relatively new drug for the treatment of rheumatoid arthritis (RA). The drug reduces joint pain and swelling and, in addition, can slow damage to cartilage and bone, as shown by X-ray. There are no studies showing leflunomide increases cancer risk; however, published studies on leflunomide have involved limited numbers of patients and, because the drug is relatively new, it is really too early to know whether the drug puts people at serious risk of malignancy somewhere down the line.

This potential to cause malignancies has been raised for a number of other RA drugs. Further epidemiological studies are needed to determine if, in fact, drugs do significantly increase cancer risk. Complicating this issue is the fact that RA itself may be associated with an increased occurrence of certain malignancies. In that case treating RA aggressively with medications may actually decrease cancer risk.

I have no easy answer to your question. The best path is to consult both a rheumatologist (arthritis specialist) and oncologist (cancer specialist) and decide which arthritis drugs will likely work best and have the fewest side effects and risks.

Interestingly, some drugs used to treat malignancy, such as methotrexate, are also effective in treating RA.

David Pisetsky, MD, PhD
Rheumatologist

Enlarged Joint Spaces: What are they?

Q. Several years ago I was diagnosed with osteoarthritis (OA). Now my doctor is telling me I don't have arthritis — just enlarged joint spaces. What does this mean?

A. That's hard to say without seeing your X-rays or speaking with your physician.

In evaluating the presence of arthritis, many physicians perform X-ray examinations of the joint. These X-rays provide information on the state of the soft tissues, cartilage and bone, and may allow diagnosis of specific joint diseases. Cartilage is measured by the distance between the bones, or joint space.

For most forms of arthritis, X-rays show a joint space that is narrowed or small because of loss of cartilage.

An enlargement of the joint space, therefore, suggests an increase, rather than a decrease, of cartilage. Such an increase [and, therefore, enlargement of joint space] can occur in certain rare metabolic conditions such as an excessive production of growth hormone (a condition known as acromegaly) that causes cartilage growth.

On the other hand, OA generally causes a loss of cartilage (reduced joint space) and an enlargement of the bones around a joint.

Without speaking to your physician and seeing your X-rays, I can't determine which, if either, of these situations applies to you. I would suggest clarifying this issue with your physician because it may determine the need for further evaluation or dictate the type of treatment you need.

Dr. Pisetsky

Pain Relief for Psoriatic Arthritis

Q. Does psoriatic arthritis tend to occur in cycles? Is there anything I can do — besides taking pain medication — to relieve the sharp pain?

A. As with any form of inflammatory arthritis, the condition known as psoriatic arthritis — which occurs in approximately 10 percent of people with the skin disease psoriasis — can wax and wane.

Periods of intense disease activity (called flares) can, as you know, be extremely painful. But even when the disease isn't flaring, you may experience intermittent joint pain for any number of reasons, including overuse and improper use of the involved joint; muscle spasm; obesity; emotional or physical stress; depression; lack of restful sleep; fatigue; poor posture or inappropriate footwear.

Once you have an idea about what's causing your pain you can take steps to ease it. For example, you might make a concerted effort to lose weight, begin wearing proper shoes, learn joint protection techniques from an occupational therapist or practice relaxation exercises on a regular basis.

When you do experience joint pain, apply ice or heat to the affected joint(s) or try using an analgesic ointment or rub, particularly one with capsaicin, a pain-relieving substance derived from hot peppers.

If there is any skin involvement over the affected joint, however, capsaicin-containing creams should be avoided, and no analgesic ointment should be used in conjunction with a heating pad because of the potential for deep burns.

If none of these practices offers much relief, or if joint pain is accompanied by warmth and swelling, you should consult your doctor. By examining you, he will be able to determine whether you need an anti-inflammatory and/or disease-modifying medication to help control your disease and its symptoms.

James McKoy, MD
Rheumatologist

Dressing and Styling with Sore Shoulders

Q. Arthritis in my shoulders causes me trouble putting on shirts and styling my hair. Do you have any tips that would make these activities easier?

A. Pain, stiffness and weakness in the shoulders can make an upper-body activity difficult. I hope these tips will help.

When getting dressed, try to select clothing that is easier to maneuver in and out of. Shirts or jackets that button — or, better yet, zip — up the front are easier to put on than turtleneck pullovers, for example. Raglan-type or big sleeves are less binding and also easier to slip into. When you dress, put the most stiff or painful shoulder into the sleeve first.

Before attempting to style your hair, try performing some shoulder range-of-motion exercises – simply shrugging your shoulders up and down, then rotating them in circles.

If lifting and holding your blow dryer in place is too stressful to your shoulders, try propping the dryer on a towel bar or mounting it to the wall — and then just stand in front of it. Brackets are available at most hardware stores.

Melissa Peavey, OTR, CHT
Occupational Therapist