Monmouth County's Ask the Doctor - Winter 2023

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Hot Shots: New Injectable Treatment Options for Arthritis Pain By Mutahir Abidi, MD

There’s good news for the more than 54 million Americans who have been diagnosed with some form of arthritis: a new class of medications are providing quick, safe relief from pain and swelling. Types of Arthritis There are more than 100 types of arthritic conditions. Symptoms include inflammation and swelling of the joints, which causes pain, discomfort, and movement issues. One of the biggest misconceptions about arthritis is that it only affects seniors, but two-thirds of ar thritis patients are younger than 65 years of age. It can even affect children. As a rheuma tologist, we are trained to diagnose and treat every type of arthritis in patients of all ages. There are two types of arthritis: • Inflammatory arthritis typically af fects younger patients. It occurs when the body’s immune system attacks the cells in the joints, which in turn causes severe joint pain, stiffness and swelling. Some of the inflammatory arthritic conditions include rheuma toid arthritis, arthritis related to pso riasis, Crohn’s disease, ulcerative coli tis, lupus, or other conditions. • Non-inflammatory arthritis primarily affects older patients. The most com mon type is osteoarthritis, a degen erative joint disease that can develop as we age and the cartilage within our joints begins to break down. Carti lage is the tissue that covers the ends of bones in a joint. It allows bones to glide over one another and acts as a “shock absorber.” A healthy knee joint also contains a small amount of syno vial fluid, a thick, gel-like substance that cushions the joint and provides lubrication to reduce friction. As we age, this lubrication decreases. Treating Inflammatory Arthritis For inflammatory arthritis, treatment is focused on stopping the immune system from attacking the joints. Because each per son’s body responds to treatment different ly, there are two classes of medications that we use: Disease Modifying Anti Rheumatic Drugs (DMARD) and biologic agents. An example of DMARD is methotrexate. Methotrexate was introduced as treatment for rheumatoid arthritis about 30 years ago and replaced high-dose aspirin and non-ste roidal anti-inflammatory drugs (NSAIDS) as the treatment of choice. Instead of masking pain, methotrexate gets to the root of the is sue to control the source of inflammation. It treats severe psoriasis by slowing the growth of skin cells to stop scales from forming and

treats rheumatoid arthritis by decreasing the activity of the immune system. A new field of medications called biolog ics have revolutionized the way we treat ar thritis. Before, people who had rheumatoid arthritis that didn’t respond to other treat ments could become crippled and wheel chair-bound. Now, within a day or two of receiving a biologic agent, patients are feel ing remarkably less pain and better mobility, with limited side effects. Depending on the medication – and there are more than 10 bi ologic medication options – it can be given as an injection, a pill, or an intravenous in fusion. Biologics are particularly helpful for patients with rheumatoid arthritis, psoriatic arthritis, and spondylitis. Some examples of biologic medications include Enbrel, Humi ra, Orencia, Remicade, and Xeljanz. Treating Non-Inflammatory Arthritis For patients with non-inflammatory ar thritis like osteoarthritis, the prevailing treat ment had been aspirin until non-steroidal anti-inflammatory drugs (NSAIDS) were developed 50 years ago. This class of medi cations include Motrin, Advil, naproxen, and ibuprofen. Local joint injections like cortisone in jections have been used to reduce joint pain. Unfortunately, some patients had a bad expe rience with shots because either not enough medication was used, shots were spread out too much to be effective, or, in some extreme cases, the provider hit a bone while adminis tering the injection. It’s important that these injections are given by a trained rheumatol ogist using ultrasound imaging to guide the needle into the joint. Ultrasound enables physicians to precisely guide the shot into the joint, increasing the effectiveness of the medication. It also can find fluid in the joint that can cause the joint to swell and dilute the medication. In these cases, fluid can be drained before the injection to ensure that treatment is effective. If you’ve had a corti sone injection before and had a bad experi ence, try it again with a physician who uses ultrasound for the best results. In fact, in jections done “blindly” without ultrasound guidance can miss the mark 30 percent of the time. Another option for osteoarthritis is vis cosupplementation injections. During vis cosupplementation, a thick fluid called hyaluronate is injected into the knee joint, improving the lubricating properties of the synovial fluid. The procedure can reduce the pain from osteoarthritis and improve mobil ity. It’s often paired with cortisone injections to boost effectiveness.

Another new option is Zilretta, an extend ed-release corticosteroid that slowly and con tinuously releases medicine into your knee for about six months. It works better and longer than traditional cortisone and doesn’t affect a patient’s blood sugar, an important benefit for diabetics. Over-the-Counter Options Some people prefer to treat joint pain with more natural, over-the-counter treatments. While they may not provide the level of treat ment necessary for everyone, for the most part, they aren’t harmful, so I don’t discour age my patients from taking them. Some options include: • Glucosamine and chondroitin: Fre quently paired together, glucosamine and chondroitin may provide some relief. However, clinical studies are inconclusive about their effectiveness. Look for formulations with 1,500 mg of glucosamine and 1,200 mg of chon droitin. • Turmeric: Studies also are mixed re garding turmeric, but many of my patients report that they have less pain while taking it. Look for a con centrated formulation with curcumin and black pepper (piperine), which increases the body’s ability to absorb turmeric. Now more than ever, rheumatologists have an array of highly specialized medica tion options to treat all types of arthritis – and change patients’ lives. Our goal is to im prove patients’ quality of life without opioids or surgery unless other treatments fail. Each patient should receive a comprehensive eval uation and a customized treatment plan that takes into account age, lifestyle, level of activ ity, other medical issues, and support system. Most treatment plans will include a physical therapy component to increase functionality and movement. Also, it’s important to look at a patient’s total body, not just the specific joint that’s in pain. For example, if you have pain in your knee, since all of your bones are connected, it could be caused by an issue with your back, feet, or ankles, so it’s import ant to rule out other issues first. There are a lot of new and promising op tions for treating arthritis, alleviating pain, and improving quality of life. There’s no rea son to continue to live with pain. Mutahir Abidi, MD, is a board-certified rheumatol ogist and medical director of the Arthritis and Rheuma tology Center at CentraState Medical Center. He can be reached by calling 866-CENTRA7.

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