Combination Treatment for Rheumatoid Arthritis

By Isadore Rosenfeld, M.D.

The term arthritis is not a specific diagnosis. It simply means that one or more of your joints are inflamed, for which there are more than 100 different possible causes. For example, you may have been injured (traumatic arthritis), or you may have gout (gouty arthritis), or one of your joints may have been infected by any one of a number of agents, including gonorrhea. The two most common forms of arthritis, however, are osteoarthritis and rheumatoid arthritis.

Osteoarthritis is the result of long-standing wear and tear on the joints that develops usually as we grow older. It involves a loss of cartilage and a change in bone constitution. Rheumatoid arthritis is totally different and results from inflammation of the joints that have been attacked because of a faulty immune system. It affects more than 2.1 million Americans, of whom 1.5 million are women. It's progressive, chronic, and often crippling. It usually starts in middle age but may occur in children and young adults. Unlike osteoarthritis, which is confined to the joints, rheumatoid arthritis usually also involves internal organs such as the heart and lungs.

There are several ways to treat rheumatoid arthritis, but the first goal is to reduce symptoms — joint pain, stiffness, and swelling. This can be done with drugs such as aspirin, nonsteroidal anti-inflammatories (NSAIDs), and corticosteroids. Exercise, heat, cold, and physiotherapy also play an important role. In addition, a category of medications, referred to as disease-modifying antirheumatic drugs (DMARDS) can affect the underlying disease process in addition to reducing pain.

For the past 20 years, the DMARD of choice has been methotrexate (Rheumatrex), originally developed for the treatment of various cancers. Unfortunately, it is effective in only one in three patients with rheumatoid arthritis. More recently, a new class of drugs — the prototype of which is Enbrel (etanercept) — has become available. It targets and neutralizes an inflammation-causing protein called tumor necrosis factor. Patients who don't respond to methotrexate are given Enbrel, but heretofore the drugs were not usually taken together.

Another form of therapy, called Prosorba, filters the blood of patients with rheumatoid arthritis and removes the inflammatory antibodies from the circulation. Older agents such as gold therapy, antimalarial medications, a variety of biologic agents, azathioprine (Azasan), and cyclosporine (Sandimmune) may also help. When joints have been badly damaged and are painful, and the patient is crippled and immobilized, surgery may be necessary.

Here's What's New According to a report published in the Lancet, treating rheumatoid arthritis with a combination of methotrexate and Enbrel is more than twice as effective as either drug alone. Here are the data: After using both drugs for 1 year, 35 percent of 682 rheumatoid arthritis patients went into remission as compared with 13 percent of those on methotrexate alone and 16 percent taking only Enbrel. The other point to note is that all these patients had been suffering from the disease for years. It may be that starting this combination therapy sooner could slow down the rate of joint destruction and have an even greater effect.

The Bottom Line There is no cure for rheumatoid arthritis. However, there are several different ways to reduce the joint pain, swelling, and deformity. Combining methotrexate and Enbrel, both of which affect the disease mechanism in addition to improving its symptoms, is more effective than either one alone. And the earlier this is done, the better.

Reprinted from: Dr. Isadore Rosenfeld's 2005 Breakthrough Health, by Isadore Rosenfeld, M.D. © 2005 Dr. Isadore Rosenfeld, M.D. (January 2005; $14.99US/$20.99CAN; 1-59486-140-4) Permission granted by Rodale, Inc., Emmaus, PA 18098. Available wherever books are sold or directly from the publisher by calling (800) 848-4735 or visit their website at www.rodalestore.com

Author: Dr. Isadore Rosenfeld is the best-selling author of nine books, including Live Now, Age Later and Dr. Rosenfeld's Guide to Alternative Medicine. He is a distinguished member of the faculty at New York-Presbyterian Hospital/Weill Medical College of Cornell University and attending physician at New York-Presbyterian Hospital and Memorial Sloan-Kettering Cancer Center. Dr. Rosenfeld can be seen every Sunday morning on his popular show Sunday Housecall on Fox News Channel. He is the health editor and a regular columnist for Parade magazine.

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