By Alan Martin, MD
During my career as a rheumatologist, there has been no more significant breakthrough in the treatment of rheumatoid arthritis (RA) than the introduction of biologic agents when Enbrel came on the market in 1998.
The traditional therapies are still used initially for treatment. These are labeled disease-modifying anti rheumatic drugs (DMARD). The most commonly used DMARD medications are methotrexate, hydroxychloroquine, sulfasalazine and leflunamide. These medications may be used alone or in combinations, as long as there are no contraindications. Some RA patients do achieve a significant improvement and can be maintained on these medications alone. Many patients, unfortunately, do not achieve an acceptable improvement, and their disease activity continues.
The biologic agents have revolutionized the treatment of RA in their ability to slow down disease progression, and in some cases, induce remission of disease. These drugs were engineered to specifically inhibit proteins secreted by cells that regulate the immune response and promote inflammation. There are multiple categories of biologics that each block specific aspects of the immune system. Some examples are Enbrel, Humira, Simponi Aria, Remicade, Actemra, Rituxan, Orencia and Xeljanz. Sixty to seventy percent of patients have a measurable improvement, and fifteen to twenty percent may have remission or close to remission of their RA.
Every patient’s disease process and response to medication is unique, and one biologic may help one patient more than another. Therefore, in some patients, multiple trials of different biologic medications may be used in succession. Treatment decisions are based on the balance of improving the disease process weighed against the risks of drug toxicity. Evaluating which medication is right for each patient, the physician takes into account lab studies, x-rays and the patient’s medical history. Conditions in a patient’s previous or current medical history that may affect the decision of using biologics are infectious exposures, current infection risk, nerve disorders, history of heart failure, other chronic diseases and pregnancy.
To assess the effectiveness of these medications, a rheumatologist uses multiple parameters, including number of joints involved, x-ray progression and functional status. Functional status is assessing the patient’s ability to perform daily activities such as walking, dressing and grooming and performing household or work duties. Unfortunately, not all RA patients are candidates for biologic medications. Fortunately, though, most patients will be able to benefit from the use of biologics and see improvement in their activity and pain level.
We have come a long way since simple analgesics such as aspirin were used to treat RA. Those simple analgesics did not address the disease process and provided minimal pain relief. Now we have biologics that can slow down the disease progression and at times put the disease in remission, which leads to a higher quality and more enjoyable life.
By Lindsay Cunningham, D.O., RhMSUS
Rheumatoid Arthritis Awareness Day is February 2, so this blog post addresses the top questions asked in my clinic regarding rheumatoid arthritis (RA):
- What can I do for myself to help my RA?
- Is there something that I should or should not be eating?
- What diet will help with my rheumatoid arthritis symptoms?
These are great questions, and unfortunately, there is not a straightforward answer with regards to diet. Diets impact our health in more ways than we could imagine, making it a very difficult subject to study. Despite the host of limitations, there is still some evidence that certain dietary changes can reduce general inflammation or symptoms from rheumatoid arthritis. One key thing to remember: Changing inflammation in our body or improvement in RA symptoms does not mean that we are changing the inflammatory process in our joints.
There is no evidence to show us that changes in diet will slow progression of rheumatoid arthritis. Dietary and lifestyle changes should only be one aspect of your complete rheumatoid arthritis care and should not be relied on solely for treatment.
Joint damage from inadequate RA treatment
There is not one specific diet recommended for rheumatoid arthritis. Symptomatic relief with regards to arthritis and diet varies greatly among individuals. There is evidence that some aspects of our diets can improve certain types of inflammation, and if desired, could be incorporated into your daily life. The changes with the most evidence include the following: high intake of foods rich in monounsaturated fats and fiber and low intake of processed foods and foods with high content of saturated fats.
The fiber intake is best if it comes from the foods we eat, not from supplementation or pills. These foods include vegetables, fruits, beans, nuts, and whole grains. Food sources rich in omega-3 fatty acids include fish, such as salmon, mackerel, oysters, etc. Try cooking with virgin olive oil, instead of vegetable oil. Remember that the focus is on a well-balanced diet that includes foods rich in fruits, veggies, healthy fats, and fiber. Other than cutting out processed foods and “junk food,” there really hasn’t been an established food group to eliminate.
One thing that’s important to notice: These dietary changes tend to be viewed as good suggestions for most health conditions, not just arthritis. Are these improvements related to weight reduction and other lifestyle improvements, or to the foods themselves? Most of the studies can’t really tell us. There’s probably a little truth to both, although the link to weight loss and reduced disease activity has been fairly well established.
Physical activity is highly recommended for those with rheumatoid arthritis. There is no evidence that being physically active does any additional damage to the joints of those with RA; however, evidence has shown that physical activity improves functional capacity. Find physical activities that focus on aerobic capacity and muscle strengthening with low joint impact overall. If you’re having trouble getting started, physical therapy is a great place to get direction.
And finally, the dreaded but most important topic: weight. Being overweight not only increases your risk of developing RA, but it also increases your body’s level of inflammation (fat tissue produces inflammatory chemicals) and has been shown to worsen control of RA.
If you are overweight, the best news to take from prior studies: weight loss has been shown to reduce disease activity! Weight loss appears to be the most important player in non-pharmacologic management of RA. Weight loss and physical activity should be emphasized over specific dietary changes.
Lifestyle, diet, and other non-pharmacologic changes are important to include in your care of rheumatoid arthritis but should not be done as the sole treatment for RA. Weight loss has been shown to have the largest benefit. Individualized improvements of RA symptoms have been noted with dietary changes, especially with incorporation of vegetables, fruits, fiber, and healthy fats. Consult with your rheumatologist regarding the best way to manage your rheumatoid arthritis in entirety, and do not rely on diet or weight loss alone.
Remember that not all diets or lifestyle changes are safe for all people. If you’re considering any changes to diet or physical activity, you should consult with your health care provider first.
By DiAnne Adams, DO
When it comes to the healing of an injury or condition, having a doctor and physical therapist who work closely together can be extremely beneficial to the patient. At Tulsa Bone & Joint Sand Springs, I work hand-in-hand with our physical therapy team on a daily basis.
In many cases, orthopedic or sports medicine doctors have to refer outside their company to a physical therapy group. Sometimes they are referring to a PT they have never met or perhaps never even spoken on the phone with. However, at Tulsa Bone & Joint, we have a qualified group of PTs on our staff – and at Sand Springs, we are literally under the same roof.
3 benefits to using a sports medicine doctors and PT who work together:
- Improved communication.
Madison is an example of a patient that Dr. Adams and Dan Skierski have been able to treat together. While cheering, Madison’s knee twisted and popped. She came to Tulsa Bone & Joint Sand Springs, and Dr. Adams and Dan treated her knee for full recovery.
I’ve been working closely with Dan Skierski, DPT, manager of physical therapy here at our Sand Springs clinic, for the last year and a half. During that time, there have been countless times when we’ve been able to consult about a patient face-to-face. Since PT visits are usually quite frequent, the PT can help if there has been an acute change between appointments, or they can identify other contributing factors to the patient’s original diagnosis that the patient may have forgotten to mention during the doctor visit.
This leaves out the middle man of a front desk person, nursing staff, etc. This direct communication can often lead to quicker outcomes on treating the patient.
Also, this direct communication increases accountability for the patient. If I ordered PT for a patient, and he only showed up once out of the six weeks that were directed, Dan lets me know. This helps me know how committed (or uncommitted) the patient may be to the healing process.
- Quicker outcomes.
For better or for worse, much of healthcare is driven by what insurance companies require. When it comes to treating injuries, insurance companies try to steer physicians to take the most conservative approach in treating patients.
Dan Skierski treating Madison for her knee injury.
As a nonsurgical sports medicine physician, I am committed to exploring various options that will help my patients, and one of the most beneficial options is often physical therapy. Insurance companies frequently mandate that before they will cover higher-level imaging (like an MRI), the patient needs to first try six weeks of physical therapy.
There have been times when this approach has actually worked to speed up the process toward needed imaging. Since the PT has a one-hour session with the patient two or three times a week, and I only see the patient for 10 or 15 minutes, the PT has more interaction with and observes the patient’s movements more than the physician. There have been times that I’ve been able to request approval for higher-level imaging just a week or two into therapy thanks to something the PT has noticed and mentioned to me.
This speeds up treatment and allows us to jump through some of that insurance red tape a little quicker.
- Convenience to the patient
It’s very convenient for a patient to be able to see both the doctor and PT in one afternoon. This means less time in the car, less time waiting for appointments, and overall – happier patients!
The next time you’re looking into sports medicine or orthopedic care, consider a group that employs its own PT team. It will no doubt benefit you as a patient in the long run!
Tulsa Bone & Joint is happy to welcome Lindsay Cunningham, DO to the Rheumatology team. Dr. Cunningham is board certified in Internal Medicine and specializes in Adult Rheumatology. She received her Rheumatology Fellowship from the University of Alabama at Birmingham and is a member of the American College of Rheumatology. She is currently accepting new patients. For more information on Dr. Cunningham or to make an appointment call 918-392-1400.
