ALLIES AGAINST ARTHRITIS

RON GASBARRO, R.Ph., M.S.

When it comes to arthritis treatment, there is no shortage of remedies available.

The mainstays of treatment, of course, are the nonsteroidal anti-inflammatory drugs, or NSAIDs. Despite their widespread use, the properties of these agents often are not well understood.

Pharmacists need to explain how these medications work so patients will use them properly. Patients may not realize that the NSAID reduces inflammation as well as relieves pain.

"On a new prescription for an NSAID, some face-to-face counseling is needed," says Sue Pennington, pharmacist at Neighborcare Pharmacy, Rosedale, Md. "I tell patients, 'Don't take this on an empty stomach. Don't take more than prescribed.'

"As patients get their prescription refilled, I ask how they are doing and apply positive reinforcement if they are doing OK. If they are not doing OK, I'll ask some questions and even call the doctor," says Pennington.

In my own experience as a community pharmacist, including working in a supermarket, too often as I was filling a prescription for an NSAID, the patient would plunk down bottles of Tylenol, Motrin IB and Ben-Gay. Careful probing into the patient's reasons for selecting all these products may uncover therapeutic duplication.

The pharmacist should explain that the NSAID will reduce the swelling that is causing the pain. The topical cream is fine for additional relief. However, if the patient keeps getting refills of an NSAID and claims that the prescription isn't working, a call to the physician by either the pharmacist or the patient is in order.

The side effects and expense of some NSAIDs can cause further frustration for patients. These patients may already feel frustrated from the pain and the limited mobility associated with their arthritis.

"For the elderly, cost of the medications is the limiting factor," says Pennington. "Some of these people will do without their medication because they can't afford it and don't have a prescription card.

"As for side effects, patients do complain about gastrointestinal problems," she says. "When they do complain, often the physician will put them on Cytotec [misoprostol], and then the person has more drugs to take and more drug costs to deal with."

The first step for someone who may be suffering from arthritis is a proper diagnosis. After all, there are more than 100 different types of arthritis, though osteoarthritis and rheumatoid arthritis are by far the most common. An estimated 6 million people, or 16% of all arthritics in the United States, have never seen a doctor for their condition.

Of all of the forms of arthritis, it is probably least desirable for patients to try to self-treat rheumatoid arthritis. A study published in the Annals of Rheumatoid Diseases showed that the most debilitating damage to the joints occurs during the first two years of the disease. As a systemic autoimmune disease, rheumatoid arthritis affects not only the joints but also the eyes, heart and lungs. In the past rheumatoid arthritis was treated almost timidly, beginning with joint rest, range-of-motion exercises and aspirin. Current treatments are much more aggressive. Methotrexate, once reserved as a last-ditch approach, now is prescribed early on. Once suppression of signs and symptoms is attained, treatment is stepped down to milder anti-inflammatory agents and joint rest.

Osteoarthritis is limited to the joint tissue, especially the weight-bearing joints, and affects half of all people over the age of 65. Gout can cause sudden, severe pain in certain joints, notably the big toe.

For some patients who have already been diagnosed with arthritis, self-treatment with over-the-counter naproxen sodium is an option. Compared with other NSAIDs, including ibuprofen, patients taking naproxen reported the greatest incidence of ringing or buzzing in the ears, shortness of breath and/or wheezing, and higher-than-average reports of fluid retention, drowsiness and pruritus.

The clearance half-life of ibuprofen is one to three hours, compared with 12 to 15 hours for naproxen. Patients must be warned not to take naproxen more than twice daily unless their doctor specifically approves it.

As with ibuprofen, OTC naproxen sodium promises a similar shortcut for any patient who can figure out that a double dose equals prescription-strength relief.

It's not at all clear, though, how many arthritics will seek to self-treat their condition with OTC naproxen sodium.

"While it's nice to have another option for the relief of general pain," says Dennis Bowman, spokesman for the Arthritis Foundation, "the drug will still be expensive and the patient will have to take high doses to obtain an anti-inflammatory effect."

"Naproxen sodium going OTC is fine as long as the dosage is less than the prescription form," says Carla Ciampi, a pharmacist at a Hannaford Bros. store in Gorham, Maine. "However, given the fact that naproxen's half-life is so much longer than other anti-inflammatories that are available over the counter, dosing should be clearly marked on the label and the pharmacists should remind the customer of the dosing differences."

"My fear is that people are going to take a greater amount than is recommended because the anti-inflammatory effect of this drug is not immediate. If one or two tablets don't work, then they will take three or four. Without monitoring by a pharmacist, the patient can end up having serious problems if the medication is taken incorrectly."

The market introduction of naproxen sodium as Aleve this spring comes on the heels of a report in the February issue of Neurology suggesting that some NSAIDs may slow the onset of Alzheimer's disease. A comparison of 50 pairs of elderly twins found that the twins who had been taking an NSAID were less likely to have Alzheimer's, or if they did have it, they were less affected by the condition.

Will people start popping OTC NSAIDs to thwart Alzheimer's? Given that disease's grim prognosis, it's certainly a possibility. Many people already ingest baby aspirin on a regular basis to avoid stroke.

A major problem in treating arthritis is the temptation for patients to try unproven remedies. Some rogue products, such as snake venom, can be downright dangerous. The long-term consequences of other remedies, such as fish oil, are still unknown. Still others, such as copper bracelets and soaking in mineral springs, do not work but are harmless.

"Let the arthritics wear their copper bracelets. It won't hurt them," says Robert Kerr, professor of pharmacy at the University of Maryland, Baltimore. "But just make sure they are taking their anti-inflammatories as prescribed."