The Burden of Arthritis on Quality of Life

In the July/August issue of Geriatrics & Aging, I wrote an editorial on falls in the elderly. Falls, of course, are part of the broader issue of mobility in the elderly, and nothing lowers the quality of life for older people as much as impaired mobility. In fact, more severe mobility restrictions (e.g., being housebound) are also correlated with decreased survival. The reasons for the association between aging and mobility impairment are very complex. In our last issue, the importance of fitness in maintaining mobility was stressed. Age- and disease-related changes in the neurological system also are important factors in decreased mobility, and neurological disease increases dramatically with advancing age. However, there is no doubt that arthritis is probably the most common reason for impaired mobility in the elderly. As I have noted in previous issues, arthritis is much more likely to impair quality of life than is angina. Often, older persons are less frightened by the issues of mortality than they are by the prospect of pain and disability.

This issue addresses problems seen in several of the common types of arthritis. Dr. Herbert von Schroeder outlines the surgical management of osteoarthritis of the hand and the wrist, Dr. Benjamin R. Davis reviews the management of temporomandibular disorders in older people, and Dr. Geoffrey F. Dervin discusses management of the arthritic knee. Oksana Davidovich gives an overview of the painful geriatric foot, a condition in which arthritis is an important, but not exclusive, factor. Our Drugs & Aging column focuses on the very expensive biologic treatments for inflammatory arthritis, and their possible role in older persons. Dr. Charles D. Ray writes about the diagnosis and treatment of lumbar spinal stenosis. I sometimes feel that this is an area in which our ability to image the problem is far advanced compared to our understanding of its clinical diagnosis and management.

We have a variety of other articles on offer as well. Dr. Alan K. Berger reviews the literature on reperfusion therapy for acute myocardial infarction while Jonathan Ship outlines the diagnosis and management of a common and often ignored issue in older people, xerostomia. Drs. Christina M. Canil and Jennifer J. Knox discuss the topic of renal cell cancer, and the relationship between statin use and dementia is reviewed by Dr. Milita Crisby.

Enjoy this issue.

Issues in the Treatment of Osteoarthritis

Dr. Shafiq Qaadri, MD, Family Physician and CME Lecturer, Toronto, ON.

Introduction
With the demographic shift in Canada--the "greying" of its population--arthritis is a growing health concern. A leading cause of long-term disability in Canada, arthritis and other musculoskeletal diseases result in $17.8 billion in lost productivity annually.¹ Currently, four million Canadians are affected by arthritis, and the number of people afflicted is expected to double in the next 20 years.² Already, 33% of Canada's seniors have osteoarthritis,2 the most common form of arthritis in older adults.

Effective osteoarthritis care requires a spectrum of approaches on the biopsychosocial model including: advice on carrying out daily activities (coping with fatigue, protecting joints, using orthotics); controlling pain through approaches such as relaxation therapy, massage therapy, hydrotherapy or acupuncture; using walking/assistive devices; and learning more about arthritis from organizations or websites. Self-help groups are a particularly valuable resource for arthritis patients.

Many patients ask about alternative remedies such as glucosamine or chondroitin, which have shown some effectiveness in studies. A full discussion of complementary therapies for arthritis is presented on the Arthritis Society website at www.arthritis.ca.

Medication remains the mainstay for controlling arthritis pain of all types.

Rheumatoid Arthritis: A Whole New Ball Game

Arthur Bookman, MD, FRCPC, Senior Staff Physician, University Health Centre, Coordinator, Core Residency Rheumatology Program, University of Toronto, Toronto, ON.

Rheumatoid arthritis (RA), traditionally, has been a difficult and discouraging condition for medical practitioners to treat. In general, physicians have been taxed to contend with the overwhelming physical destruction, as well as the sometimes devastating medical complications, seen in the disease. Our medical schools do not provide sufficient preparation, giving us inadequate tools for recognition of joint disease in general and few tools for following and monitoring disease progression.

Only 10 years ago, the treatment plan for RA was a leisurely-paced pyramid of medications. It began with non-steroidal anti-inflammatory agents (NSAIDs), and flowed through empirical remedies such as gold salts and chloroquine, into newer empirical remedies co-opted from cancer treatment or transplantation, such as methotrexate or imuran in recent years.

Over the last five to 10 years, modern studies have contributed to an evolving understanding of the disease. It is now evident that the diagnosis of RA amounts to a prediction of joint inflammation that will inevitably evolve to joint damage, leading to X-ray evidence of erosion and joint space narrowing. Furthermore, these X-ray changes are markers for loss of function and disability. The evolution of X-ray change over time is constant (Figure 1).

The Cox-2 Controversy Continues

In 2001, a report published in the Journal of the American Medical Association suggested that the new, and more gastrointestinally friendly, Cox-2 inhibitors, may place patients at higher risk of myocardial infarction.¹ A retrospective analysis of the VIGOR study found that, in patients taking rofecoxib, the incidence of myocardial infarction increased five-fold when compared with patients who received a traditional NSAID, naproxen.

However, the analysis could not determine the reason for this increase. Two mechanisms were proposed to explain the results. The first is that non-selective NSAIDs may be cardioprotective because of their inhibitory effects on thromboxane A2 (TxA2), which causes platelet aggregation. The second is that Cox-2 inhibitors could have deleterious cardiovascular effects because they do not block TxA2 but selectively inhibit the beneficial cardiovascular effects of prostacyclin (PGI2), which is a potent inhibitor of platelet activation by all recognized agonists and a vasodilator.

A recent study on mice has contributed to the discussion, without providing any definitive answers.² To determine which of the two hypotheses might account for the observed cardiovascular effects, the researchers generated mice with disordered expression of receptors--both PGI2 and TxA2 activate G-protein coupled receptors, the prostacyclin receptor (IP) and the thromboxane receptor (TP), respectively--and monitored the response to vascular injury.

Mice lacking the PGI2 receptor, a model for the clinical effect of taking Cox-2 inhibitors, had an enhanced vascular response to injury and showed increased TxA2 formation and platelet activation. This enhanced response was cancelled out in mice lacking both TxA2 and PGI2 receptors. These data establish that endogenous PGI2 modulates the cardiovascular actions of TxA2 in vitro, an interplay that may be relevant to the cardiovascular effects of selective Cox-2 inhibitors, which depress PGI2 without coincidental inhibition of TxA2 formed by Cox-1 in platelets.

The results of the mouse study are very preliminary, and what occurs in the mouse, is not necessarily relevant to the man. There are also a number of other criticisms of the JAMA study. It has been argued that the dosages used in the VIGOR trial were almost double the normal daily dosage, so even if rofecoxib has a prothrombotic effect, it may be dose-dependent. The increase in mortality in the CLASS trial, while higher in the celecoxib group, resulted from accidents, infection and cancer, and was not related to the use of celecoxib. Unless presented with firm research to the contrary, some are suggesting that Cox-2 selective inhibitors should be considered safe for arthritis patients at risk of gastrointestinal events; however, physicians should take a cautious approach when prescribing rofecoxib to patients with a history of cardiovascular disease.

Source

1. Mukherjee D, Nissen SE and Topol EJ. Risk of cardiovascular events associated with selective Cox-2 inhibitors. JAMA 2001; 286:954-9.
2. Cheng Y, Austin SC, Rocca B, et al. Role of prostacylcin in the cardiovascular response to thromboxane A2. Science 2002; 296:539-41.

Polymyalgia Rheumatica and Giant Cell Arteritis: The Lesser Known Chronic Inflammatory Illness

D'Arcy Little, MD, CCFP
Director of Medical Education,
York Community Services,
Toronto, ON.

Introduction and Historical Background
Although first described in 1888 as "senile rheumatic gout," it wasn't until the 1950s when more cases were described in the literature that Barber coined the term "Polymyalgia rheumatica" to describe a syndrome of myalgias, stiffness of the shoulder and pelvic girdle muscles, and concomitant constitutional symptoms. A case of Temporal arteritis was first described by Thomas Hutchinson in 1890 when an 80-year-old man presented with a painful, inflamed temporal artery. In 1932, Horton first described the typical histological features of temporal artery from biopsies in patients with this condition, and the term "Giant cell arteritis" was first used.^1,2,3

Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are closely related conditions that are almost always seen in patients over the age of 50 years. These conditions are relatively common and may represent a continuum of disease.^3,4 The following review will provide a framework for consideration of these diagnoses, as well as a review of their treatments.

Epidemiology
Once considered uncommon, PMR and GCA are among the most common, chronic inflammatory illnesses affecting the elderly, primarily as a result of raised awareness of the conditions.⁴ PMR has an incidence in North America of 52.

Alternative Medicine that Actually Works?

Glucosamine and Chondroitin in Osteoarthritis

Gerlie C. de los Reyes, BSc, MSc
Department of Pharmaceutical
Sciences, University of Southern California, Los Angeles, CA, U.S.A.

Robert T. Koda, PharmD
Department of Pharmaceutical
Sciences, University of Southern California, Los Angeles, CA, U.S.A.

Eric J. Lien, PhD
Department of Pharmaceutical
Sciences, University of Southern California, Los Angeles, CA, U.S.A.

"Medicine provides the means to treat diseases. Knowledge is the foundation of good health." E. J. Lien

Osteoarthritis (OA) is a chronic joint disease that is estimated to affect almost 5 million Canadians (16% of the population) by the year 2016.¹ This degenerative disorder is one of the primary causes of pain and long-term disability in the elderly. The disease is characterized by the progressive deterioration of the articular cartilage, the protective "cushion" at the articulating surfaces of bones. This degenerative process is caused primarily by a defect in the metabolism of the component macromolecules including proteoglycans (aggrecans) and type II collagen.

The non-steroidal anti-inflammatory drugs (NSAIDs) like aspirin, ibuprofen, indomethacin and piroxicam are the most widely used medications for the treatment of patients with symptomatic OA.

Rheumatoid Arthritis in the Elderly: Treatment Considerations

Dr. Angela G. Juby, MBChB, Cert Geriatrics
Associate Clinical Professor, Division of Geriatrics,
Department of Medicine, University of Alberta, Edmonton, AB.

Dr. Paul Davis, MBChB, FRCP, FRCPC
Associate Dean, Faculty of Medicine, University of Alberta,
Professor, Division of Rheumatology,
Department of Medicine, University of Alberta, Edmonton, AB

Introduction
Rheumatoid arthritis most commonly presents in the 3rd and 4th decades of life; elderly patients with initial presentation and patients whose disease persists into the later decades of life can present interesting challenges. In particular, the differences in clinical presentations of rheumatoid disease in the elderly when compared to younger patients may lead to difficulty in making a definitive diagnosis. There may be diagnostic challenges related to the interpretation of laboratory findings, particularly serological tests. Elderly patients often have comorbidities; therefore, pharmacologic management of rheumatoid disease must be undertaken with caution to reduce interference with the stability of other organ system therapies, and the potential for drug-disease and drug-drug interaction and polypharmacy must be addressed. Finally, it is important to dispel the attitude that "arthritis" is a process associated with "normal aging.