Ask the Doctors January 2003 Issue

Ask Dr. Marks: 01/03

I’m a new subscriber. I suffer from moderate joint pain, and I suspect it may be arthritis. I’ve decided to go to a doctor, but I’m confused. What type of doctor should I go to?

If you suffer from moderate joint pain, it’s best if you bring this to the attention of your primary care physician. He will examine you and obtain the necessary lab studies to rule out rheumatoid arthritis and other inflammatory conditions. If you do have the beginning of inflammatory arthritis, your primary care physician will probably refer you to a rheumatologist. If, on the other hand, you are suffering from osteoarthritis then your physician will likely put you on a nonsteroidal anti-inflammatory drug (NSAID) or a pain reliever. Your primary care physician will then monitor your symptoms and your response to the NSAID. As we report in this issue (“Drugs At War”), NSAIDs can interact with medications that you’re currently taking. Your primary care physician is in the best position to make sure that negative interactions do not occur. On the other hand, if your joint pain is related to an injury, either recent or remote, the best person to evaluate your pain would be an orthopaedic surgeon. He can evaluate your joint for conditions that can be either corrected by medicine, surgery or physical therapy. If you’re experiencing mechanical-type symptoms, such as locking of a joint or instability, you should also see an orthopaedic surgeon.

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I'm curious about NSAIDs for the treatment of arthritis. How exactly do they work?

Nonsteroidal anti-inflammatory drugs (NSAIDs)—aspirin, ibuprofen and naproxen are among nearly 20 such drugs available today— exhibit anti-inflammatory, analgesic and antipyretic properties. The mechanism of action for their anti-inflammatory properties is due to their ability to inhibit prostaglandin synthesis (an inflammation mediator). Older anti-inflammatants inhibited both cyclooxygenase 1 and 2 (Cox 1 and 2). Newer anti-inflammatants, such as Vioxx, Celebrex and Bextra, do not inhibit Cox 1, thus they have less chance of causing gastric bleeding. NSAIDs also help osteoarthritis due to their pain-relieving effect. Tylenol, which can be quite effective in the treatment of early osteoarthritis, is a pure pain reliever but it does not include anti-inflammatory properties.

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Are imaging techniques—X-ray, MRI, CT scan, Ultrasound—of any use in determining the scope and the severity of osteoarthritis?

Of all imaging techniques, X-ray is still the most important method for determining the severity of arthritis. Any chronic joint pain should be evaluated with X-rays, which can help rule out such nonarthritic conditions as tumor and infection. The MRI is a newer technique that finds its greatest use in the evaluations of soft tissues such as menisci and ligaments. Torn or worn menisci are frequent causes of joint pain. It’s important to diagnosis this, since they can be helped by surgical intervention. The MRI can also show the thickness of the articular cartilage, thus obtaining a clearer picture of the severity of the arthritis. CT scans or ultrasound are useful for special circumstances, but they are not routine for the evaluation of osteoarthritis.