Ask the Doctors April 2006 Issue

Ask the Doctors: 04/06

I have osteoarthritis in my knees. I also have a blood-clotting disorder and have been put on Coumadin, which means I can’t take NSAIDs. I take a daily dose of Tylenol, but it doesn’t seem to have much effect. What do you recommend?

Taking an NSAID while on warfarin (Coumadin) can be dangerous because NSAIDs increase the risk of bleeding—severe bleeding in the case of Coumadin. When Tylenol does not help, other analgesics, such as tramadol (Ultram) or Darvocet (propoxyphene and acetaminophen), are often used. Occasionally, a narcotic may be used if nothing else is helpful. Topical medications may also be prescribed; capsaicin cream may help when used two times per day. Its active ingredient is red pepper, which can sometimes cause burning, so you need to take care to avoid contact with the eyes. There are also topical NSAIDs, such as ketoprofen gel (20 percent), which is used three times per day. A lidocaine (Lidoderm) patch is yet another option.

Although the relief is temporary, injections of steroids into the joint can also relieve pain. Another treatment uses a group of materials called viscoelastic supplements, which are made up of hyaluronic acid compounds. These are injected into the joint weekly for three to five weeks. Lifts in your shoe or a brace on the knee can redirect forces away from an area of arthritis in the knee and provide some benefit. Surgery, a last resort, may be indicated when pain cannot be controlled or your functional ability is impaired.

----------

I’ve suffered from gout for three years and am taking colchichine to control it. I don’t drink a lot of water because I have congestive heart failure and am on diuretics. Does my lack of water intake contribute to my gout flare-ups?

Yes, dehydration may cause gout attacks. Most diuretics increase serum uric acid and the likelihood of gout attacks. Alcohol can also cause gout attacks, and minimal use is therefore recommended. If your attacks are still occurring on colchicine and your uric acid levels are high, allopurinol is usually prescribed. It can lower your uric acid levels and, after approximately three to six months, is usually effective in preventing further attacks.

----------

I have arthritis in both my thumbs, and my doctor wants to operate. What other options do I have, and what is the surgery’s success rate?

Many people with mild symptoms of thumb arthritis improve with a limited period of anti-inflammatory medication and avoidance of painful activities, with or without some type of splint. A cortisone injection into the sore area usually is helpful, at least temporarily. Relief usually lasts about two months. One or two injections provide permanent relief for about 50 percent of people with this problem.

When conservative treatment is no longer effective, surgery is an option. The most commonly performed surgery for thumb arthritis involves removal of the arthritic surfaces and insertion of a material—your own tendon or a synthetic substance—between the two ends of the bones. The success rate for this procedure is about 90 percent. Another surgical procedure used for thumb arthritis is fusion of the two bones that make up the joint. This generally eliminates the painful symptoms but produces some loss of motion and joint stiffness. Total joint replacements for the thumb have not been as successful as have replacements of larger joints, such as the hip and knee.