Ask the Doctors July 2006 Issue

Ask the Doctors: 07/06

I have severe osteoarthritis in my right knee. I’ve taken ibuprofen for years, but switched to diclofenac when research showed that ibuprofen interfered with the anti-platelet activity of aspirin. Now I have esophagitis and chronic gastritis. I’ve stopped diclofenac and am taking Nexium. I won’t take a COX-2 inhibitor because of the risk to my heart, so what can I do for my pain?  I’m trying to put off total knee replacement as long as possible.

Since you are experiencing significant side effects from your medications, I would recommend you rethink your reluctance to have a total knee replacement (TKR). Following a TKR, patients are usually able to reduce or eliminate the need for pain medications and nonsteroidal anti-inflammatory drugs (NSAIDs). You should see an orthopaedic surgeon for advice on the need and timing of a TKR.

Your current problem is knee pain. Extra-strength Tylenol is usually as effective as NSAIDs for most non-inflammatory arthritis pain. If more pain relief is necessary, your doctor can prescribe Tylenol with codeine or other narcotic-based pain relievers. By using pure analgesic medications instead of NSAIDs, you can remove the cause of your chronic gastritis and esophagitis and lessen the need for Nexium. If you cannot proceed with a TKR due to poor health, a pain management specialist can prescribe and monitor an individualized pain management program.

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I suffer from severe rheumatoid arthritis. Although I’m on methotrexate (ten 2.5mg pills per week), my condition seems to be getting worse. Has the methotrexate run its course? Any advantage in switching from an oral treatment to an injection form, or combining it with another drug?

If a patient is not doing well on methotrexate alone, the standard of care is to use methotrexate in combination with other agents, such as hydroxychloroquine (marketed as Plaquenil), sulfasalazine (Azulfidine), leflunomide (Arava), and others. Injectable methotrexate may be more “bioavailable” in that it can deliver higher levels in the blood and sometimes is more effective. The biggest advance in rheumatoid arthritis therapy has been the introduction of anti-TNF (tumor necrosis factor) agents (Enbrel, Humira, Remicade). These drugs are more effective than any previous treatments, and they are often used with methotrexate. The major side effect of anti-TNF
agents is the risk of infection.

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My doctor says I have degenerative changes in my spine. What does that mean? Is it arthritis? “Degenerative” changes in the spine often refer to those that cause loss of normal structure or function.

The intervertebral disc is one structure prone to degenerative changes associated with wear-and-tear aging. Degenerative disc disease is part of the natural process of growing older. As we age, our intervertebral discs lose their flexibility, elasticity, and shock-absorbing characteristics. The fibrous outer portion of the disc, the annulus fibrosis, becomes brittle and prone to tearing. At the same time, the soft gel-like center of the disc, the nucleus pulposus, starts to dry out and shrink. The combination of damage to the intervertebral discs, the development of bone spurs, and a gradual thickening of the ligaments that support the spine can all contribute to degenerative arthritis of the spine.