Today rheumatologists (arthritis specialists) have powerful tools to help patients with rheumatoid arthritis (RA), but it was not always like that. Imagine that you are one of the world's greatest painters and one day you become increasingly fatigued and your hands become stiff, swollen and painful. After years of suffering, the toll on your system causes severe wasting, partial paralysis and frozen, distorted joints. Or, suppose you are the most beloved performer of your time whose television show is enjoyed by people all over the world, yet no one knew the pain and agony you suffered and hid from your audience.
The painter was Renoir and the performer was Lucille Ball, of I Love Lucy.
Renoir heroically fought his Rheumatoid Arthritis to continue to create incredible beauty almost to the end.
Lucy was bedridden by Rheumatoid Arthritis for two years at the start of her career and suffered a permanent leg deformity thereafter. Rosalind Russell was another sufferer, as is Kathleen Turner, both campaigners to raise awareness about the disease.
In Renoir's time, there was no help. Today, there are treatments that by comparison are miracles that have freed many patients from much of the suffering that was the lot of RA patients in the past. Far fewer people developing RA today need to endure the worst severity of the disease.
I began my medical studies in 1964 and my rheumatology training in1970. By that time, we had some medications that could help many but not all, and seldom to the degree that either the patients or we wished. Because the drugs were so limited and were fraught with potential complications, the thinking then was to be supportive at the beginning, just suppressing symptoms, and to reserve the more powerful drugs until the disease became more severe.
The first drug for relieving pain, aching and inflammation was aspirin (acetylsalicylic acid), but it had to be pushed to near toxic levels to make a difference in RA. Aspirin, invented by Bayer in 1899, is a synthetic form of a substance in willow bark, whose soothing powers were known to Hippocrates 2300 years ago. Later came safer non-steroidal anti-inflammatory drugs (NSAIDs), like ibuprofen, introduced in Britain 1969 and in 1974 in the United States. These drugs are easier and safer to use for pain and stiffness than their predecessors, though they must still be used with care.
The most powerful anti-inflammatory agents are corticosteroids, synthetic forms of the adrenal gland hormone cortisol. They reduce pain, swelling, tenderness and stiffness but do not change the underlying course of the disease. They have been available since the 1950's. An easy to take oral form, prednisone, came in the early 1960's, with many variants following, including many in topical form for skin rashes. These steroids are quite different from the infamous ones that athletes take to pump themselves up. Since inflammation is an obvious component of RA, cortisol was tried very early on. The relief was so dramatic that doctors thought they had found the miracle drug. Then the side effects showed up.
We now know that corticosteroids are a very mixed blessing.They can provide dramatic relief for many conditions and can be lifesaving, but always at a cost, especially the longer one takes them. Taking steroids is like having Cushing's Disease, in which the adrenal gland overproduces cortisol. It is not if steroids cause side effects, only which ones, how much and when. Used briefly, even in high doses, the problems are mostly few, but used for an extended time, even at low doses, some difficulties are inevitable and are a frustrating price people must pay when they cannot do without these two-edged swords of medicine. That is true of all treatments: we must balance the need and benefit against the cost in money, side effects and risks.
The problem with steroids is that they provide only relief, blessed as it is, but do not change the course and outcome of the disease at all, so they are seldom worth the cost in side effects for most cases of RA. Sometimes their use is unavoidable; when so, they should be used at the very lowest dosage effective over the shortest time possible. Once a patient is on them, it can be difficult to wean back off. With the effectiveness of the newer biologic agents, some rheumatologists feel they can afford to use steroids at low doses for at least a while until the disease comes under control.
In Part 2, in the next posting, I will discuss agents that not only provide relief, but also slow or even reverse the course of the disease. They have risks and high costs to varying degrees, but have provided patients with much needed benefit.
Please feel free to post comments, suggest topics and ask questions, but I cannot respond to them directly. At times I will address a reader's question or comment within a posting. As with all such sites as this, it is not intended to give individual advice, to advise on your treatment or to substitute for your own doctors. It is intended to give you some insight and background that I hope will help you understand the disease better.
Published On: September 09, 2008