by Gary Craig, MD

 

Growing older can be rough. It seems to take longer each morning to unravel your joints and get them going again. You creak when you walk, and when you get to the breakfast table, your meal greets you with a mountain of pills. Fear not! Despite what your joints are telling you, there is hope. We live in an exciting time of clinical and pharmaceutical advancements that are giving patients relief from the debilitating pain caused by many types of arthritis.

 

Your joints are more durable than you may think. Their intricate and elegant engineering allows them to last much longer than any of the innumerable weight-bearing surfaces that we humans have ever designed. They are equipped with incredibly smooth cartilage at the end, which offers a nearly friction-free gliding surface. Just below the cartilage, a hard, bony endplate covers a honeycomb of bone, effectively forming microscopic shock absorbers. Durable ligaments connect the bones, and some joints contain cartilage pads (called menisci) to help keep their alignment in place.

 

Your joints are impressive, and yet, damage happens. Injuries, over-use, excessive weight and smoking may all work to break down those durable, impressive joints. Damage to any of the above components will lessen the survival of your joints, much like a tire misalignment can turn those 40,000-mile tires into 20,000-mile ones.

 

This type of arthritis is called osteoarthritis, or “Wear-and-Tear” arthritis. An injured joint becomes inflamed with use, leading to pain and morning stiffness. Once a joint is damaged, the inevitable progression of damage can be reduced by weight loss, joint protection and cessation of smoking. Anti-inflammatory drugs, cortisone injections and shots of a joint-lubricating material called Hyaluronic acid can all help to ameliorate discomfort, but will not slow down the process of deterioration. The value of over-the-counter supplements and dietary additives is, at best, debatable, with Glucosamine and Chondroitin being the most promising.

 

Wear-and-Tear arthritis is something that most people will experience as they age, but the pain can be mediated with proper treatment from a good rheumatologist. Unfortunately, osteoarthritis is not the only type of arthritis that attacks joints. There are much more insidious arthritic diseases that affect us, wherein a person’s immune system becomes misdirected and attacks its own joints.

 

Such was the case with Mary. At 22, when she should have been enjoying her senior year at college, she found herself waking with hours of debilitating morning stiffness. A trip to the student health center led to a referral to a rheumatologist. At her follow up visit, the doctor told her that she was positive for the CCP antibody, a possible marker for rheumatoid arthritis (RA). Mary immediately protested that she was far too young to have arthritis, only to hear that the peak age for immune-mediated types of arthritic diseases, such as RA, to manifest themselves is between 20 and 50 years old.

 

The rheumatologist told her of the high potential for progressive joint damage and deformities, which would eventually lead to a crippling outcome if left untreated. Although somewhat overwhelmed, Mary started Methotrexate, a drug originally developed as a chemotherapy agent, and now used in tiny doses as one of our most effective drugs for RA. She saw a 50 percent improvement in her symptoms over the next four months. She then added Etanercept (Enbrel), one of the first new-generation biotech drugs, which binds to and inactivates an inflammatory protein called TNF. Mary’s RA fortunately went into remission and remains fine now, to her immense relief. Twenty years ago, Mary would have been crippled by the age of 40. Modern advances, and her decision to use them in the treatment of her disease, undoubtedly changed the course of her life.

 

The combination of the ability to detect small, short-lived chemicals involved in immune reactions and then create other proteins (monoclonal antibodies and their relatives) has been the molecular biology equivalent of putting a man in space. In just the past 15 years, these new technologies have allowed us to control rheumatoid and other devastating types of arthritis in a large number of patients, saving them from great amounts of pain, unnecessary surgeries and even early death.

 

In the last five years, scientists decoded the human genome, and a recent Nobel Prize went to researchers who discovered the way in which genes are turned on and off. Current rheumatology research is turning to the discovery of which genes are turned on in different diseases, and some of the proteins made by these genes are being targeted for drug therapies. Rheumatologists at our practice in Spokane (Arthritis Northwest) are already involved in these exciting, cutting edge trials.

 

In many forms of cancer, genes that determine whether patients might respond (or not) to specific drug therapies have already been identified and are entering clinical use. Work on similar genetic predisposition to respond to arthritis medications is being carried out right now.

 

The “Holy Grail” of treatment of both autoimmune arthritic diseases and cancer rests in the capability to both identify genes inappropriately involved in diseases, and then turn them off, effectively achieving a long-term cure. The complexities of turning genes off are enormous, since many of the genes involved in autoimmune diseases are also important in mounting defenses against infection. We may only want to partially shut down gene function, or perhaps turn off the gene in some cells but not others. Experiments along this line are currently being run in animal models of human autoimmune diseases. 

 

Treatment for the serious forms of autoimmune arthritis went through a long dry spell between the 1970s and late 1990s, but, the last decade has brought dramatic new therapies at the rate of one every two years, and the next decade will likely finally deliver the major breakthroughs we have dreamed of for the last 50 years. There is not yet a cure for RA, but the treatments are becoming better and better. This is an important time for rheumatologists, and an exciting time for arthritis patients to seek treatment and be hopeful.