Arthritis: What treatments work?

Opening jars, hanging out washing, or even getting out of your chair. When you've got arthritis, simple activities like these can be painful or even impossible.

With more than 3 million Australians suffering from the condition, there's no shortage of treatments and strategies promising to help.

But working out which ones are effective can be tricky.

"There's so much anecdotal evidence around that it creates a lot of confusion for patients," says Dr Sam Whittle, a rheumatologist from Adelaide.

"By the time they've seen their GP, spoken to their neighbour and their grandmother and everyone else that has a well-meaning opinion, it's completely confusing for them,"

GPs don't always do the right thing either, with a survey published recently showing an increasing number are willing to prescribe medications known as opioids (made to mimic the action of the natural painkiller opium) for mild arthritis, despite this not being recommended in guidelines issued by the Royal Australian College of GPs (RACGP).

Opiates have a high risk of adverse events and the RACGP says opioids should be reserved for severe osteoarthritis when people need to wait for surgery or are unable to have surgery.

Just under half the GPs surveyed would not recommend exercise either, the survey showed, despite it being as effective as non-steroidal anti-inflammatory (NSAID) medications but having fewer side effects.

So which everyday treatments can help if you have arthritis?

Weight loss

About 98 per cent of people with osteoarthritis of the knee or hip are overweight or obese, says Professor David Hunter a rheumatologist and Florance and Cope Chair at the University of Sydney.

The average BMI seen in his arthritis clinic is around 32 - the middle of the obesity category.

"It's probably the most important risk factor, particularly for knee OA, and accounts for about 50 per cent of the reason why people develop OA in the first place," he says.

"Once they get OA it further compounds the problem by making the pain more severe and accelerates the likelihood of requiring more intervention."

Everybody who has osteoarthritis should focus on exercise and if appropriate weight reduction before they do anything else.

Evidence shows losing weight can be hugely beneficial for people with OA. A recent study found patients who shed pounds had less inflammation and pain, better function, faster walking speed, and a better quality of life.

People with OA who are overweight or obese are usually encouraged to lose 10 per cent of their body weight. Professor Hunter says this can significantly reduce people's pain.

"The effects of losing weight will be close to double what you would get from taking an anti-inflammatory medication, which typically improves symptoms by about 20 to 30 per cent," he says.

"Losing weight also has the additional benefits of reducing the overall risk of death, the need for joint replacement surgery as well as improving function in the long-term," he adds.

Exercise

Along with weight loss, regular exercise can bring enormous benefits if you have arthritis. But choosing the right type of exercise is important.

Professor Hunter encourages his patients to do 30 to 40 minutes of aerobic exercise each day, to help increase metabolism and encourage weight loss.

Some people may need to avoid high impact sports, such as running or tennis, and opt for low impact activities like walking or swimming.

Strengthening exercises are also important, particularly for muscles around the affected joints as the more strength a person gains the more their function is likely to improve, says Hunter.

The evidence of the benefits of weight loss and exercise are so compelling that most guidelines, including those from the Osteoarthritis Research Society International advocate that everybody who has OA should focus on exercise and, if appropriate, weight reduction before they do anything else.

"Unfortunately most people don't do that so they miss out on a huge opportunity to modify their symptoms and modify the course of their disease," says Professor Hunter.

"About 80 per cent of the people who present to us who are on the orthopedic waiting list for a hip or knee replacement have never tried any conservative treatment."

Complementary and alternative medicine

Many people prefer to use complementary and alternative treatments to manage their arthritis, but the evidence for these is conflicting.

Glucosamine is commonly said to help relieve pain and limit cartilage breakdown, but for every study that finds benefit there's another study to contradict it.

"The glucosamine story used to be so straightforward and now it is so confusing. It's reached the point where there's so much evidence around that you can almost suit any argument you like. It's almost reverted back to opinion," says Dr Whittle.

An analysis of all of the evidence found that taking glucosamine in combination with chondroitin did not reduce joint pain or have an impact on narrowing of joint space.

However an Australian study published this year found that taking the combination did reduce joint space narrowing, although it did not have any effect on symptoms.

"When the original studies came out almost 15 years ago they were very exciting because it looked like not only was glucosamine of symptomatic benefit in OA but it possibly also had structural benefit. And there's never been a disease modifying drug in OA so that's the Holy Grail," says Dr Whittle.

"But subsequent studies kept on showing disappointing benefit and if you look across the breadth of all the glucosamine studies, my view is that it's probably not effective," he says.

It's been years since Dr Whittle has advised patients to start taking glucosamine if they haven't already tried it. For patients who are already taking it, he recommends a three-month trial at an adequate dose.

"If they get to three months and they are not better off then they ought to stop, as it is a large financial outlay for no benefit."

According to Professor Hunter, complementary and alternative medicines are an important part of treatment, particularly as around half of all patients are taking them.

"The challenge is that a lot of people who have OA feel a great benefit from taking these treatments and if they are tolerating them well and they are relatively inexpensive I don't actively discourage them from doing it," he says.

"From the viewpoint of those that are beneficial, I think there is reasonably good evidence to suggest thatomega-3 fatty acids like fish and krill oil are helpful in reducing inflammation and pain related to arthritis.

"Outside of that there are good trials suggesting glucosamine, ginger, green lipped mussel, acupuncture, are not any better than a placebo or sham treatment.

"The most important thing is for patients to tell their health professional if they are taking a complementary medicine because some of them do have interactions with other products."

Pain relievers

Many people with arthritis use painkillers, or analgesics, to manage their pain.

There's pretty good evidence that non-steroidal anti-inflammatory drugs (NSAIDs) - including dicofenac, naproxen, ibuprofen - are effective for a large proportion of people, says Dr Whittle, who has been involved in developing international guidelines for managing pain in arthritis.

But long-term use of these painkillers has been shown to increase your risk of high blood pressure, heart failure, heart attack or stroke. The big challenge, according to Dr Whittle, is to balance the risks and benefits in the individual.

"I'm pretty liberal with my use of NSAIDs in young people in the short term because the absolute risks are incredibly low and the benefits are quite high.

"But in older people who have any cardiovascular, gastrointestinal or renal risk who need long term treatment it's very hard to make a decision.

"I'm often advising people against long-term use but I suspect there's probably a fair proportion of people who use them anyway despite my advice.

"They [NSAIDs] can be very effective and when people come off them, they really notice the difference."

Professor Hunter agrees people need to know the risks of long-term NSAID use.

"If patients have had a peptic ulcer, or are a smoker or on steroids or anticoagulants then they need to make sure that they get advice from their doctor or GP."

Even paracetamol, which has long been considered a safe way to manage pain, has recently come under scrutiny because of concerns over how well it actually works and liver and gastrointestinal toxicity.

"Paracetamol is no longer first line for treating OA pain and I don't think that is common knowledge for many people... It's not a completely benign medication," Professor Hunter says.

Reproduced from ABC Health and Wellbeing 22/10/15

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