Many treatments have been used to treat arthritis over the years. Some of these treatments are fairly mild and just relieve the pain. But more recently we have worked hard to turn off disease with quite powerful medications.
A lot of natural therapies are really mild anti-inflammatories, so things like Fish Oil, Turmeric, Rose Hip and Green Mussel extract work like a very mild form of aspirin and will certainly relieve the pain, but don’t turn off the disease process.
In Rheumatoid Arthritis and other auto-immune diseases, white cells become so activated, they can start to cause damage. And in fact, in rheumatoid disease, new tissue grows into the joint which can erode away the ligaments and bone. Natural therapies will relieve this pain, but not stop the process.
Scientists over the years have now discovered many medications that can target the cells and pathways that are involved and not just relieve the pain, but actually turn off the process. Science has pulled apart the auto-immune process and looked for very specific molecules and proteins that drive the process. Scientists now know that there are medications that can stop white cells producing these proteins and there are even quite specific antibodies now that can bind to rogue proteins called cytokines and stop the disease cold.
Hence, in auto-immune disease, rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis, treatments are now very tailored and aim to block the disease process, rather than just treat the pain.
Most Rheumatologists are quite happy for our patients to take natural therapies, particularly things like Fish Oil and Turmeric, knowing that they will relieve some of the symptoms, but we also strongly recommend now using these more targeted medications to turn the disease process off.
In rheumatoid disease in Australia, we are up to about 16 different treatments that can potentially turn the disease off. The hardest part sometimes is trying to match the right therapy to each patient, but with so many choices, there is generally a treatment that will work for every person.
Sadly, some diseases don’t have very specific therapies. Osteoarthritis is one where we are still just treating the pain. Hence, natural therapies can perform a useful role, such as topical gels and natural anti-inflammatories can be quite helpful in relieving the pain. And then we recommend a strong exercise program and weight loss and a whole range of lifestyle changes to try to prevent surgery.
However, for other diseases, particularly the auto-immune disorders like rheumatoid, lupus, ankylosing spondylitis, psoriatic arthritis, reactive arthritises, we now have very effective therapies to turn the process off. At the same time as patients helping themselves with diet, weight loss, exercise and a group of natural therapies.
As we sometimes joke, we don’t distinguish between natural therapies and prescription therapies. There are medicines that work and medicines that don’t work. There are weak medicines and strong medicines and we really don’t distinguish between natural and non-natural therapies.
In fact, some natural therapies can be quite potent and contain quite powerful medications. Most people don’t realise that even aspirin comes from the bark of the willow tree and as you know, aspirin is quite a powerful chemical that can treat heart disease, treat pain but also cause side effects like peptic ulcers, aggravate hypertension and quite severe allergies. So merely calling something “natural”, doesn’t mean it is always safe and we see them as just medications, the same as prescription medications, with their own particular benefits and potential side effects.
It is therefore important that the general practitioner and the Rheumatologist talk through whatever therapy the patient is taking, to make sure they are safe and compatible and effective.
In rheumatology we often talk about trials of therapy and most medications are given at least three months to prove their worth, either for success or failure and certainly are stopped immediately if there are any side-effects. Drugs are started at low doses and built up gradually and we often combine medications as no one medication does it all. And we frequently will combine two or three different medications to turn off the whole complex web of interactions of cells and proteins driving the disease.
The long term goal will be to have gene therapies that switch off the genes that drive the disease in the first place and there is already some gene therapies in research around the world for conditions like haemophilia. The hope is that one day this technology will help us to turn off far more complicated diseases such as the auto-immune diseases.
As well as medication, the changes in lifestyle, exercise and diet become absolutely essential to maintaining good health. Diseases like rheumatoid arthritis have many different issues like making osteoporosis more severe. And so calcium, Vitamin D, sunlight and exercise are just as important at times as the more powerful immune drugs.
We even use vitamins sometimes to offset the potential side effects of some of our powerful drugs. The most commonly used early treatment for rheumatoid is a drug called methotrexate. Methotrexate is used in very low doses in rheumatoid and used in incredibly high doses to treat certain cancers and that often scares patients as they think they are going on a chemo drug. However, the dose in rheumatology is about 1/500th the dose used in chemotherapy and rheumatology has nothing to do with chemotherapy. It simply reduces the production of inflammatory proteins. We find taking extra folic acid makes methotrexate a particularly safe drug so here we marry a vitamin with a powerful medication to make a very safe and effective outcome for patients.
The biggest technology advance in rheumatology has been the development of what we call monoclonal antibodies. And monoclonal antibodies are where scientists have identified key proteins that drive the disease process – make an antibody against that particular protein and that is then injected or taken orally to turn the disease off. These monoclonal antibodies are now used in all forms of diseases from rheumatology patients, gastroenterology patients, multiple sclerosis and even cancer patients. They are powerful medications, quite expensive, but when used appropriately, they can turn diseases off.
We now have patients with rheumatoid who have gone back to playing rugby league and rugby union, who previously would have had joint damage because of the advent of these monoclonal antibodies.
They’re powerful and it’s possible to have quite significant side effects from them, so they have to be used with great caution and discretion, but can have amazing outcomes.
The treatments for diseases are changing rapidly and we all go to conferences regularly to find out which medications are safe, effective, what potential good points and bad points the medications have. Part of the training in rheumatology is to have regular updates throughout our career – attending conferences and meetings to keep up-to-date with the latest trends.