T H E

P E O P L E ' SPHARMACY

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Double bind: n.

1. A psychological impasse created when contradictory demands arem a d e o f a n i n d i v i d u a lso that no matter whichdirective is followed,the response will becons t rued as i nco r rec t .

2 . A s i t u a t i o n i n w h i c ha person must choosebetween equally unsatisfactory alternatives; apunishing and inescapa b l e d i l e m m a .

T h i s d e fi n i t i o n f r o mthe American HeritageDictionary of the EnglishLanguage descr ibesthe quandary arthritispatients face with painr e l i e v e r s .

Put another way, theyare between a rock anda hard place I On the onehand they must copew i t h s o m e t i m e s d e b i l i

tating aches and pains.Ontheother, manyofthedrugs doctors prescribec a n h a v e s e r i o u s s i d ee f f e c t s .

12010 Graedon Enterprises, Inc.

According to the Arthritis Foundation,70 millionAmericans (one in three adults)suffer from arthritis. Most have to takesome kind of pain reliever for their stiff,aching joints. But the history of treatments for arthritis has not provided ac lea r w inne r.

V i o x x w a s t a k e n o f f t h e m a r k e t i n2004 af ter a scandal , but Celebrexremains. Drugs of this general type,including even OTC ibuprofen, havecome under scrutiny for increasing therisk of heart at tacks or strokes.C O R T I C O S T E R O I D S

Problems with arthritis drugs arenothing new. If you turned back theclock to the 1950s, you would hearabout a wonder drug called cortisone.It was used widely to relieve joint pain,especially for people suffering fromrheumato id a r th r i t i s . Pa t ien ts loved"corticosteroids" because such drugsreduced inflammation and made it possible to function. People who couldn'tget out of bed without pain were ableto reclaim their l ives.

Many doctors loved cortisone-typedrugs too. When they prescribed prednisone in the 1950s and 1960s theyfelt like heroes because patients wereso grateful. Corticosteroids worked likemagic to relieve a host of hard-to-treatconditions, from arthritis and allergiesto asthma and atopic dermatitis. That'sbecause they have profound effects ona broad range of immunological andinflammatory actions in the body. Thereare few other drugs that can dampeninflammation and immune response soeffectively.

Early on, many physicians prescribedhigh doses of corticosteroids like cortisone, dexamethasone, prednisolone

or prednisone for prolonged periods oftime. It took quite a while before theyrealized they were playing with fire.

Side effects of long-term, high-dosecorticosteroid use include weight gain,cataracts, glaucoma, increased susceptibility to infections, elevated bloodpressure, fluid retention, potassiumloss, stomach ulcers, blood clots, irregular heart rhythms, osteoporosis,headache, thin skin, impaired woundhealing, menstrual disturbances, moonface, diabetes, muscle weakness andloss, bone deterioration, spontaneousfractures, insomnia, irritability, fatigue,and "steroid psychosis."N S A I D S

Once physicians and patients realized how dangerous corticosteroidscould be, they became more cautious.Although aspirin is a type of nonsteroidal anti-inflammatory drug (NSAID), itwasn't until prescription medicines likeindomethacin (Indocin) were developed (1965) that NSAIDs were seenas a potentially safer alternative forarthritis patients. Doctors hailed eachnew NSAID as it became available,then lost enthusiasm when the next onecame along. Drugs like Clinoril (su-lindac), Feldene (piroxicam), Motrin(ibuprofen), Naprosyn (naproxen)or Voltaren (diclofenac) were hugelypopular in their day. Such drugs arestill widely prescribed for chronic pain.And millions of people take the over-the-counter NSAIDs ibuprofen (Advil,Motrin IB, etc) and naproxen (Aleve).

Nonsteroidal ant i - inflammatorydrugs work by blocking the synthesis of chemical messengers calledprostaglandins. These hormone-likecompounds are responsible for the

NSAID Benefits?Despite the fact thatN S A I D s h a v e b e e na r o u n d f o r d e c a d e sand have been pres c r i b e d t o t e n s o fmillions of people torelieve arthritis pain,t h e r e i s n o t m u c hevidence that theyreally help for thelong term. A review(meta-analysis) of2 3 s t u d i e s i n v o l v

ing over 10,000 pat i e n t s c o n c l u d e d :"NSAIDs can reduceshort-term pain inosteoarthritis of theknee slightly betterthan placebo, but thecurrent analysis doesnot support longt e r m u s e o f N S A I D sf o r t h i s c o n d i t i o n .A s s e r i o u s a d v e r s eeffects are associatedwith oral NSAIDs,only limited use canb e r e c o m m e n d e d . "

(British Med. J. Nov.23, 2004)

redness, warmth, swelling and pain associated with inflammation. But they arealso important for other functions in thebody. For example, one prostaglandincalled prostacyclin keeps the sticky partof blood called platelets from clumpingtogether to form clots. It also dilates bloodvessels. Prostaglandins also protect thestomach lining from damage.

NSAIDS like ibuprofen and aspirin arenot very selective. They block two enzymes, COX-1 and COX-2, that produceprostaglandins. That helps explain whythese drugs can be helpful, but it also explains the downsides of NSAIDs. Irritationof the digestive tract is common. As manyas half of the patients taking such drugsregularly experience heartburn, nausea,abdominal pain or ulceration. Many peopleend up with sores in their digestive tractswithout any obvious warning symptoms.These lesions can become bleeding orperforated ulcers, which can be life threatening. Experts estimate that more than100,000 people are hospitalized each yearbecause of such complications, and morethan 16,000 die (A/. Engl. J. Med. 1999;340:1888-1899). In addition, many of thesemedicines can raise blood pressure, alterheart rhythm, cause fluid retention, dizziness, tinnitus, visual problems, headache,depression, trigger skin reactions, or puta strain on the kidneys. NSAIDS can alsointeract with many other medicines.C O X - 2 I N H I B I T O R S

Doctors were exc i ted when researchers

developed compounds to block COX-2more selectively. By allowing COX-1 toproduce protective prostaglandins, theyanticipated that patients would get painr e l i e f w i t h o u t G l u l c e r a t i o n f r o m m e d icines like Bextra, Celebrex or Vioxx. Thecommercials for this new class of painr e l i e v e r s m a d e t h e m s e e m l i k e w o n d e r

drugs. People with arthritis were dancing,ice skating, and doing martial arts. Theevidence that Celebrex actually protectedthe digestive tract from serious damagewas not strong enough for the FDA toallow the manufacturer to promote it assubstantially safer than other NSAIDs.

Vioxx may have been somewhat easieron the stomach, but it increased the riskof heart attacks and strokes enough tooutweigh its benefits.The problem is thatblocking COX-2 prevents the productionof prostacyclin, and prostacyclin preventsunwanted blood clots. In 2000, a largestudy of Vioxx showed an increased riskof hear t a t tacks and other card iovascu lar

problems. Later, when Vioxx was takenoff the market and warnings were issuedon Bextra and Celebrex, the popularity ofthese COX-2 inhibitors was compared toa "house of cards" based on wishful think

ing {JAMA 2005; 293:366-368).Soon after Vioxx was taken off the mar

ket, a safety expert for the FDA, Dr. DavidGraham, estimated that up to 139, 000Americans might have suffered a heartattack or stroke as a side effect of Vioxx.

Although a similar drug, Bextra, has alsobeen removed from the market, Celebrexis still available and remains quite popular.A S P I R I N

One of the earliest arthritis drugs, aspirin, might still be one of the best choices.Unlike the newer, pricey prescriptiondrugs, it costs just pennies a pill. No otherarthritis drug has been shown to relievearthritis pain more effectively than aspirin.

Aspirin has another benefit in addition topain relief. Unlike Vioxx and other COX-2inhibitors, aspirin actually lowers the risk ofheart attacks and thrombotic strokes. One

large, long-term study the Physicians'Health Study, demonstrated that aspirinreduced the risk of a heart attack by 44%in apparently healthy middle-aged men.(There were 22,000 of them in this trial.)Those who were at high risk for heart attack actually got even more benefit.

Men are not the only ones to benefit.T h e Wo m e n ' s H e a l t h I n i t i a t i v e O b s e r v ational Study found that women who tookaspirin lowered their risk of dying fromtheir heart disease by about 25 % {Circulation. Cardiovascular Quality & Outcomes,March, 2009). As a bonus, aspirin hasb e e n a s s o c i a t e d w i t h a r e d u c e d r i s k o f

many types of cancer.Rheumatoid arthritis (RA) can be

Despite the good news about Diclofenac lotion was shown toaspirin, it is not without risk. Many be more effective than placebopeople develop ulcers, includ- in a randomized trial {Archives ofing life-threatening bleeding ul- /nterA7a/Med/c/ne, Oct. 11, 2004).cers. This results in an estimated In a 12-week head-to-head trial,100,000 hospitalizations and far Pennsaid was just as good as oraltoo many deaths each year. Older diclofenac, but less likely to causepeoples may be especially vulner- side effects like nausea, stomachable to this complication. ache, indigestion or liver problems

Some people are allergic to as- {Journal of Rheumatology, Oct.pirin or take drugs that are incom- 2004). Pennsaid is interesting be-patible with it. No one should take cause it uses DMSO to penetrateaspirin regularly without medical the skin and carry the NSAID intosupervision. There are, however, the joint.some relatively old drugs that The FDA eventually approvedcan provide pain relief like aspirin topical diclofenac. It is avail-does, without the digestive dan- able as Voltaren Gel as well asg e r s . ( S e e b o x . ) P e n n s a i d . V o l t a r e n G e l c o n t a i n sT O P I C A L N S A I D S d i c l o f e n a c a s i t s a c t i v e i n g r e d i e n t

For many years, people in Eu- although it does not have DMSO.rope and Latin America have been Studies show these prescriptionusing NSAID medications in gels gels ease arthritis pain in handsor creams applied directly to the {Journal of Rheumatology, Sept.painful joints. Americans had no 2009) as well as knees and otheraccess to such medications, oth- joints {Expert Opinion on Phar-er than certain aspirin-like drugs macotherapy, Nov. 2008). Side(salicylates) found in products effects are uncommon except forlike BenGay. When diclofenac gel skin reactions, but it may be bestbecame available in Canada, we for relatively short-term relief-urged people seeking relief to get comparable to an oral NSAID. Aska prescription for Pennsaid. your doctor about pros and cons

A L T E R N A T I V E ST O A S P I R I N

Q. What can you tell me aboutthe pain reliever salsalate? Mydoctor says that it will not onlyhelp ease my arthritis pain butmight help control my bloodsugar. Diet has not controlledmy borderline diabetes.A. Salsalate has been used formore than century to relievearthritis pain. It is related tosalicylic acid, which is similarto aspirin (acetylsalicyhc acid).Like aspirin, salsalate is effective against inflammation andpain, but it does not irritate thedigestive tract as aspirin does.Preliminary research suggeststhat salsalate may help controlblood sugar levels in peoplewith type 2 diabetes {Diabetes Care, Feb. 2008). Two otherstudies are now underway todetermine how well this drugworks fo r d iabe tes .

D R U G S O T H E R T H A N A S P I R I N

There are two little known aspirin-like drugs thathave been around for years. Both are less likely toin-itate the stomach than aspirin. Salsalate (salicylicacid) is only absorbed from the small intestine whichaccounts for less tummy trouble, but it is about asgood as aspirin when it comes to relieving joint painor morning stiffness. It may be more likely to causehearing problems or dizziness, though. Salsalate isavailable only by prescription as Amigesic, Artha-G,Disalcid, Mono-Gesic and Salflex. It is unlikely toprevent blood clots the way aspirin does.Choline magnesium trisalicylate (Trilasate, Tri-

cosal, Trisalicylate) may also be a little less likeyto upset the stomach than aspirin. Like salsalate,this pain reliever won't protect against heart attacksor strokes the way aspirin does. It also requires aprescription.

Acetaminophen (Tylenol) is the other non-aspirinanalgesic people rely on to relieve pain. Traditionallyit has not been thought of as an arthritis drug becauseit does not have the anti-inflammatory properties ofaspirin or other NSAI Ds. Nevertheless, many peopleturn to acetaminophen to relieve osteoarthritis ofthe knee, hip or fingers. Some physicians evenrecommend acetaminophen as a first-line treatmentbecause it does not cause digestive tract upset theway NSAIDs can. A review of arthritis research,however, suggests that NSAIDs are better thanacetaminophen at improving symptoms {ArthritisRheum. Oct. 15, 2004). Despite the fact that mostpeople believe acetaminophen is totally safe, onestudy suggested that regular use of this drug forlong periods of time may increase the risk of kidneydamage {Arch. Intern. Med. July 26, 2004).

H O M E R E M E D I E S

"I am a 62-year-oldprofessional piano player. The last few years I'vebeen getting pain in mythumb and some fingerk n u c k l e s . I a t t r i b u t e d i tmore to mousing at thecomputer than to arthritis catching up with me.I took aspirin and Alevew i t h n o r e s u l t s . T h e n Istarted drinking eightounces of tart cherryjuice a day and the painwas gone within 10days. I had some pain inmy right knee and it hasgone away as well."

" G i n - s o a k e d r a i s i n shave worked for me formore than two years.When I forget to eat myraisins for a few days or(especially) a week ormore, my arthritis getsso much worse I can' tbelieve how much betterI feel when taking them.S i n c e I d o n o t t o l e r a t em e d i c a t i o n f o r i n fl a mmation at all, the raisinsare my only relief. I amso grateful."

Although NSAIDs are the most common treatments for arthritis pain, youh a v e l e a r n e d t h a t t h e s e m e d i c a t i o n sh a v e s e r i o u s r i s k s . A m e r i c a n s w e r eshocked to learn that the pills theyrelied on to relieve aches and painscould cause potentially life-threateningperforated ulcers or heart attacks ands t r o k e s .

Yo u h a v e a l s o r e a d t h a t N S A I D s a r enot all that effective. When investigatorsreviewed 23 studies involving more than10,000 patients they concluded that;"The advantage of oral NSAIDs overplacebo for short term pain relief is smalland probably clinically insignificant.Evidence of long term effects from oralNSAIDs is still lacking." {British Medical Journal, Nov. 23, 2004. They go onto say that, "This may in turn explainnon-compliance with prescribed drugtherapy in 29% of patients and the useof non-conventional drug therapy byone in four patients with osteoarthritis."

That makes sense to us, and it is whywe pay attention when our readers reportbenefit from home remedies. As long asit is inexpensive and not harmful, whynot give it a try? It just might help. Keepin mind that there are no scientific studies for many remedies, just anecdotes.

"I'm a nurse in a rural hospital. Someof the mountain folk I care for tell methat a bee sting every two years or sowill significantly decrease arthritisinflamation and pain. They attributethis remedy to the Chinese who cameto this area to work on the railroads andlogging industry."

Apitherapy, the deliberate use ofbee stings for medicinal purposes, ispopular in the traditional folk medicineof Europe as well as China. Researchin rats suggests that there may be ascientific basis forthese reports {In Vivo,July-Aug. 2005). We haven't seen anyclinical studies published in the medicalliterature yet. People with bee-sting allergies MUST avoid this remedy!

C h e r r i e sCherries have a reputation for fight

ing inflammation, and studies supporti t . C e r t a i n m a r k e r s o f i n fl a m m a t i o n

dropped significantly after volunteersconsumed 10 ounces of Bing cherriesdaily for a month {Journal of Nutrition,April, 2006). Tart cherries are alsopopular with readers like this one:

"I have suffered from arthritis inmy right hip for almost ten years.Last fall, the arthritis in my hip gotso bad that I could hardly walk. Overthe years, I have tried a lot of supplements for joint health and I have hadtwo very expensive injections into myhip. They only gave me relief for afew days. Nothing was helping me.

"I was unable to exercise and was

having a very difficult time doing myjob. My x-rays looked horrible. Thesurgeon who will do my hip replacement next year wondered how I waseven walking.

I don't remember exactly when Iheard about cherries and cherry juice,but I started eating a lot of Bing cherries last spring. I also started drinkingtart cherry juice concentrate mixed incold water. IT WORKS GREAT! I canclimb stairs, exercise, mow the grass,work without a lot of pain, and doa lot of other things that I have notbeen able to do for a few years. Iam still getting the hip surgery nextsummer, but until then, tart cherryjuice is the best."

Joint pain due to gout may also bereduced with regular cherry intake.One study found that women hadlower uric acid levels after eating10 ounces of Bing chen-ies {Journalof Nutrition, June, 2003). Tart cherries have also been shown to speedmuscle recovery after exertion suchas a marathon {Scandinavian Journalof Medicine & Science in Sports, Oct.21, 2009; British Journal of SportsMedicine, Aug. 2006).

"Empty one box ofgolden light raisins intoa large shallow container. Pour enough ginto completely cover theraisins. Let stand, uncovered, for about sevendays until all of the liquid evaporates. Stirringoccasionally will helpthe evaporation process.After the gin has evaporated, place the raisinsin a closed container ...Eat nine raisins a day.If you don't like raisins,put them on your cerealor in a salad."

A t t r i b u t e d t o " T h e A c t s o fSaint Lucas," the newslett e r o f S t . Lucas Lu the ran

Church, Toledo, OH.

"I suffered arthritis painin my lower back andhip joints for more than15 years. Prescriptionsfrom my doctor didnothing for me. ThenI tried golden raisinsand gin and am livingpain free again afterso many years. What agodsend!"

G i n - S o a k e d R a i s i n sGin-soaked raisins are a perenially

popular home remedy for arthritis, butthe re a re no c l i n i ca l t r i a l s o f t he i r e ffectiveness. Nonetheless, grapes havesome compounds that are related tothose in cherries (proanthocyanidins),and these compounds have anti-inflammatory potential {Acta PharmacologicaSinica, Dec. 2001).

Many readers have found that gin-soaked raisins offer relief, even whenother approaches have fallen short:

"As an active senior I was more thandismayed with increasing arthritis to thepoint of pain when I attempted simpleactivities. Aspirin and exercise helped abit. I tried deleting the 'reds' (meat, tomatoes, eggplant) from my diet, taking'guaranteed' OTC arthritis remedies (Igot my money backbecause they didn'twork) and capsules with Boswellin/Turmeric/Bromelain mix.

"Then I tried the gin-soaked raisinsand I am pain-free and flexible oncemore. I am so very grateful to you foryour advice! My horses thank you, mygrandkids thank you and my gardenalso thanks you."

Some people speculate that the ginis responsible for the effects of gin-d r e n c h e d r a i s i n s . G i n i s fl a v o r e d w i t h

juniper berries, which was used historically for treating stomach problems, asan inhalant for bronchitis, and even forarthritis. But hard as we tried, we couldfind no research confirming that juniperis helpful for arthritis. The medical literature is silent on gin-soaked raisins. Onthe other hand, the formu la doesn't seemlikely to do much damage, especiallyonce the gin has evaporated.

People often snicker about this recipeand suggest that it would be just as effective to skip the raisins and go straight tothe gin. Although people with an alcoholproblem should choose another remedy,once the gin has evaporated there is justone drop of alcohol in all nine raisins.

F r e q u e n t l y A s l c e d Q u e s t i o n s :How long does it take for the ginto evaporate?It depends a bit on the humidity in theair. It may take just a day or two, or itcan take up to 10 days. The raisinswill not be dry, but there will be no ginpuddled in the dish.Once the raisins are ready, shouldthey be refrigerated?They should be kept in a tightlycovered container. Refrigeration willextend the shelf l i fe.H o w m u c h a l c o h o l i s i n t h e r a i s i n s ?There is approximately one drop inthe daily dose of nine raisins.Does it matter what type of gin?You don't need to buy the most expensive gin, since you will let it evaporate.Don't buy the cheapest one, either.Ask the clerk to help you find a ginthat is flavored with real juniper berries rather than artificial flavorings.Some people report using sloe gin.Sloe gin is flavored with blackthornberries ratherthan juniper. Blackthornberries were traditionally used fordigestive problems but might havesome anti-inflammatory properties.Can you use dark raisins?Some people do. Most people preferthe golden raisins. Others report usingdried apricots. One variant, soakingdark raisins in sloe gin, results in avery dark purplish concoction. But ifit helps ease aches, color should notbe a problem.Are there any side effects?People who are sensitive to sulfitesmust avoid golden raisins, since theyare treated with sulfites. Sticking tonine raisins daily should reduce anydigestive tract issues such as gas.Will I flunk a Breathalyzer testaftereating the raisins?Don't keep the raisins in your vehicle.Take them at least half an hour before

you might be tested. A Breathalyzermight be able to pick up traces ofalcohol within a few minutes of eatingthe ra is ins .

Grape Juice andO t h e r R e m e d i e s

Q. My wife and I triedyour golden raisins andgin for arthritis and wewere unimpressed. Weh a v e d i s c o v e r e d s o m e

thing else, though. Taketwo teaspoons of Certodissolved in three ouncesof grape juice. Do thisthree times a day.We have been told to cutback to one teaspoonCerto in grape juice twicea day after the joints quitaching.We buy Certo in thegrocery store near thecanning jars. Ifs simpleand cheap and seemsto be helping. I am onCoumadin so I can ' t take

anti-inflammatory drugsl i k e A d v i l o r A l e v e .A. Certo contains pectin, anatural ingredient foundin the cell walls of plants.It is used as a thickeningagent in jams and jellies.T h i s i s t h e fi r s t w e ' v eheard of using pectin forarthritis pain. It seemssafe, however, thoughthere is no sc ient ific ev idence to suggest it is eff e c t i v e .

Perhaps the grapes are just as important as the gin in gin-soaked raisins.Remedies utilizing grape juice as oneingredient are numerous and popular.We have heard from a great manypeople that Certo, a liquid pectin productused in home canning to make jams andjellies thicken, can be mixed into grapejuice for an arthritis remedy that somefind very helpful:

"My high blood pressure prevents mefrom taking anti-inflammatory drugs forarthritis. I am in constant pain from thiscondition, complete with degenerativediscs in my spine."Certo and purple grape juice made

from purple grapes help tremendously.I take only one glass a day. I can reallytell if I skip two days, however."

Other readers have suggested simpleapproaches to mixing the Certo withConcord grape juice. Some prefer atablespoon of Certo in 8 ounces of grapejuice daily. Others buy a 64-ounce bottleof grape juice and add the entire packetof Certo. (To avoid overflow, a smallamount of grape juice must be removedfirst.) This makes it easy to pour out 6or 8 ounces of the mixture daily.

Other readers prefer a mixture thatmay include grape juice, apple juiceand apple cider vinegar, with or withoutadditions like honey. Apple cidervinegarand honey have long been popular asa home remedy. Dr. D. C. Jarvis wroteabout vinegar in his 1958 book, FolkMedicine: A Vermont Country Doctor'sGuide to Good Health. He learned aboutit from the farm families he cared for. Dr.Jarvis claimed that a teaspoon of applecider vinegar in water with honey wasan excellent remedy.

"I gave the Certo and grape juice infoto my sister in England, as she was suffering from hip problems. It has helpedher enormously, and she takes it faithfully every morning. She has also passedthe info to several other friends and

neighbors, as has also her brother-in-law. One man had to stop takingit, as he was apparently allergic, butothers have come back to my sisterto say how grateful they have beenfor the help and what a difference ithas made to them. "

The following recipe is said to havebeen used by Sam Houston: "Make apotion of five parts grape juice, threeparts apple juice, and one part cidervinegar. A daily dose of this potion,half a cup will do, helps relieve theaches and pains of arthritis." Themos t recen t va r ia t i on on th i s theme

supposedly comes from a formerowner of the Dallas Cowboys: "Iput one teaspoon of a half-and-halfmixture of apple cider vinegar andhoney into a 6-ounce glass of waterwith a teaspoon of orange gelatinpowder stirred in."

The re i s no sc i en t i fi c ev i dence f o rthe activity of any of these homeremedies against arthritic joint pain.But there is now some suggestion ofa scientific reason to include Concord

grape juice in any such mixture. Dr.Jane Freedman, associate professorof medicine and pharmacology atBoston University School of Medicine,has found that Concord grape juicer e d u c e s m a r k e r s o f i n fl a m m a t i o n i nthe blood, and also raises good HDLcholesterol modestly but consistently{Arteriosclerosis, Thrombosis, andVascular Biology, Nov. 2004). Sheand her colleagues compared thegrape juice to a placebo purplebeverage, which had no effect oni n fl a m m a t i o n .

"My high blood pressure preventsme from taking anti-inflammatorydrugs for arthritis. I am in constantpain from this condition, completewith degenerative discs in my spine.Certo and purple grape juice helptremendously."

Does diet affect arthritis? Dr. Joanne Jordan,Associate Director of theUniversity of North Carol i n a T h u r s t o n A r t h r i t i sResearch Center says itcan: "It actually doesn'ttake that much weightloss to make a difference.You can lose as little as10 to 12 pounds and cutyour risk of developingsymptomatic knee osteoarthr i t is in hal f . "

Researchers at Tuf tsUniversity have reportedthat small changes indiet may help arthritispain. Omega-3 fatty acids found primarily infish, but also in flax seed,pecans, walnuts, tofu andgreen leafy vegetables,can fight inflammation.But o ther common o i lssuch as corn, sunflowerand safflower oil are fullof omega-6 fatty acids andmay actually promoteinflammation and jointpain.

Dr. Michael Holick suggests 1000 to 2000 lU ofvitamin D daily. According to Dr. Jordan's research, adequate vitaminD helps to protect againsta r t h r i t i s .

Other fruits that may act to dampeninflammation. Pineapple contains ananti-inflammatory enzyme called bromelain, and we have heard from a numberof readers who swear by it:

"Several years ago friends told me thatdrinking a glass of pineapple juice everyday helped them. I have found it to bemore effective than the aspirin, prescription pain killers and acupuncture I hadtried previously. If s inexpensive, nutritious and has no side effects."H e r b sIn many parts of the world, people use

herbs to alleviate pain. Some of thesemay also fight inflammation. The mostpopular of these flavorings come fromIndia: ginger, turmeric and Boswellia.Ginger and turmeric show up on thespice shelves of American kitchens,but Boswellia, a resin from a tropicaltree, is not commonly used in cooking.Boswellia serrata is the Latin name forIndian frankincense, used in traditionalIndian medicine for stiff, sore joints.Animal research confirms that the resincan alleviate stiffness and reduce inflammation. There are few good studiesin humans, though, and some peopledevelop allergies.Ginger is mostly thought of as a diges

tive aid, but it can help block the manufacture of some prostaglandins. It hashad promising results in experimentalarthritis in animals {Journal of NaturalProducts, Feb. 13, 2009). It appearsthat it might be helpful against joint inflammation. Allergies to ginger are rare.Turmeric (the spice that gives curry

powder its yellow color) is another flavoring much favored in South Asia. Turmericcontains curcumin, which has shownstrong anti-inflammatory activity in thelaboratory. One reader is enthusiastic:

"I take two capsules of turmeric perday and I have good movement in myfingers now. The pain I was previouslyexperiencing is all but gone."

Anotherherbforrheumatism is stinging nettle, Urtica dioica. An extract ortea made of leaves and stems canbe taken for joint pain. Some peoplewith access to fresh leaves stingthemselves on the sore joints. Otherless hardy souls may prefer a linimentwith a spirit extract of the leaves.

Speaking of liniments, creams andrubs containing capsaicin have beenpopular for years. Capsaicin giveshot peppers their zing. By depletingnerves of substance P, it makes sorejoints hurt less. OTC rubs with eithercapsaicin oroil ofwintergreen (methylsalicylate) have a long history in thequest for arthritis relief. They cancause buming, stinging and redness.S s a cWhen we first heard the suggestion

that soap under the bottom sheetmight ward off nighttime leg cramps,we were skeptical but interested. (Wethen tried it ourselves and found ithelpful.) But we were rathersurprisedwhen we began hearing from readersthat soap could also ease arthritispain:

"I have arthritis in my hands, sowhen I go to bed I hold a bar of soapand the pain goes away immediately."

"I recently read your article concerning soap for relief of arthritis painand decided to give it a try. I have abar of soap under the fitted sheet ofour bed and have been astounded athow well it works."Small pieces of soap in my socks

work for me. My husband thought F dlost my mind, but I encouraged himto try the soap in a pocket or sock. Itworks for him too. F ve been pain-freefor the first time in several years. Aftertrying many arthritis medicationsand finding none that my stomachcould tolerate, I thought I would justhave to live with the pain. I, too, amcurious how the soap works but amsimply satisfied thatit works for me."

R H E U M A T O I DA R T H R I T I S

M e t h o t r e x a t e

Methotrexate is quiteoften used as a first-l i ne t rea tmen t f o r RA .

It is potentially veryhelpful, but it has anumber of significantcomplications, including liver toxicity, bonemarrow suppression,lung disease, digestiveproblems, lymphomaa n d i n f e c t i o n s .

As w i t h o the r med i ca

tions, discuss benefitsand risks, doses andd u r a t i o n o f t r e a t m e n t

w i th the doc to r be fo re

beginning treatment.

Rheumato id ar thr i t is can be devas

tating. This auto-immune diseasecan strike people of any age and caneventua I ly leave thei r j oi nts deformedand painful. Doctors sometimes mayend up feeling nearly as frustratedand powerless as their patients,because pretty much all the treatment options they can offer havesignificant drawbacks.

On the first page, we discussedcorticosteroids. They were amongthe first drugs, otherthan aspirin, thatshowed clear benefits for rheumatoidarthritis patients. But in many cases,the risks outweigh the benefits.

NSAI Ds too were used for rheumatoid arthritis as well as for osteoarthritis. But they are equally problematicwhen used at high doses for longperiods. One classic study concludedthat more than 16,000 people diedeach year of digestive tract bleedingas a result of taking NSAIDs (NewEngland Journal of Medicine, June17, 1999). The COX-2 inhibitorsthat were developed in the hopesof minimizing Gl side effects weresomewhat successful, butincreasedthe risk of heart attacks and strokes.

In the late 1990s, "biologic medica t i ons " ca l l ed TNF b locke rs we reintroduced. (TNF stands for tumornecrosis factor, a natural compoundproduced in the body.) Drugs such asadalimumab(Humira), certolizumab(Cimzia), etanercept (Enbrel), go-limumab (Simponi) and infliximab(Remicade) were heralded asmiracles against rheumatoid arthritis.

By affecting the immune system,such drugs were supposed to eliminate inflammation in the joints, slowor reverse the disease process andprevent joint deformities. They wereexpected to change the treatment ofrheumatoid arthritis radically.

Unfortunately, the TNF blockersa l s o h a v e t h e i r s h a r e o f s e r i o u sside effects. The FDA warns thatthese drugs can increase the riskof certain cancers (lymphoma andleukemia). Because these drugssuppress the immune system,both bacterial and fungal infectionsmay become life threatening. Inaddition, people who never hadpsoriasis may develop this skinproblem when they stop the medicine. Liver damage is another rarebut very serious reaction.

In January 2010 FDA approvedanother med ic ine fo r rheumato idarthritis. Like so many of its predecessors, it is being heralded asa potential "blockbuster" againstth is ser ious d isease.

Pat ien ts shou ld be aware tha tActemra (tocilizumab) may alsohave a dark side. In Japan, whereit has already been on the marketfor years, this immune systemmodulator has been l inked to ser ious in fec t ions and dea ths . The

drug can cause life-threateningallergic reactions (anaphylaxis),gastrointest inal perforat ions,headache, hypertension, elevatedliver enzymes or cholesterol. Likeother immune-suppressing drugs,there is also concern that Actemramay increase the risk of cancer.

What does this mean for peoplew i t h r h e u m a t o i d a r t h r i t i s ? I t ' s

important to discuss the benefitsa n d r i s k s o f t r e a t m e n t w i t h t h edoctor before starting treatment.There are also many approachesthat are equally important in helping people cope with RA: gettingregular exercise, adequate restand good nutrition, not overdoing,using helpful tools, and maintaining social contact are all critical.