A colleague recently made this declaration among a group of rheumatologists. There was a long group pause that made me consider this observation. This is an important issue, because it is sad if true and we may be leaving our patients with the wrong impression. It’s also important as new laws have liberalized the patients’ rights to his/her lab tests and records.
Thus, why do patients believe their labs more so than their doctors? And what do physicians do with this open sharing of lab values? To understand this we should look at both the patient and physician perspective on this issue.
The Patient Perspective
Trust a doctor or trust a lab number? Doctors are human, occasionally fallible or poorly groomed. Not surprisingly, it takes a while for patients to learn to trust a physician. Urgency and severity don’t engender trust either. My new patient with the melon-sized, swollen, hot knee may trust the prescription given but will trust less when I’m wielding a large needle and 20 cc syringe. Physicians’ lingo also undermines trust. I think patients are perplexed when we deliver the shortest possible message using the longest possible polysyllabic terminology. Medical speak is the third leading cause of patient bewilderment and malpractice suits. Patients are keenly aware that if a doctor cannot speak plainly, there must be something wrong with the doctor, rather than the patient.
Laboratory tests on the other hand, are numbers – and numbers don’t lie (the latter is likely to be attributed to an accountant or administrator, not Osler). Numbers are countable, incremental and delivered by and/or on computer printouts. Hence, those values that appear in red and are “out of range” are meaningful to the owner or those red values. Even though I try to convince my patients that the red, seemingly elevated BUN/Creatinine ratio is not important, my patients are not easily convinced. I use the analogy that driving at 37 MPH (in a 35 MPH zone) may be considered speeding; no one gets a policeman’s ticket for such a number. Or that the number has to be interpreted in context. So if I’m driving 37 MPH in a school zone full of flashing buses and crossing guards, a penal code prize will be duly served.
Everyone values free stuff. You don’t always get your money’s worth in healthcare and when you don’t, it costs more. These are the built in pitfalls of healthcare and physicians that every patient must cope with. Cognitive dissonance may explain why humans value that which is free, but still I’m amazed when patients are compelled to react (without calling me) to a TV news report or a pharmacy six-page printout or a lab report. These info bits, presumably from authoritative sources, are valued and believable as they are free, personalized and clear in their message. This contrasts with physician messages that are expensive, occasionally uninterpretable and delivered at the end of a rushed medical visit.
Doctors specialize in messaging that isn’t so clear. We commonly use statements like, “you’re much better or “this is a setback”. Patients wonder whether “better” is relative to my last visit or other patients on the better to worse scale. This contrasts with lab tests are quantitative and digital. Patients believe that a lab test is a numeric systematic representation their biology and a pivotal arbiter of wellness. This they can understand – or at least look up on Google. My labs say I’m either normal like everyone else or a red number, falling out of range. “Doc my lab must mean I’m at least as abnormal as the test says I am”.
Doctors are to blame. Patients think labs are important because doctors tell them so. “Let’s wait and see what the labs show” (meaning I can’t make a diagnosis without them). “Your labs are just fine” (implying the patient must be also). “Mr. Sample there’s a problem with your labs” (uh-oh, sell the farm Mr. Sample!). Then Dr. Jekyll becomes Dr. Hyde when the patient wishes to discuss lab abnormalities only to observe the doctor dismiss the labs as either hanging chads in a meaningless election or a result that should never have been reported (because it takes too long to explain why the result in physiologically unimportant even though it may be psychologically damaging). I’m not surprised when my patients struggle and say it’s sometimes hard to tell who I should believe, the lab test or the doctor.
The Physician Perspective
Laboratory testing is usually an integral part of comprehensive healthcare delivery. Testing can be used to assess a patients metabolic status, organ function, immunologic abnormalities, disease risk, drug safety or toxicity, and occasionally a diagnosis.
Labs are important. But a lab is meaningless without a symptom narrative, list of diagnoses or drugs, or a detailed patient examination. Clinicians need labs to answer specific questions and use them as adjunctive “info bits” to enhance their understanding of the disease, management of the patient and safety of therapies given.
Patients want and should have their lab results. But it is the physician’s responsibility to educate their patients about labs, why they are being done, what is being examined and looked for. Here are a few principles of lab testing that clinicians need clearly communicate to their patients and payers of labs:
A lab test does not equal a diagnosis. Hence, while we would like to see a positive rheumatoid factor in someone with suspected of rheumatoid arthritis, this test is not required to establish the diagnosis.
More labs means more chances for an abnormal finding. The more lab tests that are ordered, the more likely one or more will fall out of normal range. Normal values of a particular lab reflect the bell curve limits established in a large number of “normal” people. Values that fall “out of range” beg the question, “when is abnormal really abnormal?” Explaining the difference between a random spurious finding and a pathologic result can be difficult, but requires trust and communication between patient and physician.
Monitoring and serial labs. Labs are important when monitoring disease status (e.g., sed rate or creatinine) or drug toxicity. This is why repeated or serial labs may be necessary.
Once is enough! Many autoimmune laboratory tests need only be done once or confirmed by a second by different lab. Hence there is no value in repeating and following the following tests: ANA, RF, CCP, ENA or ANCA as these have not been shown to change as the disease does. There are other tests often used as a “disease activity” measure – these can be quite valuable in certain clinical situations.
Result communication. Physicians and patients need to have an agreed upon plan addressing how the patient will learn about his/her lab results.
Patient folders. Patients need to keep copies of their labs in a folder, bring these to all medical visits and share the results with all caregivers.
Patients should understand their labs and believe that they are being used to effectively diagnose and treat their medical predicament. They should be given copies and encouraged to maintain a file of their wellness and labs to share with other doctors. Patients who are overly fixated on a specific lab result are that way because we made them that way! It’s the physicians’ responsibility to educate the patient on which labs are needed or important and when concern over a lab results is appropriate.
Vitamin D supplementation for individuals with knee osteoarthritis and low 25-hydroxyvitamin D levels did not reduce knee pain or slow cartilage loss, according to a study appearing in the March 8 issue of JAMA.
Symptomatic knee osteoarthritis occurs among 10 percent of men and 13 percent of women age 60 years or older. Currently, there are no disease-modifying therapies for osteoarthritis. Vitamin D can reduce bone turnover and cartilage degradation, thus potentially preventing the development and progression of knee osteoarthritis. Observational studies suggest vitamin D supplementation is associated with benefits for knee osteoarthritis, but current evidence from clinical trials is contradictory.
Changhai Ding, MD, PhD, of the University of Tasmania, Hobart, Tasmania, Australia, and colleagues randomly assigned 413 patients with symptomatic knee osteoarthritis and low 25-hydroxyvitamin D to receive monthly treatment with oral vitamin D3 (50,000 IU; n = 209) or an identical placebo (n = 204) for 2 years. The study was conducted in Tasmania and Melbourne, Australia.
Of 413 enrolled participants (average age, 63 years; 50 percent women), 340 (82 percent) completed the study. The researchers found that vitamin D supplementation, compared with placebo, did not result in significant differences in change in MRI-measured tibial cartilage volume or a measure of knee pain over 2 years. There were also no significant differences in change of tibiofemoral cartilage defects or change in tibiofemoral bone marrow lesions. Vitamin D levels did increase more in the vitamin D group than in the placebo group over 2 years.
“These data suggest a lack of evidence to support vitamin D supplementation for slowing disease progression or structural change in knee osteoarthritis,” the authors write.
New study shows that walking reduces risk of functional limitation associated with knee osteoarthritis (OA). In fact, the study funded in part by grants from the National Institutes of Health (NIH) and published in the American College of Rheumatology (ACR) journal, Arthritis Care & Research, suggests that walking 6,000 or more steps per day may protect those with or at risk of knee of OA from developing mobility issues, such as difficulty getting up from a chair and climbing stairs.
Nearly 27 million Americans age 25 and older are diagnosed with OA according to a prevalence study by Lawrence et al. (Arthritis Rheum, 2008). Previous research reports that knee OA is the leading cause of functional limitation among older adults, making walking and climbing stairs difficult. Moreover, data from the National Health and Nutrition Examination Survey (NHANES III) state that 80% of OA patients have some limitation in movement, with 11% of adults with knee OA needing assistance with personal care assistance.
While walking is a common daily physical activity for older adults, medical evidence reports that two-thirds of U.S. adults with arthritis walk less than 90 minutes each week. “Our study examines if more walking equates with better functioning, and if so, how much daily walking is needed to minimize risk of developing problems with mobility in people with knee OA,” said Daniel White, PT, ScD, from Sargent College at Boston University in Massachusetts.
For the present study, researchers measured daily steps taken by 1788 people with or at risk for knee OA, who were part of the Multicenter Osteoarthritis Study. Walking was measured with a monitor over seven days and functional limitation evaluated two years later, defined as a slow walking speed and a Western Ontario and McMaster Universities Arthritis Index (WOMAC) physical function score greater than 28 out of 68.
Walking an additional 1,000 steps each was associated with between a 16% to 18% reduction in incident functional limitation two years later. Walking less than 6,000 steps daily was the best threshold for identifying those who developed functional limitation.
Dr. White concludes, “Walking is an inexpensive activity and despite the common popular goal of walking 10,000 steps per day, our study finds only 6,000 steps are necessary to realize benefits. We encourage those with or at risk of knee OA to walk at least 3,000 or more steps each day, and ultimately progress to 6,000 steps daily to minimize the risk of developing difficulty with mobility.”
The most effective approach you can take when dealing with your fatigue is to be aware that fatigue is a part of arthritis, and that you might have to adapt your schedule. Don’t look at your fatigue as a sign of personal weakness or try to deny it. It is simply one more symptom of your arthritis that you can learn to handle.
Here are some fatigue tips that are worth trying:
Adjust your schedule as needed. Many people with arthritis adjust their daily schedules, starting their days an hour or two later. This makes it easier to deal with morning stiffness and may also enable you to sleep longer. Ultimately, the result is less fatigue and a more productive day. Other people may rest or nap in the afternoon, which then allows them to continue their daily activities without exhaustion at the end of the day.
Avoid eating heavy meals. Instead, opt for a light lunch, perhaps with a healthy morning and afternoon snack thrown in.
Get enough rest. Rest is crucial. But doing too little can often lead to deconditioning – which makes you feel more fatigued. Moderate exercise keeps your muscles and joints in condition, and has the added benefit of helping you sleep better at night.
Get a good night’s sleep. A lack of restful sleep is a problem shared by many Americans – and caused by a variety of factors: stress; depression; caffeine, alcohol or drugs; not allowing enough time for sleep; and pain. When you have rheumatoid arthritis (RA) or other forms of arthritis, pain may keep you from falling asleep easily, or it may awaken you during the night. Research has shown that some people with RA experience light, easily disrupted sleep with many mid-sleep awakenings. This contributes to fatigue.
There are several stages of sleep. During the night, your brain moves between these stages in cycles, and the types of electrical brain waves generated vary from stage to stage. To feel rested, your brain requires what is called “delta sleep,” named after the brain waves that occur in the third and fourth stages of sleep. REM (short for rapid eye movement) sleep is also important. It’s the stage of sleep when dreaming occurs, and without it, you will feel tired.
Prioritize your time and energy. There may be times when you feel more fatigued than others, and you will have to deal with limitations to your energy. Think of your energy as a resource that you have to conserve for your most important activities. This may involve saying no to lower-priority activities that take up too much of your energy.
Of course, saying no isn’t always easy, but it helps you stay focused on the priorities in your life, such as earning a living or spending time with your children. When you’re feeling fatigued, opting out of an activity may allow you to get the rest you need. Saying no to one activity may allow you to say yes to something more important to you.
Ask for help. Successful managers know that they cannot do everything themselves. Borrowing from their techniques, you can learn to delegate tasks that will help you manage your activities. Asking for help may be difficult at first. Because the effects of RA are not always visible, you may be afraid that co-workers and acquaintances will perceive you as lazy.
You may feel embarrassed to ask for help, especially if you’ve always viewed yourself as a high achiever. When asking for help, be specific. For example, if you ask someone to take you shopping for one hour every other Tuesday morning, you are letting them know precisely what you need. Also, you show that you understand his or her time is valuable.
Also, develop a pool of helpers. Spreading out the tasks keeps the burden from falling on any one person. Keep a list of friends and family and the tasks they’re willing to help with.
Consider bartering or trading services. If you dislike asking for help, perhaps you can provide a service in return. For instance, offer to watch your friend’s children one afternoon a week at your house, if she will run some errands for you.
Sexuality is an integral part of being human. It is linked to our quality of life and self-identity. Yet, living with the pain, stiffness, fatigue, limited movement, decreased strength and depression associated with arthritis can reduce our ability for sexual expression and enjoyment.
WHAT IS THE IMPACT OF ARTHRITIS ON SEXUAL EXPRESSION?
Aspects of arthritis which can cause problems that affect your sexuality include:
- Severity of the disease
- Levels of fatigue
- Degree of pain
- Physical limitations
- Contribution of movement, touch, and bearing weight to discomfort
- Self-perception, self-esteem and emotional attitude
- Side effects of medications
- Effects of surgery
Recent studies have shown that the higher the levels of pain, physical disability and depression, the greater the effect on sexuality, regardless of gender. Those affected by some forms of rheumatic disease, including lupus, fibromyalgia, scleroderma,osteoarthritis, rheumatoid arthritis, Sjögren’s syndrome, Raynaud’s phenomenon and juvenile arthritis specifically, also may experience:
- Decreased sense of sexual attractiveness
- Decreased sexual desire and satisfaction
- Difficulty with sexual arousal
- Decreased sensation or blood circulation
- Increased sensitivity to being touched
- Decreased endurance
- Limitation of motion
- Vaginal dryness
- Inability to have an orgasm or decreased orgasmic sensation
- Erectile dysfunction or impotence
BEGIN OVERCOMING BARRIERS
Sex is not simply about reaching rapid orgasm with a partner. A slower approach can prove satisfying for partners who share mutual respect, care, trust and love. Exploring ways of returning pleasure can build excitement and intimacy. Begin overcoming potential barriers by letting your partner know if something is uncomfortable as well as what is particularly pleasurable. While arthritis rarely affects the sexual organs themselves, the physical effects of the disease also can have an emotional impact on sexual relations. A change in appearance, weight gain or loss, or a decrease in mobility or energy can affect self-esteem and self-image. The person with arthritis may feel less desirable or more fragile. The fear of pain can prompt anxiety that makes it difficult to relax and enjoy sex or cause sexual partners to worry about causing pain.
Address the emotional effects openly and honestly with your partner. Express your fears with statements like “I am afraid that …” This provides your partner with the chance to reassure and support you. Also, talking about these fears early on allows you to let go. Remember, one partner’s discomfort or fears may be misread as rejection by the other, causing greater distance and emotional pain. If talking is too sensitive initially, consider writing a note to your partner to express your fears or concerns. Talking openly about the sentiments expressed in your letter is often an easier next step.
DO MEDICATIONS HAVE AN IMPACT?
Medications used in the treatment of arthritis do not appear to affect sexual functioning. However, some cases of erectile impotence have been reported in persons treated with methotrexate, sulfasalazine, or hydroxychloroquine. Other drugs may interfere with libido (for example, cimetidine, diclofenac, misoprostol, and naproxen). Loss of desire and difficulty with orgasm also are common side effects of antidepressant medications.
SEXUAL WELL-BEING AND ARTHRITIS
Psychological well-being and social support contribute more to a fulfilling sexual life than does the condition of arthritis. By separating the limitations of pain from sexual self-confidence, you can take a more practical approach to the changes brought about by arthritis.
Plan Ahead for Sex: Keep fatigue or stiffness from getting in the way of pleasurable sexual activity by thinking about the times of day you are likely to be more rested. For instance, if you experience morning stiffness, the afternoon or evening are probably better times for sex. To put you more at ease, consider:
- Napping before sexual activity.
- Taking a warm shower or bath or using a heating pad or electric blanket to help ease stiffness, and soothe joints and muscles.
- Timing pain medication so its maximum effect is during sex.
- Using massage to help relax muscles and joints, even as a form of foreplay.
- Piling up pillows or rolled sheets to support joints.
- Pacing yourself to save energy for you and your partner.
Women with arthritis may experience vaginal dryness, making manual stimulation uncomfortable or penetrative sex painful. This can be relieved by water-based lubricating gels. Never use petroleum-based products. Be Creative and Communicative: Discussing the issue of arthritis and sex may be uncomfortable for you and/or your partner. In some cases, it may even make your doctor uncomfortable to discuss it. Don’t let this discomfort stand in the way of your enjoying a fulfilling sex life despite your arthritis. Consult with your physician when you have medical concerns.
Talk openly with your partner to find the positions and techniques that give both of you the most amount of pleasure with the least amount of discomfort. With a little creativity, patience, and planning, individuals affected by arthritis can discover and rediscover the pleasures of sexual intimacy.
POINTS TO REMEMBER
- Open and honest communication between partners about feelings, desires, challenges and sexual needs is critical. Be willing to define intimacy through creative touch, different techniques, sexual devices and new positions.
- Incorporate sexual activity into the times of day or evening when you are feeling your best. If necessary, take pain medication at least 30 minutes in advance.
- Avoid cold temperatures by taking a warm shower or bath or using an electric blanket to stay warm.
- Remember, attitude is everything. Rather than setting intercourse as the goal, strive for emotional and physical closeness. The sexiest part of your body is your mind and how you use it.
WHAT IS IT?
Arthritis is a complex family of musculoskeletal disorders consisting of more than 100 different diseases or conditions that destroy joints, bones, muscles, cartilage and other connective tissues, hampering or halting physical movement. Juvenile arthritis (JA) is an umbrella term used to describe the many autoimmune and inflammatory conditions that can develop in children ages 16 and younger.
Arthritis typically affects joints – the word “arthritis” literally means joint inflammation: arth (joint) and itis (inflammation) – but JA can involve the eyes, skin and gastrointestinal tract as well.
In addition, there are several different types of juvenile arthritis. As JA’s prevalence rises, researchers and doctors alike are working to develop a more sophisticated understanding of the differences between the different forms.
The most common type of JA is juvenile idiopathic arthritis (JIA). To receive a diagnosis, a child should be younger than 16 and have initial swelling in one or more joints for at least six weeks.
WHAT CAUSES IT?
No known cause has been pinpointed for most forms of juvenile arthritis, nor is there evidence to suggest that toxins, foods or allergies cause children to develop the disease. Some research points toward a genetic predisposition, which means the combination of genes a child receives from family members may cause the onset of arthritis when triggered by other factors.
WHAT ARE THE EFFECTS?
Having arthritis will affect your entire family, but you can maintain a sense of calm and normalcy. Stick to as many of your child’s daily routines and comforting habits as possible. Having arthritis should be part of your child’s life – not the central focus of his life.
Coping with a chronic illness diagnosis is difficult for anyone, but especially for children who are not emotionally or physically equipped to handle the situation. Expect and prepare for your child to sometimes feel sad or angry that he or she has arthritis. It’s important to address, rather than ignore these emotions. Help your child maintain the attitude that “arthritis is part of who I am, not the only thing I am.”
Arthritis is truly a family diagnosis. Parents experience many emotions – from sadness to guilt to anger that their child has arthritis. It’s tempting to keep a low profile and avoid participating in too many activities when your child is first diagnosed, but everyone will benefit by keeping relationships and schedules as consistent as possible. Parents should be sure to spend time with their other children and make time for one another – and themselves.
Siblings of children with arthritis will feel a full spectrum of emotion from guilt that they’re healthy, to resentment, anger, loneliness and a need for attention. One key to minimizing sibling tensions is to keep everyone equally involved in and informed about your child’s diagnosis and treatment. If your child who doesn’t have arthritis exhibits signs of clinginess, anxiety or dangerous behaviors, seek help from a counselor who can help ease this transition for your family.
HOW IS IT DIAGNOSED?
The most important step in properly treating your child’s JA is getting an accurate diagnosis. The diagnostic process can be long and detailed, but be patient. Your child’s pediatrician will likely recommend that you visit a pediatric rheumatologist who will then take a complete health history to determine the length of time and type of symptoms present.
There is no single blood test that confirms juvenile arthritis. In fact, blood testing will reveal relatively little in terms of your child’s diagnosis. In children, the key to diagnosis is a careful physical exam, along with taking a medical history.
Along with the physical exam itself, your child’s doctors will take a number of other diagnostic steps – such as laboratory work and x-rays and other imaging tests – in part to rule out other potential causes of symptoms. Blood work, for example, can rule out the possibility of an underlying infection.
WHAT ARE THE TREATMENT OPTIONS?
Unfortunately, there is no cure for juvenile arthritis. The goal of treatment for JA is to relieve inflammation, control pain and improve your child’s quality of life. Most treatment plans involve a combination of medication, physical activity, eye care and healthy eating.
Every treatment plan is unique and requires that your child’s health care team, which might include a pediatric rheumatologist, dentist, ophthalmologist, nurse practitioner and physical therapist, among others.
Medications used to treat JA can be divided into two groups: those that help relieve pain and inflammation (nonsteroidal anti-inflammatory drugs, or NSAIDs, corticosteroids and analgesics) and those that can alter the course of the disease, put it into remission and prevent joint damage, a category known as disease-modifying anti-rheumatic drugs (DMARDs) and a newer subset known as biologic response modifiers (biologics).
Each child responds to his or her treatment plan differently, so there’s no set course of attack for JA. Your child’s doctor might try several different medications and/or dosages until your child responds positively to treatment. Some medications affect the immune system or have other side effects, making careful and frequent monitoring very important.
New research aims to shed much-needed new light on the mysterious condition that is palindromic rheumatism. Jane Tadman reports. Like many types of arthritis, palindromic rheumatism can strike without warning, causing extreme pain in one or several joints. But what makes it different to most other types of arthritis is that it then disappears as mysteriously as it came, although these attacks, or ‘flares’, can last days or weeks.It’s this very unpredictability, along with the intense pain, extreme fatigue and a general lack of awareness or understanding of the condition, that makes the lives of people with palindromic rheumatism so difficult.
Taking a glucocorticoid medication (sometimes called corticosteroids) for treatment of inflammatory arthritis or other health problem may weaken your bones. This, in turn, can lead to osteoporosis. The good news is there are ways you can protect your bones while taking glucocorticoid medicine.
- Anyone taking a glucocorticoid medicine is at risk of osteoporosis.
- Daily calcium and vitamin D supplements can help prevent loss of bone mass. Calcium alone is not effective.
- A rheumatologist can advise about other treatment options.
What is Glucocorticoid-Induced Osteoporosis?
Glucocorticoid-induced osteoporosis is a form of osteoporosis—sometimes called OP—that is caused by taking glucocorticoid medicines. These drugs include prednisone (Deltasone, Orasone, etc.), prednisolone (Prelone), dexamethasone (Decadron, Hexadrol), and cortisone (Cortone). They are common treatments of many rheumatic (joint and muscle) diseases, including rheumatoid arthritis, lupus, myositis (muscle inflammation) and polymyalgia rheumatica.
What causes glucocorticoid-induced osteoporosis?
Glucocorticoid medicines have both direct and indirect effects on bone tissue that lead to bone loss. These drugs have a direct negative effect on bone cells, resulting in a reduced rate of forming new bone. Also, they can interfere with the body’s handling of calcium and affect levels of sex hormones. Either of these problems can lead to increased bone loss.
Anyone who is taking glucocorticoid medications and has other risk factors for OP is at increased risk of getting glucocorticoid-induced OP and breaking a bone (fracture). You can change some of these risk factors, but not others.
Major risk factors that you cannot change include:
- Older age (children are at risk too)
- Non-Hispanic white or Asian ethnic background
- Small bone structure
- Family history of OP or an OP-related fracture in a parent or sibling
- Prior fracture due to a low-level injury, particularly after age 50
Risk factors that you may be able to change include:
- Low levels of sex hormone, mainly estrogen in women (e.g., menopause) and men
- The eating disorder anorexia nervosa
- Cigarette smoking
- Alcohol abuse
- Low calcium and vitamin D, by low dietary intake or poor absorption in your gut
- Sedentary (inactive) lifestyle or immobility
- Certain medications besides glucocorticoids, including the following:
- excess thyroid hormone replacement
- the blood thinner heparin
- some treatments of breast cancer (Arimidex, Femara, etc.) or prostate cancer (e.g., Lupron) that deplete sex hormones
- A disease that can affect bones
- endocrine (hormone) diseases (hyperthyroidism, hyperparathyroidism, Cushing’s disease, etc.)
- inflammatory arthritis (rheumatoid arthritis, ankylosing spondylitis, etc.)
Who gets glucocorticoid-induced osteoporosis?
Anyone who needs to take glucocorticoid medicine is at risk of developing OP and fractures.
How is glucocorticoid-induced osteoporosis diagnosed?
You can learn if you have OP by having a simple test that measures bone mineral density—sometimes called BMD. BMD—the amount of bone you have in a given area—is measured at different parts of your body. Often the measurements are at your spine and your hip, including a part of the hip called the femoral neck, at the top of the thighbone (femur). Dual energy X-ray absorptiometry (referred to as DXA and pronounced “dex-uh”) is the best current test to measure BMD.
The test is quick and painless. It is similar to an X-ray, but uses much less radiation. Even so, pregnant women should not have this test, to avoid any risk of harming the fetus.
DXA test results are scored compared with the BMD of young, healthy people. This results in a measure called a T-score. The scoring is as follows:
||Bone Mineral Density (BMD)
|Not lower than –1.0
|Between –1.0 and –2.5
||Osteopenia (mild BMD loss)
|–2.5 or lower
How is glucocorticoid-induced osteoporosis treated?
Osteoporosis is a condition of weak bone caused by a loss of bone mass as well as a change in bone structure. The first picture is normal bone and the second shows osteoporotic bone.
Anyone taking glucocorticoid medicine must get enough calcium and vitamin D. The American College of Rheumatology recommends you should take at least 1,200 to 1,500 milligrams (shortened as mg) of calcium and 800 to 1,000 International Units (called IU) of vitamin D supplements each day. Your doctor may measure the vitamin D level in your blood to find out if you need more vitamin D supplementation.
Some people also will need medication. The decision to start prescription medications will depend on your other risk factors, the dose of glucocorticoid medication you are taking and how long you may be on it, as well as your BMD results by DXA.
The US Food and Drug Administration (better known as the FDA) has approved certain drugs to prevent and treat glucocorticoid-induced OP. In a drug class called bisphosphonates, risedronate (Actonel) and zoledronic acid (Reclast) are FDA approved for both the prevention and treatment of glucocorticoid-induced OP. Another drug in this class, alendronate (Fosamax), is approved for the treatment of this type of OP.
Teriparatide (Forteo), a different type of drug, also is approved for treatment of glucocorticoid-induced OP. This manmade form of parathyroid hormone helps stimulate bone formation. You can find more information about these drugs in the “Osteoporosis” fact sheet, under the section “How is osteoporosis treated?”
Women planning a pregnancy should talk to their doctor about the pros and cons of using a bisphosphonate or teriparatide. None of the prescription drugs for managing OP has enough safety data available to recommend using them in women who are pregnant or breastfeeding. (For more information, see the section “Young women and pregnancy” in the patient fact sheet about OP.
If you take glucocorticoid medicine for any length of time, you should start taking calcium and vitamin D supplements at the doses recommended in the prior section. Work with your doctor to help use the smallest dose of glucocorticoid for the shortest duration possible that will still keep your disease under control.
Patients taking glucocorticoid medicine should:
- Be physically active and do weight-bearing exercises, like walking, most days each week.
- Change lifestyle choices that raise your risk of OP, such as quitting smoking.
- Implement strategies to help decrease your risk of falling, which raises the risk of fractures. (See “Living with osteoporosis” in the “Osteoporosis” fact sheet.)
- Get DXA testing of your BMD.
If you have low bone density and a high risk of breaking a bone, your doctor may suggest medicine to prevent your bones from getting weaker. (See the section “How is osteoporosis treated?”) Health care providers now have a tool for estimating the risk of a patient having an osteoporotic fracture in the next 10 years. This fracture risk assessment tool, from the World Health Organization, is called FRAX. It can help guide treatment decisions.
Broader health impact of glucocorticoid-induced osteoporosis
The most serious health consequence of any type of OP is a fracture. Spine and hip fractures especially may lead to chronic pain, long-term disability and even death. The main goal of treating glucocorticoid-induced OP is to prevent fractures.
Points to Remember
- A bone density test can safely measure changes in bone density during glucocorticoid treatment.
- Both men and women can decrease bone loss from glucocorticoid treatment by using calcium and vitamin D supplements.
Weight-bearing exercise is a key part of prevention.
Raynaud’s phenomenon is a condition in which the body reacts to strong emotions or exposure to the cold by restricting blood flow to the extremities, such as fingers and toes, resulting in colour changes in the skin and some discomfort. Raynaud’s phenomenon can last from just a few minutes to many hours.
Around five per cent of the population has the condition to some degree. It is much more common in women and girls, with those under the age of 25 more commonly affected. Raynaud’s phenomenon doesn’t usually cause permanent damage. However, it can be a symptom of more serious underlying illnesses, so it is important to see your doctor if you experience it.
SYMPTOMS OF RAYNAUD’S PHENOMENON
The body prevents heat loss in cold weather by redirecting the blood away from the extremities. In a person with Raynaud’s phenomenon, this reaction is exaggerated. The blood vessels constrict tightly, starving the tissues of blood and causing the characteristic blue or white colour change. When blood flow returns, the skin turns from blue to red and finally back to the normal pink colour. Circulation to the rest of the body is generally perfectly normal.
PRIMARY RAYNAUD’S PHENOMENON
Primary Raynaud’s phenomenon (or Raynaud’s disease, or just Raynaud’s) is the most common form of Raynaud’s phenomenon. It is called ‘idiopathic’ because there is no clear underlying cause. It is often so mild that the person never seeks medical attention.
SECONDARY RAYNAUD’S PHENOMENON
Secondary Raynaud’s phenomenon is generally more complex and serious than primary Raynaud’s. The most common causes of secondary Raynaud’s are underlying autoimmune disorders such as rheumatoid arthritis, scleroderma and systemic lupus erythematosus (SLE or lupus).
Other common causes of secondary Raynaud’s phenomenon are:
- mechanical vibration – such as using a power tool for long periods. This is known as ‘industrial white finger’. It is thought that the vibrations disrupt the nerves
- atherosclerosis – in which a narrowing of the arteries is caused by a build-up of fatty plaques. Blood flow to the extremities may be hampered by this condition
- smoking – constricts blood vessels
- some medications – such as beta blockers, medications that contain ergotamine, certain chemotherapy agents and medications that cause blood vessels to narrow
COMPLICATIONS OF RAYNAUD’S PHENOMENON
In most cases, Raynaud’s phenomenon is harmless and has no lasting effects. In severe cases, however, loss of blood flow can permanently damage the tissue.
Complications of severe Raynaud’s phenomenon include:
- impaired healing of cuts and abrasions
- increased susceptibility to infection
- tissue loss
DIAGNOSIS OF RAYNAUD’S PHENOMENON
It is not hard to diagnose Raynaud’s phenomenon, but it is sometimes hard to tell the difference between the primary or secondary form of the disorder. Your doctor may use a range of methods to decide which form a person has, including:
- a complete medical history
- physical examination
- blood tests
- examining fingernail tissue with a microscope.
TREATMENT FOR RAYNAUD’S PHENOMENON
For most people, primary Raynaud’s phenomenon is a nuisance rather than a disabling condition. However, if Raynaud’s phenomenon does occur, warming the body and the extremities is helpful. Retreat indoors, and soak fingers or toes in warm water. If a stressful situation triggers the attack, try to remove yourself from the situation and relax.
The general response to secondary Raynaud’s phenomenon is to treat the underlying illness. In severe cases, vasodilating medications (that dilate the blood vessels) may be prescribed to prevent tissue damage. Surgery may be needed if a person has skin ulcers or serious tissue damage.
PREVENTION OF RAYNAUD’S PHENOMENON
- There is no cure for Raynaud’s phenomenon. Managing the condition requires avoiding known triggers, particularly exposure to cold temperatures. Some suggestions include:
- Avoid prolonged exposure to cold weather or sudden temperature changes, such as leaving a warm house on a cold day.
- Make sure your whole body is kept warm, using several layers of clothing to trap body heat. Keep your extremities warm with gloves and woollen socks.
- Be aware that even holding something cold, such as a can of drink, can trigger symptoms.
- Don’t smoke cigarettes or drink caffeinated beverages, since nicotine and caffeine constrict the arteries.
- Avoid medications such as vasoconstrictors, which cause the blood vessels to narrow. Avoid beta blockers, many cold preparations, narcotics, some migraine headache medications, some chemotherapeutic medications and clonidine (blood pressure medication). Of course, decisions about the use of medications need to be discussed with your doctor.
- Learn to recognise and avoid stressful situations. Stress and emotional distress can trigger an attack, particularly for people with primary Raynaud’s phenomenon. Relaxation may decrease the number and severity of attacks you experience.
- Keep a journal of when episodes occur. Triggers for these episodes may become evident.
- Hand care – dry hands can cause skin cracks. Moisturise your hands to prevent dryness and protect hands when in water with barrier creams. Speak to your doctor about which type to use.
- Exercise regularly to maintain blood flow and skin condition. Physical activity can also help increase your energy levels, control your weight, improve your cardiovascular (heart) fitness and help you to sleep better. Talk to your doctor before starting any exercise program.
WHERE TO GET HELP
THINGS TO REMEMBER
- Raynaud’s phenomenon is the short-term interruption of blood flow to the extremities, such as the fingers and toes.
- Raynaud’s phenomenon may be a sign of an underlying autoimmune disorder such as scleroderma or lupus so it is important to see your doctor for diagnosis.
- Management options include avoiding cold weather and sudden temperature changes.
People with gout are significantly more susceptible to flare-ups of their condition at night than during daylight hours, a new US study has shown. Led by Boston University School of Medicine and published in the medical journal Arthritis & Rheumatology, the research utilised data from the Boston Online Gout Study – which investigated triggers for gout attacks from 2003 to 2013 – to see when these attacks were most prevalent.
A total of 724 gout patients were recruited and followed for one year, providing dates and hours for when gout attacks occurred, as well as answering questions on their symptoms, medication use and certain risk factors (such as alcohol use and seafood consumption) during the 24 and 48 hours preceding the gout flare. Findings indicated that participants experienced 1,433 gout attacks during the study period. Of these, 733 were recorded between midnight to 07:59, 310 were between 08:00 and 14:59, and 390 took place between 15:00 to 23:59.
This means the risk of a gout flare was 2.4 times higher overnight and 1.3 times higher in the evening compared to daytime hours. This trend persisted even among those with no alcohol intake and low purine intake during the 24 hours prior to the attack, and after accounting for gender, age, body mass index and use of various medications. Lead author Dr Hyon Choi, a former Boston University researcher who is currently at Massachusetts General Hospital and Harvard Medical School, said: “Our findings provide the first prospective evidence that the risk of gout flares is higher during the night and early morning hours than during the day. As a result of our study, prophylactic measures that prevent gout flares, especially at night, may be more effective.”
A spokeswoman for Arthritis Research UK welcomed the findings as clinically useful, adding: “It could be that people at risk of gout attacks are more dehydrated at night, because they may have eaten a rich meal with red wine or drunk alcohol in the evening and this has a knock-on effect, causing a flare-up.