Do I Have Arthur-itis?

Ahh, arthritis. A common lament.

Actually, arthritis is not a specific diagnosis. It is a symptom that describes pain in your joints.

Any initial evaluation of arthritis should consider uncommon but potentially disabling forms of arthritis in which your immune system is actually attacking your own joints. Yes this can happen, often runs in families and can be treated very well by a rheumatologist with medications that can alleviate pain and prevent crippling deformity. Examples of these kinds of arthritis include rheumatoid arthritis and systemic lupus erythematosus (lupus).

By far, the most common kind of arthritis is simply related to day-to-day, year-to-year wear and tear on the cartilage that lines your joints. Most folks call this age-related or wear-and-tear arthritis. It is technically called degenerative joint disease or osteoarthritis.

This will affect load-bearing joints such as shoulders, back, hips and knees and also frequently used joints such as the fingers. It differs from the nastier ones described earlier by typically being worse as the day goes on, and not being at its worst first thing in the morning.

What to do for it?

First, stay active. Avoiding absolutely everything that hurts can be worse in the long run because you can gain weight which will increase the load on joints, and lose muscle strength that supports your joints.

Exercise that is non-weight bearing is best: swimming, water aerobics, aqua running. If this is not practical, exercise that does not involve impact against the ground is good. This is referred to as closed-kinetic chain exercise and includes bicycling, stationary bike, elliptical trainer, Stair Master, etc.

Applying ice or a warm water bottle several times a day is also helpful.

Tylenol would be the best medication to use first. It relieves pain as well as any other over-the-counter or prescription medicine and has fewer side-effects. Kidney injury is rare, it cannot cause bleeding or stomach problems and it cannot hurt your liver (if you have hepatitis or drink over 2 drinks a day, cut the following doses by half or bring it up with your doctor).

The correct dose of Tylenol (or generic acetaminophen) is 1,000 mg at a time, 3-4 times a day. Yes, that's 8 extra-strength Tylenols a day.

If you take an aspirin a day for your heart or are on "blood thinners", it is okay to take Tylenol. It does not interfere with the aspirin's ability to prevent heart attacks and strokes, and cannot cause bleeding, and does not interfere with Coumadin/warfarin.

If that isn't enough, try adding topical capseicin (such as Zostrix). This is a topical ointment containing an oil-based extract of cayenne pepper. You apply it to your arthritic joints 3-4 times every day. It burns a bit for the first week or two, but after this it relieves arthritis pain by depleting a chemical that your nerves use to send pain signals to your brain. Native Americans in the Southwest have eaten cayenne for centuries as a treatment for pain. Applying it as an ointment works very well to relieve pain, though you should wash your hands thoroughly after rubbing it on!

If Tylenol and Zostrix are not adequate, then you may want to try anti-inflammatory pain relievers (NSAID's) such as Advil or Aleve instead. Tylenol is usually worth trying first since wear-and-tear arthritis doesn't cause joint inflammation.

Prescription level doses on these are double those on the label: 4 Advils 3 times a day, OR 2 Aleves 2 times a day.

• Do not take NSAID's along with Tylenol. You should only use them if Tylenol isn't working well enough, therefore you should then stop the Tylenol.
• Do not play mix-and-match. Use on or the other, not both.
• It's okay to take them with food or on an empty stomach.
  
• You cannot use NSAID's with Coumadin/warfarin or Plavix/clopidogrel which are prescription "blood thinners". Taking NSAID's along with these can cause fatal bleeding problems.
• If you have had a heart attack or have congestive heart failure, you should consider use of NSAID's with caution. They can keep aspirin from protecting your heart, and can cause fluid retention which could worsen your heart disease.
  
• If you take an aspirin a day to prevent heart attacks or strokes, you may as well stop taking it since the NSAID keeps the aspirin from doing its job. Yes, that does mean you are losing your heart attack and stroke protection!
• You can prevent these medicines from causing an ulcer, which is definitely worth doing, especially since 85% of these ulcers are totally painless.
• Take one 20-mg Prilosec OTC a day, and this will reduce the chance of an ulcer to nearly zero.
• Ignore the labeling on the package about not taking it for over 14 days. Or rather, do not suppose that this means it's not safe to use. The label is intended to keep folks from using it for stomach pain for over two weeks without seeing a doctor about it.

Narcotic pain pills may be appropriate for treating arthritis since the disease can really impact your quality of life. However, they have numerous side-effects and can be addictive so should be used with caution.

Mail Order Pharmacy

Mail order prescription services are known to your medical insurance companies as Pharmacy Benefit Managers (PBM's).

PBM's are middlemen that obtain contracts with pharmaceutical manufacturers ("drug companies") for discount prices on large sales volumes for the insurance companies. In theory, this is supposed to be a win-win situation for everyone. The insurance companies save money on cost of medications, they incentivize you to participate by lowering the out-of-pocket cost of your pills, and otherwise pass on the savings to you.

Of course, you could reasonable ask why your premiums keep going up, but that's a topic for another time. You might also ask what that's doing to your friendly and trustworthy local pharmacist, but I guess the idea is that it's a tough old world out there.

If you want to use your PBM, and would like our help in making it work for you as smoothly as possible,

• They will usually send you a renewal form for each of your medicines when your yearly prescription is up.
• Please let us use these for renewals. Using hand written prescriptions for renewing already existing prescriptions is very confusing to them.

• PLEASE, PLEASE USE YOUR LOCAL PHARMACY FIRST FOR NEW MEDICINES OR FOR CHANGES IN DOSES ON MEDICINES!
• It's not unusual to start or change a medicine, only to find that you have to switch to something else because of side-effects, or that you have to make another change in dose at the follow-up visit.
• Because of this, it's a good idea to make sure that the medicine and it's dosage is right for you before getting 3 months worth for a year!
• Yes, we know it's cheaper to do mail order.
• Yes, we know a few dollars is a lot of money these days, especially if you are on a fixed income.
• The problem is that serial mail-in prescriptions reflecting changes in medications and/or dose changes can lead to confusion as to your medications.
  

Do I Need Antibiotics Before I Get My Teeth Cleaned?

Short answer: For most patients, probably not.

Long answer:

The American Heart Association has been refining recommendations on who should take antibiotics before certain kinds of surgeries or procedures for about 50 years.

Revisions to prior recommendations were made last year. Factors that weighed into these new recommendations included existing evidence, recognition that bacteria entering the bloodstream occurs with normal daily activity, and the awareness that antibiotic use itself is not without risk.

Who may need antibiotics for dental visits? Those with conditions of highest risk for heart infections as a result. These would be folks who (1) have had heart infections before (Infectious Endocarditis), (2) those who have artificial heart valves or heart valve repairs using artificial materials, (3) those who had a heart transplant and then developed heart valve problems, and (4) those who were born with structural heart problems (Congenital Heart Disease) which were not repaired, or were repaired with artificial materials.

What kind of dental visit needs antibiotics? This would really depend on what your dentist plans to do.

What antibiotics should be used? Amoxicillin is the best choice, though there are several alternatives if you allergic to it. The antibiotics should be taken 30-60 minutes before hand, though could be taken for up to 2 hours after the work.


PLEASE NOTE:

We will work in conjunction with your dentist to identify whether you fit into one of the four high-risk groups described above.

However, only your dentist knows whether what they plan to do will make antibiotic treatment beforehand advisable or not. That decision needs to be made by them.

Peter Lockhart, DDS, Chair of Oral Medicine at Carolinas Medical Center is a member of the committee that wrote these new recommendations, and comments that:

"the primary care physician’s responsibility is to determine whether the patient has one of the four qualifying cardiac conditions. If the patient has one of those conditions, it’s the dentist’s responsibility — not the physician’s — to determine whether the upcoming dental procedure warrants prophylaxis."

Back Pain

Back pain is the most common problem people see a doctor for, and runs to about $6,000 per person per year in terms of U.S. medical care expenses. So, it's not just you...

Sudden back pain certainly gets your attention, and should also raise some concern especially if a cause is not evident.

Alarm bells should go off if back pain comes with fever, chest pain, shortness of breath, vomiting, loss of normal bowel or bladder function or tingling or weakness in your legs. These may be signs of infection, heart attack, aneurysm rupture, or spinal cord injury and should prompt urgent medical care.

However, most back pain that comes on for no memorable reason or after a hard day brush clearing or gardening is the result of muscle strain.

When this happens, muscle and other connective tissues are torn and your body responds through inflammation which tries to limit the damage by causing swelling and pain. This limits further use of the inflamed strained muscle until it can heal.

Unfortunately, this inflammatory response can be counter-productive as anyone who has "pulled a back muscle" can agree!

So, best treatment at the outset is a cold pack for 15-20 minutes 3-4 times a day for the first day or two to decrease inflammation to the area. Do not put ice right to the skin as this can cause frostbite injury. Use a chilled rice bag or other cold pack.

After the first day or two, use warm packs if this feels better. Do not overuse heat as this can cause burns or worsened muscle spasm.

Anti-inflammatory pain relievers are helpful for both relieving pain and also reducing the inflammatory response. Examples include aspirin, ibuprofen (Motrin, Advil) and naproxen (Aleve). These should be safe to use for brief periods of time assuming that you do not have any pre-existing stomach, liver or kidney problems.

If you smoke or drink or have ever had an ulcer (or if you are simply interested in keeping these medicines from being able to cause an ulcer while you take them), take one 20-mg Prilosec/OTC a day while you are using these medications. This medication is not dangerous to take for over 14 days. The warning on the box is to prevent people who take it and overlook dangerous symptoms from suing the manufacturer.

Please note that normal adult prescription level doses of Aleve would equal two pills twice a day, and Motrin at four pills three times a day.

Normal daily activities can be continued. Just pay attention to your body, and avoid activity that starts to worsen pain.

Back pain can actually take a surprisingly long time to go away. Half of people with simple back muscle strain have pain that lasts over one month; one quarter for over three months and ten percent of folks take over six months to heal up!

If your back is taking longer than seems right, physical therapy can be very helpful in alleviating some of the pain and in strengthening underused muscles that can add support to your back and help you heal more quickly and also prevent re-injury.