John Conte, MD
More about arthritis
On July 18, visitors to www.Turnto10.com chatted online about arthritis treatments with from John Conte, MD, a rheumatologist at The Miriam Hospital and Rheumatology Associates in Providence. Below are excerpts from the chat.
Moderator: Welcome to the NBC10 Chat. Dr. Conte will be taking your questions about arthritis treatments. Please note that Dr. Conte can give general medical advice only.
Hazel: Good afternoon, Dr Conte.
Melissa: Hi, Dr. Conte. Does glucosamine build/replace cartilage?
Dr. Conte: In truth, glucosamine sulphate has not yet been demonstrated to actually replace lost cartilage. However, one long-term study, over 3 years, demonstrated a slowing of progression of osteoarthritis of the knees. The difference between placebo and glucosamine sulphate was one to two millimeters of retained cartilage.
Hazel: You mentioned that hip pain and knee pain could be a form of arthritis. Could this pain have come out after playing softball for about 1 month but then it hasn't gone away after not playing for about 2 months. Even though I haven't played in a while? I wake up every morning with stiff knees. I also have tendonitis in my elbows and carpal tunnel.
Dr. Conte: Persistent pain is always a concern and should be further investigated. The possibilities are sundry. Your pain could be related to your baseball enthusiasm, but other unrelated causes should also be considered. It may be a soft tissue injury such as bursitis or tendonitis of the hip or knee, or a cartilage injury. But, certainly a hands-on evaluation by an orthopedist or rheumatologist would likely be helpful.
Melissa: What does glucosamine do? Does the pill that has glucosamine chronditin help osteoarthritis?
Dr. Conte: Melissa, the mechanism of action is still under study. Most researchers do not believe it goes directly from our guts into the joint cartilage, but is rather involved somehow in the prevention of further cartilage loss.
Teddy: Dr. Conte, I recently had an MRI of my spine for the placement of a morphine implant pump for chronic neuropathic pain in my right lower leg and foot. The doctor told me that my spine was full of arthritis. Although he said the pump will help the leg pain he does not think that it will help my arthritis. Also, I have been taking Celebrex for over a year and my weight will change 30 lbs. in a month. I have stopped taking Celebrex and within a month I lost 32 lbs. Any comments?
Dr. Conte: Teddy, your problems are certainly complicated and not easily addressed fully in this format. A few thoughts, however.Celebrex may, as an aspirin-like drug, have general pain relieving properties helpful to either neuropathic or arthritis pain. One side effect in some patients however, may be the retention of water and salt, leading to weight gain.
Dr. Conte: This is best addressed by your primary care physician. Another thought regarding treatment of chronic neuropathic pain is a medication called Neurontin, an anti-seizure medicine that has been found helpful in many cases of patients with chronic neuropathic pain such as yours.
Melissa: Thank you very much for answering my questions, Dr. Conte!
Hazel: Melissa, my cousin started taking it [glucosamine sulphate] and he has no cartilage left in his knee and he says he no longer has pain.
mimi: Dr., I have had RA for 12 years. I take Plaquenil and am usually in good control. Should I try any new meds?
Dr. Conte: Mimi, I am happy to hear that Plaquenil is providing you with such persistent and good relief. This is a relatively side effect-free medication. Therefore, unless there is clinical or x-ray evidence of progression of your rheumatoid then I would stick with what is working and thus avoid potential new side effects.
mimi: Thanks, Dr. My latest hand x-ray showed no joint damage, although I have "drift" of both wrists. Thanks again for your time.
doodlebug: My mother is 88 and is filled with arthritis--current medication is Mobic. Is there anything else out there to help the pain beside narcotics?
Dr. Conte: The answer or answers would depend on what your mom has been treated with heretofore; Mobic is a relatively new aspirin-like preparation, somewhat akin to Celebrex and Vioxx. These preparations were developed in an effort to avoid stomach and intestinal ulcers, complications of standard aspirin drugs.
doodlebug: We have tried all the standards (Celebrex, Vioxx) and she still is in pain; any suggestions? We have her back again in physical therapy.
Dr. Conte: If she has already tried these, then if she has osteoarthritis, for example, of which there are various types but no cure, depending which joint or area of the spine is affected, then bracing physical therapy, aquatics, weight loss, glucosamine sulphate preparations and general analgesics, including narcotics, may be appropriate in a specific case.
dan5: What test confirms the presence of arthritis?
Dr. Conte: There are many (over 80) forms of arthritis. In general, I make the majority of diagnoses after I have taken a good history and examined the patient. Lab investigations generally help to confirm, but rarely make a diagnosis in and of themselves. Your question is too general to relate to specific laboratory tests that we may use to confirm our clinical impressions. Basically, I would trust the judgment of an experienced clinician over an unexpected laboratory result.
Teddy: Dr. Conte, the Celebrex I was taking was 200 mg. twice daily and it helped with reducing the swelling of my foot. Can I take a "water pill" to take care of the weight gain? Because if it was not for the weight gain, Celebrex was like a miracle pill. Thank you.
Tina: Hi, Dr. Conte...My sister has RA. She urged me to get tested. My results were negative. Will I always test negative or can it show up anytime?
Dr. Conte: Tina, I'm glad to hear that right now you are free of evidence of rheumatoid arthritis. I would say, however, that if you experience unusual joint pain or swelling lasting over 4 to 6 weeks that you seek re-evaluation. Unfortunately, we have no crystal balls to predict the future in siblings of patients with confirmed RA. Auto-immunity may occur out of the blue, although is a slightly more common in affected family members.
Tina: Thank you. I have had some knee pain for a few months. I am seeing a doctor this week. The test I had was at least three years ago. Maybe another test would be warranted.
bobo: How do I relieve arthritis in my ankle?
Dr. Conte: Bobo, not knowing of a specific type of arthritis in your ankle, which could include such entities as osteoarthritis, psoratic arthritis, gout and rheumatoid arthritis, I am a little bit at a disadvantage. In general, one seeks to reduce any inflammation with aspirin-like drugs at first, and then more specific medications aimed at a specific diagnosis, such as rheumatoid arthritis, gout, etc.
Dr. Conte: Always helpful is weight reduction. Sometimes helpful is splinting or the use of a cane or crutches to reduce weight bearing on the affected joint and, of course, physical therapy and/or aquatics. Sometimes, corticosteroid injections are appropriate and, in terribly advanced cases, a partial fusion by an orthopedic surgeon. Finally, orthotics, either off-the-shelf or specifically fabricated, are helpful. It's best to consult a specialist who can examine you in person as opposed to this virtual reality.
Tina: Thank you, Dr. Conte and NBC 10. This has been very helpful!
Dr. Conte: Bella, maybe, although I cannot be certain. Other things to consider are bursitis, tendonitis, little nerve tumors (called neuromas) in the feet, as well as vascular problems with veins or arteries. As always, I would suggest an evaluation by your primary care doctor and/or specialist. X-rays and blood tests, etc., may then be more specifically targeted for your individual problem.
Teddy: Dr. Conte, I do take Nerontin 1200 mg. three times a day and Elivel 150 mg. a day.
Dr. Conte: For those of you who have rheumatoid arthritis, there are new medicines recently available that have proved effective when other, more standard treatments have failed. These include Enbrel, Remicade and Arava. They, of course, are unfortunately not free of any side effects. But if the disease is moderate to severe they can be remarkably helpful when used appropriately and carefully monitored. Also, there are many new "biologics" that should be available over the next 5 years.
pete: My wife has osteoarthritis in her hands, knees, neck and hips. She wants to know if there is any such thing as pain free? She also wants to know if you are taking new patients?
Dr. Conte: Pete, I believe "pain-free" is a brand name for an over-the-counter preparation that includes glucosamine sulphate. If so, this is a chemical precursor of cartilage that is receiving widespread support and usage both in the alternative and mainstream therapeutic community. Empirically, I have observed some people to have a gratifying response. It warrants, however, further scientific investigation and justification before I can wholeheartedly endorse its use.
pete: My wife did not mean a brand name, she meant "free of pain."
Dr. Conte: Pete, are you asking if it is reasonable to expect an arthritis patient to be entirely free of pain?
Dr. Conte: Pete, not intending to be flippant, I do not think it is entirely realistic to expect a pain-free existence if one has generalized osteoarthritis. I would rather expect to attempt to achieve a state of relative comfort and maintenance of one's function. Over-reliance on arthritis drugs and/or narcotics can lead to its own problems. I am not adverse, furthermore, to considering other forms of therapies, including massage, relaxation techniques, acupuncture and chiropractic.
Bella: Thank you, Dr. Conte and News 10.
Dave: Any comment on methyl-sulfonyl-methane (MSM) or dietary sulfur for use in arthritis treatments?
Dr. Conte: MSM is a preparation that is again found in precursor chemicals of cartilage, somewhat akin to glucosamine sulphate. I am not aware myself of any long term placebo-controlled studies looking at MSM as there have been with glucosamine sulphate. I and many of my patients have received fliers in the mail promoting various commercial preparations. None of these are monitored by the FDA. I can only tell you that anecdotally some patients say they have received benefit from its use.
Dave: Thank you, Dr. Conte, for your MSM opinion.
Teddy: Thank you, Channel 10 and Dr. Conte, and I think this is a great way for viewers to get more information then a few general questions that the broadcast has time for. And again, thank you.
BigK: I totally agree, Teddy!
Symptoms of arthritis
Kids and arthritis
Other Doc Chats | Better Health for Life