Cornell Women's Health Advisor

WEILL MEDICAL COLLEGE OF CORNELL UNIVERSITY

H E L P I N G W O M E N O V E R 5 0 M A K E I N F O R M E D H E A L T H D E C I S I O N S TM

May 2005 Volume 9 / Number 5

IN THIS ISSUE 2

Frontline

• Radiation therapy for breast cancer no longer seems to pose heart risks • Physical activity in middle age aids functioning later • Genetic mutation linked to macular degeneration • Cancer warning for prescription eczema creams

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Your Healthcare

An FDA panel says Celebrex and Bextra can remain on the market—but with cautions

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Cardiac Health

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Solutions

Mentioning the unmentionable—fecal incontinence

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FYI

News from the Society for Women’s Health Research: Surprising differences in male and female brains

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Ask Dr. Etingin

• What causes acid reflux?

• Does caffeine trigger atrial fibrillation?

Separating the hype from clinically proven remedies can be difficult when you’re in pain—here’s what you should know The controversy over the arthritis medications called COX-2 inhibitors has raised concern among the many patients who rely on these and other antiinflammatory medications for pain relief. Even before the withdrawal of Vioxx last fall (see page 3), many patients started looking into other options for pain management, including complementary and alternative medicine (CAM). According to a survey by the National Center for Complementary and Alternative Medicine (NCCAM), joint pain and arthritis tied in fourth and fifth place among the top 10 reasons Americans turn to CAM. One of the biggest problems when dealing with CAM is people equating the words “natural” with “safe,” stresses rheumatologist Steven Magid, MD, of the Weill Cornell-affiliated Hospital for Special Surgery.

Dr. Magid says when his patients protest that a remedy is “natural,” he counters: “So is asbestos.” This is not to say that natural remedies can’t and don’t help arthritis. As Patience White, MD, chief public health officer of the Arthritis Foundation (AF), points out, “Aspirin is made from tree bark.” Here’s a look at what may work—and what may not.

Exploring acupuncture Acupuncture utilizes hair-thin needles placed in the skin at specific points along the body to facilitate the circulation of the body’s energy (called Qi). This energy is said to flow to the various organs along a network of invisible channels called meridians. How it works is unclear, but the meridians do correspond to nerve networks involved in pain transmission. One theory is that acupuncture may stimulate nerve fibers, which send impulses to the spinal cord and the brain to activate specific brain chemicals to produce

pain relief. Acupuncture has been proven so safe and effective that it has become a widely accepted therapy for a variety of problems; 1 million people a year try acupuncture, primarily for pain relief.

Recent studies have found traditional Chinese acupuncture reduces knee pain and improved function for people with OA when added to medical therapy. Researchers at the University of Maryland’s Center for Integrative Medicine recruited 570 patients with knee OA and randomized them to either 23 acupuncture treatments, “sham” treatments (taping of needles at the same points on the leg), or a 12-week educational program, the “Arthritis Self-Help Course.”

All participants, two-thirds of whom were women (average age 65.5) were told to continue using their analgesic or antiinflammatory medications during the 26week trial.

Both the real and fake treatments were done with a sheet over the stomach blocking patients’ vision, so no one could tell what was being done. That’s one of the reasons the results of the study were so impressive, according to one of the chief investigators, Lixing Lao, PhD, Lac, a licensed acupuncturist. While it took 8 weeks before the first benefits were seen, results held through 26 weeks, even when treatments decreased to once a month. Overall, those who received acupuncture had a 40 percent decrease in pain and a nearly 40 percent improvement in function, compared to those who attended the educational program (which had previously been shown to be an effective adjunct to medical therapy), or those who received the sham treatment.

Lao feels the maintained benefits are very promising, and thinks that the average patient Continued on page 6

ILLUSTRATION BY MARINA TERLETSKY

• Why heart disease is now a global killer of women • Vital new information on aspirin

Alternative Therapies for Arthritis

ALTERNATIVES Continued from page 1 might benefit with monthly treatments.

Ultimately, he thinks, “we might consider using acupuncture first instead of medication, at least for less severe cases of osteoarthritis. Or this therapy might enable the patient to benefit from lower doses of pharmaceutical treatment.”

Glucosamine and chondroitin Glucosamine is a natural substance the body uses to build and repair cartilage; it also has Glucosamine anti-inflammatory properties.

Chondroitin exists naturally in cartilage, where it acts to draw fluid into the tissue and also has antiinflammatory properties.

Glucosamine supplements are made from crab, lobster, or shrimp shells; chondroitin is made from animal cartilage. Each seems to have a positive effect on human cartilage. Laboratory studies show the glucosamine and chondroitin provide added elasticity and even repair damaged cartilage.

There have been dozens of clinical studies of glucosamine and chondroitin over the years, but many of these were funded by the supplements’ makers. So in 2000 the government started enrolling 1,588 participants at 13 sites around the country for the GAIT (Glucosamine/Chondroitin Arthritis Intervention Trial). GAIT won’t be completed until November 2005.

While one recent study reported in the American Journal of Medicine found glucosamine was no better than placebo for knee OA, Dr. Magid is a believer in glucosamine. “I’m 100 percent sure that glucosamine works,” he says.

Dr. Magid recommends 1,500 mg of glucosamine daily to patients. For chondroitin, the suggested dosage is 1,200, and it’s recommended that this be broken into three doses throughout the day. The Arthritis Foundation offers these caveats: Because glucosamine is an amino sugar, check your sugar levels more frequently if you have diabetes. Check with your doctor about chondroitin if you’re on bloodthinning drugs, and do not use glucosamine if you’re allergic to shellfish.

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WHAT YOU CAN DO Hyaluronic acid One of the more debated therapies involves injections of hyaluronic acid (HA), a fluid that naturally occurs in the joints. It’s kind of like a “lube job” for creaky joints.

Dr. Magid was initially dubious of HA. “I tried it on five or six patients when it first came out, and it worked on maybe one patient. I couldn’t believe the literature was favorable.” But a few years later, he tried it again. “I’ve used it on 30 people in the last two years and it’s been really effective. I’m ASU very impressed with it now.”

HA therapy requires 3-5 doctor visits, and it’s very expensive, Dr. Magid points out.

But you have to weigh the expense against the minimal risks, taking an inexpensive antiinflammatory, and the risk of a stomach ulcer. When you’re comparing expenses, he reminds patients, HA “may be worth trying because joint replacement is expensive, too.”

Magnetic attraction Magnet therapy has been widely touted over the years by arthritis patients, but until recently it has not been clinically tested. Worldwide sales of magnetic bracelets and other products were estimated at $5 billion in 1999.

Magnets are believed to interfere with pain transmissions by nerve fibers, but study results so far have been mixed.

A recent study in England involving 194 men and women with knee or hip OA found a significant reduction (27 percent) in pain scores of patients who wore a standard-strength bipolar magnet bracelet for 12 weeks, compared to those wearing a nonmagnetic bracelet. However, the researchers reported in the British Medical Journal in December 2004, they couldn’t determine how much of the reported effectiveness was also due to the subjects’ use of painkillers.

By contrast, a U.S. study of 49 patients found magnets did not change the “pain information” transmitted by neurons and so concluded they weren’t really a viable therapy. Both

The Center for Women’s Health Care

To safely use CAM therapies: ■

Before you use any herbal and dietary supplements, visit the Arthritis Foundation website:www.arthritis.org/conditions/alttherapies/default.asp

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For information on CAM therapies, check the National Center for Complementary and Alternative Medicine web site: www.nccam.nih.gov

studies hypothesized that any “relief ” came from the placebo effect; subjects simply believed it would work.

Less well tested options Among other CAM therapies touted for arthritis, few have much credibility.

Avocado-soybean unsaponifiables (ASU) has had limited testing. One six-month study of 114 people with knee OA and 50 people with hip OA found a “statistically significant” increase in pain relief and mobility, but it took a while for the effects to kick in. Once they did, the study said, benefits persisted for up to eight months. (ASU is available as AvoSoy through various Internet sites.)

Devil’s claw is made from the root of an African herbal plant. The Clinical Journal of Pain and Rheumatology recently pooled data from several small trials, and found only limited support for its use. People who took six 435 mg capsules daily for 1-2 months had modest relief of OA pain in the knee and hip. Possible side effects include lowered blood pressure and interference with blood-thinning, cardiac, or diabetes medications.

MSM (methylsulfonylmethane) is sometimes combined with chondroitin and glucosamine, but so far its effectiveness has not been proven.

“I tell my patients it’s bad enough to take poisons that we know are poisons,” says Dr. Magid, who adds that even FDA-approved medications can and do have side effects. So he cautions against taking any “nutraceutical” that hasn’t been clinically proven.