Conditions we Treat

Rheumatoid arthritis is a chronic disorder for which there is no known cure. The goal of rheumatoid arthritis treatment now aims toward achieving the lowest possible level of arthritis disease activity and remission if possible, minimizing joint damage, and enhancing physical function and quality of life. Treatment options include medications, reduction of joint stress, physical and occupational therapy, and surgical intervention.

As with any rheumatoid arthritis treatment, we will discuss the benefits and drawbacks before beginning an alternative or new type of therapy. Our center will determine and find an approach that has value and will not be harmful.

Gout is a painful and potentially disabling form of arthritis that has been around since ancient times. Gout can be treated and controlled. Symptoms are often dramatically improved within 24 hours after treatment has begun. Attacks can be prevented with appropriate therapy to lower the blood uric acid levels and change in lifestyle by addressing the modifiable risk factors.

NY Integrative Rheumatology is providing latest technology and equipment available for medical observation to evaluate and treat a patient at any stages of medical condition.

Fast Facts

• Though some of the joint changes are irreversible, most patients will not need joint replacement surgery.
• OA symptoms (what you feel) can vary greatly among patients.
• A rheumatologist can detect arthritis and prescribe the proper treatment. The goal of treatment in OA is to reduce pain and improve function.
• Exercise is an important part of OA treatment, because it can decrease joint pain and improve function.
• At present, there is no treatment that can reverse the damage of OA in the joints. Researchers are trying to find ways to slow or reverse this joint damage.

Osteoarthritis (also known as OA) is a common joint disease that most often affects middle-age to elderly people. It is commonly referred to as “wear and tear” of the joints, but we now know that OA is a disease of the entire joint, involving the cartilage, joint lining, ligaments, and bone. Although it is more common in older people, it is not really accurate to say that the joints are just “wearing out.” It is characterized by breakdown of the cartilage (the tissue that cushions the ends of the bones between joints), bony changes of the joints, deterioration of tendons and ligaments, and various degrees of inflammation of the joint lining (called the synovium).

This arthritis tends to occur in the hand joints, spine, hips, knees, and great toes. The lifetime risk of developing OA of the knee is about 46 percent, and the lifetime risk of developing OA of the hip is 25 percent, according to the Johnston County Osteoarthritis Project, a long-term study from the University of North Carolina and sponsored by the Centers for Disease Control and Prevention (often called the CDC) and the National Institutes of Health.

OA is a top cause of disability in older people. The goal of osteoarthritis treatment is to reduce pain and improve function. There is no cure for the disease, but some treatments attempt to slow disease progression.

CASE 1

A 68 year old woman presents to your office after retiring from New York City to South Carolina. She is interested in discussing her bone health. She notes that she had a DXA scan performed 3-5 years ago and was told that her bone density was slightly reduced and it was recommended that she take Calcium and Vitamin D supplementation. She is otherwise healthy. She has no specific complaints. She has never sustained a fracture. She denies tobacco or alcohol use. She reports that her mother fell and broke her hip at age 88 years old. Her current medications include Calcium with Vitamin D. Her vital signs are normal and her physical examination is unremarkable.

For her evaluation you request routine laboratory testing to include a comprehensive metabolic panel (CMP), complete blood count (CBC), and serum 25 (OH) Vitamin D level, and all of these tests are normal. A DXA scan is performed and reveals a T-score of L1-L4 to be -2.2, and the right femoral neck T-score is -2.6.

What are your recommendations to this patient?

The DXA scan interpretation reveals that the patient has osteoporosis of the femoral neck T-score of -2.6. She has a family history of osteoporosis with a maternal history of hip fracture. She is thus at increased risk for fracture and should be treated with pharmacologic therapy. The options include anti-resorptive agents such as the bisphosphonates, raloxifene, and denosumab. Raloxifene has been demonstrated to reduce the incidence of vertebral fractures however it does not reduce hip fracture incidence. She is at highest risk for a hip fracture, thus a better choice would be either a bisphosphonate or denosumab therapy. Considerations in the selection of an agent include route of administration (oral or intravenous bisphosphonate therapy or subcutaneous denosumab), frequency of administration and cost to the patient.

CASE 2

A 72 year old woman presents to your office after retiring from New York City to Florida. She is interested in discussing her bone health. She notes that she had a DXA scan performed 3-5 years ago and was told that her bone density was slightly reduced and it was recommended that she take Calcium and Vitamin D supplementation. She is otherwise healthy. She has no specific complaints. She has never sustained a fracture. She denies tobacco or alcohol use. She reports that her mother fell and broke her hip at the age of 88 years old. Her current medications include Calcium 1200 mg daily with Vitamin D 1000 IU daily. Her vital signs are normal and her physical examination is unremarkable.

For her evaluation you request routine laboratory testing to include a comprehensive metabolic panel (CMP), complete blood count (CBC), and serum 25 (OH) Vitamin D level, and all of these tests are normal. The DXA scan interpretation reveals a T-score of L1-L4 to be -1.8, and the right femoral neck T-score is -1.9. The FRAX scores corresponding to these T-scores indicate a 17% and 6.3% ten year probability of a major osteoporotic fracture and hip fracture, respectively.

How would you discuss the meaning of her DXA scan results and of the FRAX scores? What are your recommendations to this patient?

The FRAX tool is a fracture risk assessment tool based on the patient’s age, body mass index (BMI), tobacco use, alcohol use, presence of RA, use of glucocorticoids, prior history of fracture, parental history of hip fracture and presence of secondary causes of osteoporosis. The FRAX tool can be applied to patients with osteopenia (T-score between -1.0 and -2.5) who have not been taking medications for osteoporosis (except for Calcium and Vitamin D). It utilizes the femoral neck bone mineral density. Fifty percent of fractures occur in patients with osteopenia, so the FRAX tool is helpful to identify those patients at higher risk for fracture. The FRAX tool provides both a ten year probability prediction for a major osteoporotic fracture (hip, vertebral, forearm, humerus) and for a hip fracture. Thus, two risk predictions are provided for a ten year probability for fracture. For the United States, based on economic factors relating to the cost:benefit ratio, a 20%or higher probability of a major osteoporotic fracture or a 3% or higher probability of a hip fracture at ten years would warrant pharmacologic therapy for osteoporosis.

Thus, this patient is at increased risk for a fracture and should be treated for osteoporosis. She should be offered anti-resorptive therapy with the option of a bisphosphonate or denosumab.