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ARTHRITIS AND RHEUMATISM ASSOCIATES A NEWSLETTER FOR PATIENTS VOL. 10, NO. 3 • WINTER, 2000

NINTH PHYSICIAN JOINS ARA Margaret Dieckhoner, Administrator

The physicians Dr. Kelly was awarded her under- training, Dr. Kelly remained at and staff of graduate degree from Dartmouth Albany Medical College where she Arthritis and College, in Hanover, New was an Assistant Professor of Rheumatism Hampshire. She earned her Medicine in the Division of Associates, P.C. medical degree from Albany Rheumatology until joining our (ARA) enthusi- Medical College where she was a group. astically member of Alpha Omega Alpha, a welcomed medical honor society. Dr. Kelly Dr. Kelly is a native New Yorker. Dr. Sheila Kelly to our practice in completed her residency at She was born in the Bronx, but her early September. Dr. Kelly is a Albany Medical Center Hospital family moved to Westchester Board Certified Rheumatologist and received her fellowship County when she was eight years who comes to us from Albany training in Rheumatic Diseases at old. Her family still resides in Medical College in Albany, New Albany Medical College. After New York. York. completing her fellowship When asked at what stage of her life she developed an interest in POINTS ON JOINTS medicine, Dr. Kelly recalls a desire to become a physician as far back CORTISONE – CURE-ALL Norman S. Koval, M.D. as age six. She notes two major influences in her decisions to both OR POISON? enter medicine, and subsequently to specialize in rheumatology. Glucocorticoids (also known as nied “high dose” therapy. The cortisone or “steroids”) have been challenge of glucocorticoid steroid As a child, Dr. Kelly came down extremely important agents in therapy continues to be the coun- with a routine illness that treating diseases that are character- terbalancing of desirable remained misdiagnosed until her ized by inflammation and anti-inflammatory and immuno- pediatrician, whom she fondly exaggerated immune responses. suppressive actions versus the describes as “an old-fashioned Cortisone, the parent compound, undesirable pharmacologic activi- clinician”, took charge and set was first isolated from the adrenal ties. The decision to institute things straight. His knowledge and gland tissue in the 1930’s, but glucocorticoid steroid therapy style of practice reinforced her interest in glucocorticoids really must be derived from an under- interest in medicine into her adult soared with the research of Philip standing of these agents and the life. Showalter Hench and his adverse reactions that may accom- colleagues in the late 1940’s. pany their use. The minimal dose Later, as a resident, Dr. Kelly Hench began to use this hormone of glucocorticoid steroids that are decided to change her focus from compound in the late 40’s and necessary to suppress the disease OB GYN to medicine. At that received the Nobel Prize for it in process being treated should be point, she did a rotation with Dr. 1950. The enthusiasm for the used. These goals generally can Joel Kremer, a highly respected pharmacologic use of glucocorti- be at least partially attained by rheumatologist. It was this coid steroids in the treatment of using short acting glucocorticoid mentor’s influence that ignited a inflammatory diseases was soon steroids at the lowest possible special interest in Dr. Kelly, and dampened by the recognition of dose and for the shortest period of led her to seek additional training serious side effects that accompa- time. to become a Rheumatologist.

see CORTISONE continued on page 5 see PHYSICIAN continued on page 5

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ANSWERS Evan L. Siegel, M.D. To Herbert S. B. Baraf, M.D. David G. Borenstein, M.D. Your Questions

Q. If I have arthritis, can I to discuss the parameters of a chi. Illness causes an imbalance exercise? new exercise program with in the flow of chi in these your physician or physical meridians. Stimulation of A. The answer to this question is therapist. Physical activity in specific points along the merid- an emphatic YES! Not only those who have been inactive ians can correct the flow of chi can patients with arthritis should be started slowly and to optimize health, or block exercise, but it is extremely gradually increased. pain. important that they do so. Cardiovascular testing may be Studies have shown that appropriate for some patients Traditional acupuncture uses patients with osteoarthritis before starting vigorous exer- thin needles at specific points who exercise have improved cise training. Low impact along the meridians to rebal- muscle tone which can aerobic type exercises such as ance the flow of energy. prevent or delay further joint walking, swimming, water Between 5 to 15 thin, flexible, deterioration. Some of the exercise, or bicycling are solid, sterile needles are many benefits of exercise in helpful in maintaining muscle inserted from a fraction to 4 people with all types of tone and strength without inches deep. As the needles arthritis include improvement much stress on the joints. Tai are inserted, the recipient feels in joint pain and mobility, Chi and Yoga are good ways a range of sensations from reversal of muscular atrophy to maintain flexibility and normal to tingling, warmth, or and improvement in bone muscle tone. Gentle, but pinching. The needles are left mineral density. This latter progressive, resistance and in place from 5 to 60 minutes effect is of special importance weight training have been (20 minutes is usual). A course to post menopausal women shown to be of significant of 10 treatments may be and patients on corticosteroid benefit to patients with required to obtain maximum therapies who are already at arthritis. Joints that are benefit. Follow-up treatments great risk of osteoporosis. acutely inflamed should not every few months may be Inactivity specifically be vigorously exercised, but necessary to maintain normal increases the risk of osteo- can benefit immensely from energy balance. porosis, as well as the risk of isometric and range of motion bone, joint and muscle injury. exercise. Significant pain The mechanism that makes Nonspecific benefits of should always be respected. acupuncture work to relieve exercise, of course, abound. Finally, stretching before all pain is related to the release of People who exercise are forms of exercise is important endorphins (the body’s own healthier and live longer. to prevent local injuries. pain reliever) and the stimula- Cardiovascular status is tion of the large sensory fibers improved, the risk of falling In many forms of arthritis and that block the transmission of is reduced, weight control other musculoskeletal disor- pain signals from small pain becomes easier, the risk of ders, a prescription for fibers. Pain relief from colon cancer and diabetes exercise can be just as impor- acupuncture can be reversed by diminish and symptoms of tant as a prescription for naloxone, a medication that depression and anxiety are medicine. Discuss this with reverses endorphin effects. relieved by regular exercise. your doctor soon. Sleep patterns improve and Acupuncture fits the role of a even smoking cessation is Q. Is acupuncture helpful as a complementary therapy. easier with exercise. therapy for pain? Complementary therapies supplement the efficacy of While the benefits of exercise A. Acupuncture is based upon the other therapies including drug are clear, several restrictions Chinese theory that energy and physical therapy for the and caveats apply to patients pathways, called meridians, treatment of chronic pain. The with arthritis. First, it is wise carry the body’s energy, called frequency of a positive

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response to treatments is coordinators are primarily disability caused by their unknown. Acupuncture is responsible for this reputation. illness. We are proud to have worth the effort if all other Together with the pharmaceu- assisted in the endeavor, while therapies have been tried and tical industry and the FDA, always keeping patient safety are not fully effective. they have helped bring about as our utmost concern. Some Acupuncture should also be some of the most significant patients become involved in considered if toxicities prevent advances in arthritis therapy the process to find treatments the use of first-line treatments. in our lifetime. Many of our which may help when stan- Acupuncture is a passive, time- patients have enjoyed, or bene- dard therapies have failed. consuming procedure. It is fited from, the experience so Other patients are pleased to also relatively expensive since much that they have volun- be involved in our research insurance coverage for this teered to enter additional program because costly drug therapy is not universal. study programs. treatment is free to partici- pants. Finally, many Q. I have been asked to People have various reasons participants learn more about participate as a subject in for participating in clinical the nature of their arthritis, a clinical trial. Why should research. No one would argue and its response to treatment, I participate? that the knowledge gained in the clinical trial process. from the clinical research A. Over the years, hundreds of process brings rewards to We respect whatever motiva- patients have participated in society as a whole. This is tion you may, or may not, clinical trials at our Center for evident in the recent spectac- have to be a part of this Rheumatology and Bone ular advances in arthritis program. Participation is Research. Our research is therapies. Many study voluntary and consent can be nationally respected by the patients feel a need to do their withdrawn at any time, for any pharmaceutical research part in advancing medical reason. If you are interested, industry for the quality of our knowledge, which in turn, or have any questions, speak work. Our patients and highly helps all arthritis patients find to your doctor or fill out the qualified clinical research relief from the pain and enclosed form and mail it in.❄

CLINICAL TRIALS QUESTIONNAIRE

If you or someone you know would like to learn more about our clinical trials program, call our study department at (301) 942-6610 or return this form to: The Center for Rheumatology and Bone Research 2730 University Blvd. West, Suite 306, Wheaton, MD 20902

I am interested in learning more about participating in a clinical trial.

Name: ______Phone #:______Address: ______Best time to reach you: ______Your Physician______Diagnosis and/or symptoms? ______Check here if you are interested in receiving a free pamphlet on clinical trials.

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THE FUN RHEUM

In the spirit of “Who Wants to be a Rheumatologist?” here are 10 questions to test your knowledge of Rheumatology. While there are no monetary rewards, you’ll probably be interested in some of the tidbits surrounding what we do here at Arthritis & Rheumatism Associates.

Please choose the best correct answer.

1. Rheumatologists deal with diseases of the: 6. Rheumatoid Arthritis probably first occurred in: A. Joints A. New World Indians 3,000-5,000 years ago B. Bones B. Europeans during Middle Ages C. Muscles C. Chinese D. All of the above D. Egyptians during the reign of Ramses

2. By the year 2010 the number of practicing 7. Rheumatoid Arthritis is best treated with: Rheumatologists will be: A. The old tried and true medicines A. More than we need B. New potent and safer medicines B. Half the number required C. Over the counter medicines C. Just right D. “Natural Products” D. None. All arthritis will be cured 8. Arthritis treatments proven effective include: 3. Rheumatologists have ____ years of additional A. Anti-inflammatory medications training after completing medical school: B. Dietary supplements A. 2 C. Magnets B. 5 D. Copper bracelets C. 6 D. 10 9. Arthritis can be caused by: A. Infection 4. Arthritis can effect: B. Immune disease A. The very young C. Injury B. The very old D. All of the above C. Only the middle aged D. All age groups 10. Arthritis medications can adversely affect the: A. Blood 5. In addition to arthritis, Rheumatologists B. Stomach also treat: C. Kidneys A. Osteoporosis D. All of the above B. Back Pain C. Bursitis and Tendonitis Answers on page 6 D. All of the above

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POINTS ON JOINTS

CORTISONE continued from page 1 PHYSICIAN continued from page 1

Several side effects of glucocorti- bursitis. Most studies confirm In addition to her enthusiasm for coid therapy are characteristic minimal long-term adverse effects her profession, Dr. Kelly pursues early in therapy, including when corticosteroids are adminis- many other interests. She is a insomnia, emotional lability, tered in this fashion. It has been voracious reader—usually reading enhanced appetite or weight gain estimated that approximately one two to three books (on a wide or both. Common in patients with patient in 50,000 to 60,000 injec- range of subjects) simultaneously. underlying risk factors or other tions will develop an infection. She also enjoys running, skiing, drug toxicities are hypertension, Our patients who receive injec- hiking and going to the movies. diabetes, peptic ulcer disease and tions are always directed to call acne. the office immediately if swelling If you ask Dr. Kelly what brought develops at the site of injection, or her to the D.C. area, she will tell Other side effects are anticipated if there is fever. you she had decided to leave with use of sustained and intense academic medicine, but was only treatment. Risk can be minimized Low dose daily oral therapy at the interested in joining a progressive, by conservative dose regimens and lowest possible dose (generally well-run, cutting-edge group. Her other medications known as less than 5 to 7.5 mg of prednisone extensive search and interview steroid-sparing agents when by mouth per day) appears to be process ended, she states, when possible. Cushingoid habitus the safest route of systemic corti- she found our practice. (moon face, buffalo hump, obesity costeroid treatment. of the trunk), pituitary and adrenal We are pleased to welcome Dr. gland suppression, infection, Alternate day therapy is associated Kelly as the ninth member of our osteonecrosis (sudden severe bone with fewer side effects than high physician team. She will see pain), muscle abnormalities, or dose daily therapy. Alternative patients in our Laurel and impaired wound healing are all day therapy is attempted when the Wheaton offices.❄ possible in these patients. primary disease has been brought under control by the daily dose Insidious and delayed side effects regimen. There are groups of which are likely dependent on patients that will need to stay on cumulative doses include osteo- daily corticosteroid therapy. porosis, thinning of the skin, cataracts, atherosclerosis, growth Your rheumatologist has been retardation in children or fatty trained to use these drugs and is liver. knowledgeable about the side effect profile. Most patients who Rare and unpredictable problems are at risk for the development of include psychosis, pseudo tumor GIOP (glucocorticoid induced Rheumors Volume 10, Number 3 cerebri, glaucoma and inflamma- osteoporosis) will be started on Fall, 2000 tion of the pancreas. concomitant medicine to prevent A NEWSLETTER FOR PATIENTS this side effect. A quarterly publication brought to you by Alternative forms of corticosteroid Arthritis & Rheumatism Associates, P.C. Norman S. Koval, M.D. dosing and delivery will help Dr. Hench’s pioneering work in Herbert S. B. Baraf, M.D. reduce the side effect profile. glucocorticoid therapy has Robert L. Rosenberg, M.D. There are topical corticosteroids provided literally millions of Evan L. Siegel, M.D., Editor provided as lotions, creams or patients the opportunity to survive Emma DiIorio, M.D. ointments. severe diseases and reduce pain Sheila M. Kelly, M.D. states. As with all drugs, corticos- David G. Borenstein, M.D. Specific local injections of corti- teroids should be treated with John L. Lawson, M.D. costeroids are of great value in respect and reverence, but not Werner F. Barth, M.D. selected patients and clinical with fear. They are neither cure- Margaret Dieckhoner, Editor settings. These are used in the alls nor poison.❄ © 1990 Arthritis & Rheumatism Associates treatment of arthritis, tendinitis or

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To Our Enbrel Patients

PRACTICE NOTES Since its introduction 2 years ago, demand for Enbrel has grown rapidly. So rapidly in On November 1, 2000, at the Annual Conference of the fact, that demand could soon, American College of Rheumatology, and in the pres- temporarily, exceed supply. ence of thousands of his colleagues, Dr. Werner F. Because of this, Wyeth and Barth was awarded the prestigious title of Master of the Immunex have created the American College of Rheumatology. Please join us in Enbrel Enrollment Program. congratulating Dr. Barth on his significant accomplish- This program will ensure that ment. your Enbrel therapy will not be interrupted. If you do not Dr. Robert L. Rosenberg was interviewed along with enroll, you may experience other national osteoporosis experts on the National delays in getting your Enbrel Public Radio (NPR) show “All Things Considered” in prescriptions filled. To enroll August. He appeared on WRC News with Doreen call toll-free 1-888-4 ENBREL Gentzler in April and in July he was a guest on a Voice (436-2735). PLEASE call now to ensure your enrollment by of America call-in show about osteoporosis. December 31, 2000. If you have questions, please feel free to Dr. David G. Borenstein was a guest on NPR’s “All call our office. Things Considered” last spring where he discussed the new Cox-2 drugs Celebrex and Vioxx. ANSWER KEY: 1-D, 2-B, 3-B, Congratulations! 4-D, 5-D, 6-A, 7-B, 8-A, 9-D, 10-D

PRESRT STD U.S. POSTAGE PAID Arthritis & Rheumatism ROCKVILLE, MD Associates PERMIT # 1632 2730 University Blvd. West, #310 Wheaton, MD 20902 301-942-7600