A Patient’s Guide to Arthritis

What Is Arthritis?

Arthritis means inflammation of the joints. Inflammation generally includes symptoms of redness, heat, swelling, and pain. Many different diseases can result in inflammation of the joints. Arthritis is therefore a general term that describes more than one hundred different diseases of the joints of your body.

In some types of arthritis, the cause of the disease is known, but in others it is still unknown. Some types of arthritis come on suddenly, and others develop slowly. Any joint can be affected, including your knees, hips, neck, shoulders, and fingers.

The diseases that cause arthritis can also attack muscle and connective tissue around joints. Some diseases may even damage other organs of the body, such as the kidneys, intestines, and heart. Because the diseases inflame the joints, most arthritic conditions and related diseases involve chronic (long-term) pain. Over time, they may cause increasing damage to the joints or soft tissues of your body.


Your joints are beautifully designed to minimize stress and damage while you move. Nearly all joints of the body are synovial joints. Most synovial joints occur where two bones come together and must rub against one another to allow motion. Smooth, slick articular cartilage covers the end of the bones so they don’t rub together. Synovial fluid lubricates the joint. Around the joint, connective tissue forms a watertight sack that is called the joint capsule. Small, fluid-filled sacks, called bursae, cushion parts of the joint. Ligaments connect the bones together and tendons connect the muscles to bones. A problem with any one of these parts can lead to joint pain and inflammation–arthritis.


Many people of all ages suffer from arthritis. It is estimated that forty million Americans–that’s one in seven of us–have arthritis. Almost two-thirds of arthritis patients are women, but for some types of arthritis most sufferers are men.

Arthritis and related diseases are often painful to live with and difficult to treat. But your doctor can help you find treatment and pain management strategies that work for you. The method of treatment will vary depending on the specific disease.


A Patient’s Guide to Gout


Gout is a disease that involves the build-up of uric acid in the body. About 95 percent of gout patients are men. Most men are over 50 when gout first appears. Women generally don’t develop gout until after menopause. But some people develop gout at a young age.

This guide will help you understand

  • how gout develops
  • which parts of the body are affected by gout
  • what can be done for the condition


What is gout?

Gout was the first disease in which researchers recognized that crystals in the synovial fluid could be the cause of joint pain. Synovial fluid is the fluid that the body produces to lubricate the joints. In gout, excess uric acid causes needle-shaped crystals to form in the synovial fluid. Uric acid is a normal chemical in the blood that comes from the breakdown of other chemicals in the body tissues.

Everyone has some uric acid in his blood. As your immune system tries to get rid of the crystals, inflammation develops. For the person with too much uric acid, this inflammation can cause painful arthritis.


The first attack of gouty arthritis usually happens in just one joint. Half of the time, gout affects the metatarsophalangeal (MTP) joint. This is the joint at the base of the big toe. Eventually, 90 percent of people with gout will have pain in the MTP joint. Other joints that are commonly affected include the mid-foot, ankle, heel, and knee joints. Less commonly gout affects the fingers, wrists, and elbows.

Over time, patients with gout can develop tophi, or lumps that grow around crystal deposits in joints or near pressure points. Tophi most often occur in the fingers, wrists, ears, knees, elbows, forearms, and heels. Tophi can also grow in the kidneys, heart, and eyes.


Why does gout develop?


The underlying condition that causes gout is called hyperuricemia. It means that you have high levels of uric acid in your blood. This can happen for two reasons: (1) your body creates too much uric acid, or (2) your kidneys don’t excrete the uric acid effectively. Whether or not you will develop gout is related to how bad your hyperuricemia is over time.

For people who create too much uric acid, the cause is usually genetic. Some rare genetic and metabolic disorders can cause overproduction of uric acid, which can eventually lead to gout. The breakdown of purines in the body also releases uric acid. Purines are ingested through certain types of food such as sweetmeats (e.g., liver, kidney, brain) and seafood. The increased intake of fructose-sweetened soft drinks has also been linked with an increased risk of gout. Usually the excess uric acid is then passed out of the body through the urine.

More than 90 percent of people with gout have kidneys that don’t effectively get rid of uric acid. Sometimes this is caused by certain kinds of drugs, such as diuretics, cyclosporine, and low-dose aspirin. Other medical conditions, such as obesity, hypertension, and diabetes, can also make some people more likely to develop gout.

Many gout patients have a combination of overproduction and under-excretion of uric acid. Their bodies create too much uric acid and have problems getting rid of it. This combination of problems happens with drinking alcohol, especially beer. The more alcohol the patient drinks, the worse the problem is. Alcohol both raises uric acid levels in the body and impairs the kidneys’ ability to excrete the buildup.

Acute Causes

Attacks of gouty arthritis seem to be caused by sudden increases in the amount of urate (a solid form of uric acid) in your synovial fluid. This rapid change can be caused by injury to the joint, alcohol use, or use of certain drugs.

An injury that can trigger gout can be very slight. Even gentle exercise can cause inflammation in the joint, although you may not notice it. Once the joint is at rest, the body absorbs some of the water in the synovial fluid. This leaves the synovial fluid more concentrated with urate, which may allow crystals to grow.

Other Factors

Heredity plays a role in gout. In some families, hyperuricemia tends to develop into gout, while in other families it doesn’t. But genes alone don’t account for gout. The rising number of people with gout since World War II suggests more than just a genetic or hereditary basis for this condition.

Dietary changes may be the major difference over the last 60 years. Food scarcity during the 1940s was followed by an increased intake of carbohydrates and especially carbohydrates containing high-fructose corn syrup. The increase in obesity (another risk factor for gout) during the same time supports this idea.

There are several other risk factors for gout. These conditions do not cause gout, but they are closely related to severe hyperuricemia. The risk factors include metabolic syndrome, kidney problems, high hemoglobin levels, high triglyceride levels, and hypertension (high blood pressure). About 14 percent of hypertension patients have gout. A combination of factors such as eating lots of organ meat, a sedentary lifestyle without exercise, and drinking lots of alcohol increases the risk for symptomatic gout.

It is important to note that hyperuricemia alone doesn’t cause gout. Most people with high levels of uric acid in their blood never develop any symptoms of gout. At least five percent of Americans have at least one period of hyperuricemia as adults without showing any symptoms of gout. And most people can tolerate fairly high levels of uric acid in their bloodstream without damage to their kidneys.


What does gout feel like?

Gout causes attacks of very painful joint inflammation. This pain is often described as burning pain. Early gout attacks usually affect only one joint. This joint is most commonly the MTP joint at the base of your big toe. The joint becomes swollen, warm, and red within eight to 12 hours. Most of the time the attacks happen at night. Patients say the pain is so bad the joint can’t even stand the slightest touch. Even the weight of a sheet causes excruciating pain. Walking and standing are almost impossible if the legs or feet are affected. Many patients have flu-like symptoms, including fever and chills. The pain may go away on its own in a few hours, or it may take a few weeks.

Gouty arthritis attacks come and go. There may be months between attacks. Over time the attacks happen more often, last longer, and involve more joints. Eventually the pain doesn’t ever completely go away. The joints stay swollen and tender even between flare-ups, and the flare-ups start to happen every few weeks. Eventually, some patients develop tophi on joints or pressure points and kidney stones.


How do doctors identify the condition?

Diagnosis is important because crystals within the joint can lead to joint damage. This can happen without you knowing it. Patients with arthritic episodes that come and go may not seek medical help. Some patients are medically evaluated but complete testing is not done. They are misdiagnosed with rheumatoid arthritis. Either of these situations will delay treatment and increase the risk of erosive damage to the joint.

The diagnosis begins with a history of your symptoms and a physical exam. Your doctor will need to look at synovial fluid from the affected joint to identify the needle-like crystals. This is the most important part of the diagnosis. To get a sample of the synovial fluid, the physician performs an arthrocentesis. A long, thin needle is inserted into the affected joint and a small amount of synovial fluid is aspirated or removed. The fluid is sent to a laboratory where it is viewed under a special polarized light microscope to determine if uric acid crystals are present.


If there are uric acid crystals, then you have gout. But only 80 per cent of the tests are positive when the person really has gout, so this test is not completely accurate. In some cases (such as the midfoot), it isn’t easy to aspirate fluid. Without the use of fluoroscopy (a special X-ray imaging) or ultrasound to guide the needle, aspiration isn’t done. In these situations, the diagnosis is made without joint aspiration when the patient responds favorably to therapy.

Ultrasonography may be helpful in the diagnosis because the crystals form into the shape of rosary beads inside the hyaline cartilage and this can be seen in the ultrasound pictures. Hyaline cartilage coats the ends of the bones to protect them. Ultrasonography can also show the double contour sign. This sign looks like a top covering or extra coating of the joint surface when crystals are deposited in the hyaline cartilage. Ultrasound studies do not replace fluid removal and examination under a microscope because ultrasound does not confirm infection.

The diagnosis must rule out the presence of infection, which can be a hidden problem. Your doctor may also get a blood test to look at the levels of uric acid. However, uric acid levels rise and fall depending on many complex factors in your body. It is possible to have a normal uric acid level while you are having severe gout pain.

If you have tophi, your doctor may want to biopsy one of the lumps.

Your doctor will need to rule out other forms of arthritis. Gout can occur with other forms of arthritis, such as septic arthritis and rheumatoid arthritis. There are also other diseases that cause different kinds of crystals to form in the synovial fluid.

X-rays don’t show doctors much in the early stages of gout. X-rays can help monitor your disease, and they may be needed to rule out other problems.


What can be done for the condition?

Gout cannot be cured, but it can be very successfully treated. The main goal of treating gout is to reduce the amount of urate in your blood. Joint crystals will not dissolve or go away unless the serum urate concentration is below six mg/dL.

During the acute or early phase of a gouty attack, doctors prescribe medicines called colchicine, certain nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroids to decrease swelling and relieve pain. All of these drugs work quickly and are very effective. The sooner they are given after an attack starts, the faster the pain goes away. These drugs may be given by mouth, through an intravenous line into your bloodstream, or injected directly into the joint. There are some potential adverse side effects of these medications. It may take a bit of time to find the most effective drug with the least intolerable side effects for some patients. But it is important to start treatment during the first few days of an attack to get the best results.

Your doctor may also decompress the affected joint. Aspiration of synovial fluid immediately decreases the pressure in the joint. And the needle leaves a pathway or track that acts as a vent for continued drainage after the needle is removed.

Lifestyle changes can help you manage intermittent gout without using drugs every day. Your doctor may ask you to do the following:

  • Change your diet. Diets that are lower in meat, shellfish, and some other foods can help decrease the amount of uric acid in your body. Avoid fructose sweetened foods and beverages.
  • Quit taking drugs such as diuretics.
  • Lose weight.
  • Quit drinking alcohol.
  • Avoid activities that stress your joints.
  • Drink plenty of fluids to help your kidneys work more efficiently.

If your gout is severe, prolonged, or chronic, you may need to take daily serum uric acid-lowering (SUA) medication to reduce your uric acid levels. Your doctor will put you on the lowest dose possible of medications such as uricosuric drugs or xanthine oxidase inhibitors. Doctors usually prescribe allopurinol (Zyloprim, a xanthine oxidase inhibitor) for patients who overproduce urates or have tophi, kidney disease, or kidney stones. Allopurinol is useful in preventing recurrence of gouty attacks. It blocks the production of uric acid and decreases the formation of purine. For patients who have difficulty getting rid of uric acid through the kidneys, medications to help the kidneys remove more uric acid from the blood may be prescribed as well. Probenecid is one of the commonly prescribed drugs that increase the removal of uric acid in the urine.

Another, serum uric acid-lowering (SUA) medications that has been shown to
reduce the risk of occurrence is Uloric (Febuxostat). Febuxostat has been approved by the FDA for patients with mild to moderate kidney disease. It lowers uric acid slowly enough to avoid flaring up the gout. It isn’t processed by the kidney, so it’s possible patients with kidney disease may be able to take it. But it is metabolized by the liver. Anyone with a liver problem or who abuses alcohol may not be able to take this drug.

As with all medications, you should report any side effects to your doctor right away. Watch for skin rashes, itching, fever, nausea, vomiting, diarrhea, or other new symptoms not present before taking the serum uric acid medications.

Sometimes patients experience a flare-up after taking urate-lowering agents. This reaction can come as a surprise, since you expect your pain and swelling to get better. Flares of this kind mean that old deposits of crystals stored in the tissues are being released. The increase in symptoms is not a sign that new crystals are forming. Don’t stop taking your medication without first checking with your doctor. Getting rid of the old crystals can help protect the joint from further damage.

Doctors seldom treat hyperuricemia without symptoms of gout. However, if hyperuricemia is at least moderately bad over several years, it is more likely to lead to gout. In this case, a doctor may begin treatments to prevent gout. This is called prophylaxis.

A program to control uric acid levels and manage symptoms often includes daily colchicine and allopurinol or probenecid (usually both are not taken at the same time) along with dietary restrictions. Regular follow-up with your physician and blood tests to detect serum uric acid concentration that are above the six mg/dL target level are important in maintaining good control and preventing joint erosion.

So far, there are no drug treatments to prevent the formation and deposit of these crystals in the joints. Researchers continue to look for pharmacological and other biologic therapies that might prevent, if not cure, gout for those who suffer from symptomatic outbreaks.

Joint Injections for Arthritis

A Patient’s Guide to Joint Injections for Arthritis

Doctors recommend joint injections of corticosteroids (also commonly known as cortisone) for many arthritis patients. Cortisone is a powerful anti-inflammatory medication that can reduce joint inflammation. Because the medication is injected directly into the joint, the effects of the medication are concentrated on the painful joint. The injected cortisone can bring the inflammation in the joint under better control and decrease the swelling and pain.

These injections involve putting a needle directly into the joint. Through the needle, your doctor can remove excess synovial fluid (the lubricating fluid found in joints) and inject corticosteroid medication to help reduce the inflammation, pain, and swelling.

This process may sound risky. It is actually safe and fast. It involves little or no pain. And therapeutic injections have important benefits. They deliver the medicine to the exact spot that needs it. They also allow you to use lower and fewer doses of oral steroids, which are highly toxic.

Most doctors give only three to four injections per year in large, weight-bearing joints. This includes joints in your knee and hip. However, patients with arthritis pain that cannot be controlled in other ways can get injections more often.


The most common side effect from injections is a temporary increase in pain and swelling. Rest, cold packs, and anti-inflammatory drugs help this pain go away within four to twenty-four hours. Studies have shown that about 6 percent of arthritis patients who receive injections in their joints experience this passing pain. It is probably caused by the body’s reaction to the corticosteroid crystals in the medicine. If you have problems with pain and swelling after injections, your doctor may want to change the type of corticosteroid in your next injection.

Another fairly common complication is mild, temporary flushing (sudden redness of the skin) and agitation. Injections can also make diabetic symptoms worse.

There is a chance that the injection can introduce an infection into the joint. However, the odds of this are very slight. Studies show infections following injections happen from 1 in 1000 to 1 in 1600 times. Still, infections in the joint can be very serious. It is important to have an experienced professional perform the injection.

Some doctors and patients have wondered if the cartilage and other tissues of the joints are damaged by injections into the joint. Studies have not shown this to happen.

Systemic Lupus Erythematosus

A Patient’s Guide to Systemic Lupus Erythematosus


Systemic lupus erythematosus (also called SLE, or lupus) is an autoimmune disease of the body’s connective tissues. Autoimmune means that the immune system attacks the tissues of the body. In SLE, the immune system primarily attacks parts of the cell nucleus.

SLE affects tissues throughout your body. Five times as many women as men get SLE. Most people develop the disease between the ages of 15 and 40, although it can show up at any age.

This guide will help you understand

  • how SLE develops
  • how doctors diagnose the disease
  • what can be done for the condition


Where does SLE develop?

SLE causes tissue inflammation and blood vessel problems pretty much anywhere in the body. SLE particularly affects the kidneys. The tissues of the kidneys, including the blood vessels and the surrounding membrane, become inflamed (swollen), and deposits of chemicals produced by the body form in the kidneys. These changes make it impossible for the kidneys to function normally.

The inflammation of SLE can be seen in the lining, covering, and muscles of the heart. The heart can be affected even if you are not feeling any heart symptoms. The most common problem is bumps and swelling of the endocardium, which is the lining membrane of the heart chambers and valves.

SLE also causes inflammation and breakdown in the skin. Rashes can appear anywhere, but the most common spot is across the cheeks and nose.


Why do I have this problem?

Doctors and researchers know quite a bit about the changes in the bodies of SLE patients. But the cause of SLE is a mystery.

Heredity plays a role in SLE. If you have a close relative who suffers from SLE, you are much more likely to develop the disease yourself. However, genes alone do not seem to cause SLE. It seems to be triggered in unknown ways. Not everyone with a tendency toward SLE will develop the disease. Researchers think some of the triggers that set off SLE may be infections, stress, diet, and toxins, including some kinds of prescription drugs. These triggers may also help explain why SLE has a cycle of flare-ups and remissions.


What does SLE feel like?

The symptoms of SLE come on in waves, called flares or flare-ups. In between flares, patients may have almost no symptoms. Almost every SLE patient suffers from general discomfort, extreme fatigue, fever, and weight loss at some point. In addition to these general symptoms, SLE produces different symptoms in different body systems.


Rashes caused by SLE are red, itchy, and painful. The rash can show up on any part of the body. The most typical SLE rash is called the butterfly rash, which appears on the cheeks and across the nose. SLE also causes hair loss. The hair usually grows back once the disease is under control.

People with SLE tend to be very sensitive to sunlight. Being in the sun for even a short time can cause a painful rash. Some people even get a rash from fluorescent lights at work.

Muscles and Bones

Systemic Lupus Erythematosus

Almost everyone with SLE has joint pain or inflammation. Any joint can be affected, but the most common spots are the hands, wrists, and knees. Usually the same joints on both sides of the body are affected. The pain can come and go, or it can be long lasting. The soft tissues around the joints are often swollen, but there is usually no excess fluid in the joint. Many SLE patients describe muscle pain and weakness, and the muscle tissue can swell.

In its late stages, SLE can cause areas of bone tissue to die, called osteonecrosis.. Osteonecrosis can cause serious disability. It can be caused at least in part by using high doses of corticosteroids over a long time. Corticosteroids help control the symptoms of SLE.


People with SLE usually don’t notice any problems with their kidneys until the damage is severe. Sometimes kidney problems aren’t noticed until the kidneys are actually failing.

Nervous System

SLE can cause headaches, seizures, abnormal blood vessels in the head, and many other problems with the nervous system. SLE can also cause organic brain syndrome. This disorder involves serious problems with memory and concentration, emotional problems, and severe agitation and hallucinations. Any of these symptoms may show up alone, without any other symptoms of SLE.


In the body, membranes surround your internal organs. The membranes around your lungs, heart, and the organs in the abdomen become inflamed in SLE. This is called serositis and can be seen on X-rays. Many SLE patients develop symptoms of pleurisy (swelling of the membrane around your lungs). The pericardium, the membrane around your heart, is often affected as well.

Digestive System

Problems with the stomach and intestines are common. Symptoms include abdominal pain, loss of appetite, nausea, and sometimes vomiting. In most cases this is caused by serositis in the membrane around the organs in your abdomen.


SLE can cause many lung problems.

  • Inflammation of the lungs, called Lupus pneumonitis, can come on suddenly or slowly. It has many of the same symptoms of pneumonia.
  • A hemorrhage (burst blood vessel) can occur in the lungs.
  • A blood clot can form in the artery going to the lungs.
  • The blood vessels in the lungs can begin to contract.
  • Shrinking lung syndrome involves scarring of the lungs due to long standing inflammation decreases the lungs’ capacity to take in air. It seems that the lungs can no longer hold normal amounts of air.


SLE causes very low levels of red and white cells in your blood. SLE often does not directly cause low levels of red blood cells, called anemia. Anemia is instead caused by blood loss, kidney problems, or the drugs taken to control the disease.

You may have few of these symptoms, almost all of them, or any combination in between. The disease affects different people in very different ways. There is even a group of patients considered to have latent lupus. They have some chronic SLE symptoms, but the disease never seems to progress into true SLE.

A few patients have drug-induced lupus. In these cases, SLE symptoms come on suddenly while taking certain kinds of drugs. The symptoms are usually milder than in true SLE, and the symptoms go away when the patients stop taking the drug.


Because so many SLE patients are young women, pregnancy is a major concern. Women with SLE can get pregnant. The disease can be managed during pregnancy if it has already been brought under control. However, the chances of miscarriage, premature birth, and death of the baby in the uterus are high.


How do doctors identify the condition?

Your description of symptoms and a detailed medical history will help your doctor make a diagnosis. Your doctor will also do a complete physical exam. You will be asked to give a blood sample.

The exams and tests your doctor will do to diagnose SLE depend on your symptoms. You may be asked to have X-rays taken of joints or organs. You may need to have an ultrasound of your heart or kidneys. Many other tests and exams can help diagnose SLE. Because SLE can develop and change over time, your doctor may ask you to do some of these tests again, to help monitor your disease.

Treatment Options

What can be done for SLE?

Treatment options for SLE have improved dramatically since the 1970s. SLE cannot be “cured” and will most likely be a lifelong disease that will require management and attention. You and your doctor should be able to find ways to manage flare-ups.

Lifestyle Alterations

One of the most important parts of dealing with SLE is learning about your own disease. The more you know, the better you can help yourself. Many patients find support groups helpful, both to learn about the disease and to meet others with SLE.

The skin of many SLE patients is extremely sensitive to sunlight. To avoid painful rashes, avoid going outside during the middle of the day, use sunscreen, and wear hats and long clothing.

Infections are common with SLE. If you come down with a fever, talk to your doctor right away. This is especially important if you are on certain drugs, including high-dose corticosteroids and cytotoxic drugs, those that are destructive to cells.

Birth control is important in women with SLE. It is especially important in women with kidney disease. Many of the drugs used to treat SLE can harm a growing fetus, so any pregnancy must be planned with the help of your doctor.


Several types of drugs can be used to treat the complications of SLE. What your doctor prescribes for you will depend on your symptoms.

  • Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to treat muscle, bone, and joint pain, and mild cases of serositis (inflammation of internal membranes). They may also be used for fevers.
  • Corticosteroids are used in many forms. Creams are rubbed into rashes, and oral or intravenous forms are used to treat flare-ups and to keep the disease under control. Corticosteroids can be injected directly into painful arthritic joints. These drugs are very toxic, however. It is important to use them only when absolutely necessary.
  • Antimalarial drugs (hydroxychloroquine, chloroquine, and quinacrine) work to manage the skin problems of SLE. They can also help treat other symptoms. These drugs can hurt your eyes. As a precaution, you may need to get regular eye exams if you take antimalarial drugs.
  • Methotrexate in low weekly doses can help manage arthritis, rashes, serositis, and other symptoms.
  • Cyclophosphamide, given intravenously, is often used when SLE is affecting the kidneys, heart, and lungs. This is an extremely toxic drug, with many side effects. Patients often experience severe nausea and vomiting and almost total hair loss. The hair does grow back, even when patients must continue taking the drug.
  • Azathioprine can be used instead of cyclophosphamide to treat kidney disease. Doctors consider it less effective, but it is also far less toxic. It can also be used instead of steroids.

SLE progressively damages the kidneys over time. In late stages of the disease, kidney failure requires dialysis or kidney transplants.

SLE is a very serious disease. Its effects on the kidneys, heart, and lungs can cause many long-term problems. Although doctors now have better ways to help you live with SLE, there are not many options to help prevent or reverse the damage to your organs.