PSORIATIC ARTHRITIS MEDICAL NEWS

Hello, and welcome once again to our fourth newsletter. Since I
started in
September, my biggest challenge has been to narrow down the
absolutely huge
amount of medical information available on the websites that I use.
It's a
good problem to have.

For new members interested in browsing past newsletters, just sign in
at our
web site
PsoriaticArthritis@y... Using the messages link, look up the
following:
Issue No. 1 is #15233 - 09/03/01
Issue No. 2 is #15455 - 09/09/01
Issue No. 3 is #16018 - 10/18/01
If you are unable to access the newsletters, please e-mail me direct
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Please remember that any information published in this newsletter is
intended
for your general knowledge only and is not a substitute for medical
advice or
treatment for specific medical conditions. You should seek prompt
medical
care for any specific health issues by contacting your health care
providers.

In our last issue I covered:
1- How you Measure the Severity of your Psoriasis.
2- Current Traditional Methods of Treatment.

As I stated in our last newsletter, this issue will explore
additional news
on Alternate Treatment Methods for Psoriasis. Some of the following
information is provided by the National Psoriasis Foundation.
Alternative
Methods will cover Acupuncture, Ayurveda, Chiropractic,
Climatotherapy, Diet,
Dietary Supplements, Homeopathy, Magnets, Meditation/Relaxation,
Miscellaneous Topical Products, Traditional Chinese Medicine.

PSORIASIS THERAPIES - ALTERNATIVE METHODS
Self-treatment and the use of alternative medicine are very common
among
people with psoriasis and psoriatic arthritis. In some cases, they
may be
tired of the challenge of finding a traditional therapy that works,
or they
may be concerned about the possible side effects associated with many
of
those therapies. No matter the reason, the popularity of
nontraditional
treatment approaches is growing.
In many areas of alternative medicine, there is little or no
scientific
evidence that these practices will improve symptoms of psoriasis and
psoriatic arthritis. But the NPF hears success stories involving just
about
everything one could imagine being used as a treatment. Individual
experiences will vary, and one should make treatment decisions with
an open
mind and realistic expectations. The NPF also advises that a
physician be
consulted before any therapy or treatment regimen is begun.

ACUPUNCTURE - Acupuncture is a technique involving the manipulation
of
needles placed in the body. Needles are placed at
specific "meridians" or
acupressure points to relieve pain and treat disease.
The NPF has been told that physicians in China do not generally use
acupuncture to treat psoriasis, and a blinded, randomized study
published in
1997 indicated that acupuncture was not more effective than placebo
("sham"
acupuncture) in treating psoriasis. However, several uncontrolled
studies
have shown that acupuncture is an effective treatment for psoriasis.
Anecdotal reports to the NPF are mixed, with some people saying they
have
been helped by it and others not. People who have tried it and have
had
improvement say it takes many treatments. Acupuncture has few known
side
effects, so people interested in trying it have little to lose, other
than
the expense of the treatment.
Alternative Methods: Acupuncture, Ayurveda,
Chiropractic,Climatotherapy,
Diet, Dietary Supplements, Homeopathy, Magnets,
Meditation/Relaxation,
Miscellaneous Topical Products, Traditional Chinese Medicine.

AYURVEDA - This ancient healing method originated in India more than
5,000
years ago. Prevention is the key to Ayurvedic medicine. It encourages
attention to balance in one's life through diet, herbs, lifestyle and
right
thinking. Managing disease and restoring health involves assessing
the whole
person to understand the nature of the imbalance. For psoriasis, a
specific
treatment regimen might involve: topical application of certain oils,
such as
sesame or mustard; fasting and other dietary guidelines; the
elimination of
stress; and regular physical exercise. The NPF does not know of any
studies
that specifically look at Ayurvedic medicine as a therapy for
psoriasis.

CHIROPRATIC - Chiropractic is the practice of manipulating the spine
for
therapeutic benefit. The practice began in the U.S. in the late 1800s
and is
now a widely recognized alternative therapy. The NPF is not aware of
any
clinical studies on the usefulness of chiropractic in treating
psoriasis. The
treatment regimen recommended by Dr. John O.A. Pagano, a New Jersey
chiropractor, does include spinal manipulations, along with a strict
diet and
internal cleansing (enemas). There are many people who have had
success with
Dr. Pagano's treatment program, but the overall importance of
chiropractic
manipulations in the regimen has not been proven.

CLIMATOTHERAPY - Sunlight can be a valuable treatment option for
people with
psoriasis. Eighty percent of the people who get regular daily doses
of
sunlight enjoy improvement or clearing of their psoriasis.
Climatotherapy is
a term sometimes used to discuss the use of sunlight and water, such
as the
ocean or other bodies of water, to treat psoriasis. For
climatotherapy, the
best-known location is the Dead Sea in Israel, where each year
thousands of
people with psoriasis and other skin disease go for the extensive sun
exposure and baths in the unique water. This treatment is very
effective and
safe in most cases, although it is an expensive option for people
from the
U.S. Other climatotherapy sites do exist around the world, but their
facilities and reputation do not match that of the Dead Sea.
DIET - There is no specific diet that people with psoriasis should
follow.
The best diet is the one that makes the individual feel the best,
because
people with psoriasis benefit from a healthy lifestyle and eating
habits,
just like everybody else. Still, many people report that certain
foods either
aggravate or improve their skin. Several dietary regimens have been
put
forward with claims that they will improve psoriasis. Convincing
scientific
studies have not been conducted to verify these claims. However, the
NPF has
heard enough successful anecdotal reports to suggest that some people
may
benefit from these diet plans.

DIETARY SUPPLEMENTS -The category of "dietary supplements" covers a
lot of
ground-from vitamins to minerals to herbal products to a wide range
of
miscellaneous substances. In most cases, claims that a particular
dietary
supplement can improve or cure psoriasis have not been proven.
However,
clinical studies do exist on fish oil supplements and evening
primrose oil,
both of which produced some good results in psoriasis. Other
supplements
mentioned in various reference books include: burdock, milk thistle,
yellow
dock, red clover, mountain grape and sarsparilla. Taken in proper
amounts,
many supplements are probably harmless, but consumers are largely on
their
own in safeguarding their health. In addition, dietary supplements
can
interact negatively with prescription medications, so it is wise for
people
to inform their physician before they start taking a supplement, even
a
multi-vitamin.

HOMEOPATHY - Homeopathy is a school of medicine based on the premise
that
"like cures like." Practitioners believe that substances that produce
certain
symptoms in a healthy person can cure diseases that have similar
symptoms. As
an example, homeopathic physicians might use a natural product known
to cause
stomach irritation in a healthy person and administer it in a greatly
diluted
form (from three to 100,000 times) to treat a stomach ulcer.
The NPF is not aware of studies that show specific homeopathic
products or
regimens will help improve or clear psoriasis. However, several
people have
written to the NPF about success they've had with homeopathic
treatments,
including homeopathic petroleum and sulphur. Homeopathic remedies are
usually
so diluted that they will not cause any side effects if they are
tried. A
consultation with a physician trained in this practice will help
guide the
treatment.

MAGNETS - Promotion and use of therapeutic magnets for relieving pain
has
become more and more popular in recent years. While there are several
theories as to why they might be effective, no one is absolutely sure
how
magnets work. It's easy to find positive testimonials about magnet
therapy,
but rigorous scientific studies are less common. Still, they may be
worth a
try for a person suffering with chronic pain from psoriatic
arthritis.
Anecdotal reports of unpleasant side effects do exist, and magnets
are not
guaranteed to be safe, so people should talk to a physician before
starting
magnet therapy.

MEDITATION/RELAXATION - There is clear anecdotal and scientific
evidence that
stress can trigger or aggravate psoriasis in some people. Therefore,
practices that promote relaxation and stress reduction are often
recommended
for people with psoriasis.

HYPNOSIS - Both on its own and as an addition to other psoriasis
treatment,
hypnosis was cited as being helpful in clearing psoriasis in several
published case reports. One study examined the use of meditation-
based
relaxation tapes in patients undergoing ultraviolet light (UV)
treatments.
Patients who listened to the tapes during the treatments cleared
faster-in
some cases, twice as fast-than patients who had the light therapy
alone.
Along those same lines, an upublished study found that PUVA (a type
of UV
therapy) patients who had some type of psychological intervention or
relaxation training/guided imagery improved much faster than patients
who had
no intervention. The mind can be a powerful tool for healing. Any
technique
that can help people with psoriasis learn to manage stress and give
them a
better sense of control over the mental aspects of the disease is
potentially
worthwhile. These techniques, however, seem to work best when used to
supplement-not replace-traditional medical treatments.

MISCELLANEOUS TOPICAL PRODUCTS - Moisturizing the skin is an
important part
of treating psoriasis, and the market is full of moisturizing
products that
could fall into the "alternative" or "natural" category. Aloe vera
was shown
in one study to be effective in treating psoriasis. Neem oil, emu
oil, jojoba
and other substances have no evidence that they help psoriasis, but
they may
because of their moisturizing properties. Bath and moisturizing
products
containing oat derivatives are known to be soothing to the skin.
Other
topical products may have more medicinal effects, such as witch
hazel, tea
tree oil, mahonia aquifolium, capsaicin and evening primrose oil.
Capsaicin
(a natural ingredient in hot peppers) helped scaling, redness and
itching in
two studies on psoriasis, and it is also well known as a topical pain
reliever. Several capsaicin products are available over the counter.

RADITIONAL CHINESE MEDICINE- Traditional Chinese Medicine (TCM) is an
ancient
health care system that involves many different practices. The
administration
of many herbs, combined in unique formulations for each individual
patient,
is one of the primary treatments. TCM can come in oral, topical and
injectable forms. In China, many herbal preparations, both oral and
topical,
are available for treating psoriasis. Some of these make the skin
more
sensitive to ultraviolet light and are combined with traditional
phototherapy. The NPF has received anecdotal reports of people with
psoriasis
improving on TCM, but studies are difficult to conduct because the
herbal
mixtures are often individualized. In trained hands, the centuries of
wisdom
behind TCM may be able to help some people. However, caution is
advised. The
lack of quality control, regulation and standardization of TCM has
led to
several reports of products being tainted with prescription drugs or
other
contaminants. Liver complications have arisen in multiple patients

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SEVERE PSORIASIS THERAPY RAISES SKIN CANCER RISK - Reuters Saturday,
September 29, 2001 By Amy Norton NEW YORK, Sep 28 (Reuters Health) -
Psoriasis patients who have been treated with both the drug
cyclosporin and
one type of radiation therapy face a greatly increased risk of
developing
skin cancer, researchers report.
The radiation therapy, which consists of exposing skin to ultraviolet
light
along with giving the drug psoralen--a tactic known as PUVA--was
already
known to raise skin cancer risk on its own. This study shows that
when
cyclosporin is later given to PUVA patients, this sends up the risk
even
further.
"What's new here is the magnitude of the increase in risk," the
study's lead
author, Dr. Robert S. Stern, told Reuters Health.
Among PUVA patients who later took cyclosporin, the frequency of skin
tumors
after starting the drug was seven times higher than in the 5 years
before
going on it. Patients who were on cyclosporin for at least 3 months
saw a
fourfold increase in their risk of developing skin cancer, Stern and
colleague Isabelle Marcil of Beth Israel Deaconess Medical Center in
Boston,
Massachusetts, found.
The risk was specifically for a type of skin cancer called squamous
cell
carcinoma, and it was significantly increased only among patients who
had
received at least 200 PUVA treatments, according to the report in the
September 29th issue of The Lancet.
Psoriasis is a chronic, often painful, disease marked by patches of
red,
raised skin covered with silvery scales. Psoriasis is considered
severe when
it covers more than 10% of the body. These patients usually need more
aggressive therapy, which includes PUVA and treatment with the immune-
system
suppressing drug cyclosporin.
Patients who receive both treatments go through two situations that
raise
skin cancer risk--high exposure to ultraviolet light, followed by
immune-system suppression, which hinders the body's cancer-fighting
capacity.
Because psoriasis is believed to involve an abnormal immune system
response,
a number of immune suppressant drugs are now being investigated as
new
treatments, Stern noted.
These findings, he said, offer a "cautionary tale" that such drugs,
given at
some point after PUVA, could significantly boost skin cancer risk.
Stern also said the study results suggest researchers should look at
the
order in which various psoriasis treatments are given. Psoriasis is a
chronic
disease, he noted, and over a lifetime, various "cycles" of therapy
may be
tried, depending on the severity of the disease.
This study involved 1,380 psoriasis patients who had started PUVA
between
1975 and 1976, 31 of whom were also given cyclosporin by 1998.
SOURCE: The
Lancet 2001;358:1042-1045.

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EAST, WEST MAY COMBINE THERAPIES - September 24, 2001 - DERBY, Conn.
(AP) -
They come to the Integrative Medicine Center as a last resort,
believing
conventional medicine has failed them.
A woman with chronic pain syndrome. A man with progressive heart
disease. A
young person dying of cancer. All frustrated and hurting, some
desperate,
others merely curious. What gives patients hope is the center's
unconventional approach and the attitude of its caregivers - one a
medical
internist, one a naturopath who uses homeopathic or herbal remedies,
massage
therapies and acupuncture.
"They sometimes come here expecting miracles," said Dr. David Katz,
the
center's director. "We're good, but we're not that good." Katz, an
internist
and preventative care specialist, has teamed up with Christine
Girard-Couture, a naturopath, to offer what may well be the next big
thing in
health care - integrative medicine, the combination of ancient
healing arts
with modern science.

At a time when more Americans are choosing alternative therapies,
integration
can be very beneficial, said Dr. Stephen Straus, director of the
National
Center for Complementary and Alternative Medicine at the National
Institutes
of Health.
"I think it's a good idea when multiple health care practitioners put
their
heads together to come up with the best course of treatment for a
patient,"
he said. The emerging field is "absolutely the wave of the future,"
said
Larry Kopelman, a naturopath and a member of the board of directors
of the
year-old American Association of Integrative Medicine.
"It's really coming from a groundswell of people who have found a
great deal
of dissatisfaction with Western medicine," he said. The reason
integrative
medicine works, Kopelman said, is because it combines the knowledge
of two
philosophic hemispheres and treats the patient as a whole. "Western
medicine
is at its best for acute trauma," he said. "But when it comes to more
everyday ailments, Western medicine has failed miserably." On the
other hand,
Straus cautions that alternative therapies are still undergoing
rigorous
study, and patients should remain cautious.
"These are unproved treatments," he said. "They may have side
effects. They
may interact with other mainstream treatment. An herbal medicine may
negate
the ability of traditional drugs to be effective."
Integrative medicine is also struggling to find its identity and a
universal
definition. Simply putting a chiropractor and a Chinese herbalist
under the
same roof does not constitute integrative medicine, Kopelman
said. "It's much
greater than that," he said. But Katz and Girard-Couture seem to have
the
right idea, he added.

Naturopaths are not licensed in some states, but they are trained,
with four
years of pre-med courses and four years of post-graduate studies. It
is not
clear how many physicians are adding alternative medicine to their
practices.
At the Integrative Medicine Center, patients are led to one of two
exam rooms
where they spend 40 minutes each with a medical doctor and a
naturopath in a
tag-team examination.

While the patient is headed home, the two caregivers consult with
Katz and
Girard-Couture and the group comes to a decision about what treatment
to
recommend, based on the patient's preference. Sometimes the doctors
recommend
antibiotics. They might recommend acupuncture or homeopathic
remedies. For
Girard-Couture, who as a naturopath is prevented by state law from
prescribing medication, the advantage of having a medical doctor
available
means she has access to his ability to prescribe drugs, when
necessary. For
Katz, the advantage of having a naturopath on staff means he has a
walking
encyclopedia of homeopathic and botanical remedies at his disposal.
"No one individual can know it all," Katz said. "The bottom line is
to have
an open mind," Girard-Couture added.

Though integrative treatment gives patients a sense of control over
their own
health, Straus said he's afraid people might abandon effective
traditional
treatments in favor of radical treatments that might not work. But
that
doesn't mean doctors should write off what appear to be primitive
techniques.
"That bias is as unhelpful to the development of medicine as is the
bias that
just because people have used these in Africa and China they must be
safe,"
he said. As long as it's been proven safe and effective, Straus
agreed with
Katz and said it doesn't matter where a drug or treatment originates.
"Medicine is a constantly evolving discipline," he said. "It had
always
incorporated ideas that have proven themselves over time. There
really is
only one medicine, and that's good medicine."
Copyright 2001 The Associated Press. All rights reserved.

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Editors Note: Since many of us are involved with individual
treatments that
may include anti TNF agents, Remicade -(infliximab), Enbrel -
(etanercept),
or the older Methotrexate regimen, the following article provides
insight
into current medical thinking and raises interesting questions about
the
inherent risk factors.

THE DARK SIDE OF AN ARTHRITIS BREAKTHROUGH
Eric Sabo, Medical Writer

INTRODUCTION: With her quick laugh and endless charm, it's easy to
forget
just how lousy Caryn Goldstein can feel. At 33, she suffers from both
rheumatoid arthritis and Crohn's disease, two inflammatory conditions
that
leave her achy and exhausted.
"I've tried just about every drug," she says, adding that nothing has
given
her much relief.
She had high hopes that Remicade (generic name infliximab) would be
different. The new drug, which blocks a pain-causing nuisance known
as tumor
necrosis factor (TNF), has proven beneficial for both Crohn's and
rheumatoid
arthritis. A perfect fit. But for Goldstein, the drug backfired.
The series of shots left her disoriented, and for a week afterward
she felt
like she had a terrible case of the flu. Then at a hospital last
October in
Kentucky, she looked up from the needle in her arm to see her nurse's
eyes
turn "as wide as saucers."
A bright rash had spread almost instantly across Goldstein's face.
Fearing
that Remicade could put her at risk for deadly anaphylactic shock,
she and
her doctor decided that was enough.
"Remicade was a disaster for me," says Goldstein.
Many patients have experienced quite the opposite. Indeed, Remicade
and other
drugs that interfere with TNF are some of the most impressive pain-
relief
missionaries to come around in years, often providing help to those
who have
exhausted all other options.
"These drugs are the miracle drugs of the decade," says John Cush,
MD, an
arthritis specialist at Presbyterian Hospital in Dallas. "The effects
can be
just dramatic."

THE DANGER: But doctors are noticing a dark side as well. Although
problems
are rare, anti-TNF drugs are increasingly linked to unusual and
distressing
side effects. On August 17th, the Food and Drug Administration (FDA)
will
meet with their arthritis advisory board to discuss the latest
concerns.
"I have no idea how this will shake out," says one former FDA board
member.
Adverse events reports filed with the FDA put these drugs in the
vicinity of
a number of serious and potentially deadly side effects. The reports,
which
were made available to CBS HealthWatch through a Freedom of
Information Act
request, are hopelessly incomplete. They do not, for example, place
blame on
a specific drug: Rather, they simply show that a drug was taken
around the
time of a severe reaction.
Nevertheless, the FDA relies on these documents to issue new
warnings, or
worse--to determine if a drug is dangerous enough to be withdrawn.
Some
adverse events found over a 2-month period:
o From September 1 to December 31st of 2000, 22 patients died while
taking
Enbrel (etanercept) and 18 needed emergency care at a hospital.
Remicade,
which has greater sales overall, was listed in 48 deaths and nearly
100
life-saving interventions to prevent "permanent damage." Many
patients were
taking various drugs in addition to anti-TNF ones. But the only
treatment
listed for one 9-year-old girl who needed to be hospitalized was
Enbrel. The
drug is approved for use in juvenile rheumatoid arthritis.
o At least five patients developed lupus after taking Remicade,
including one
43-year-old man. Although there is no conclusive evidence that these
drugs c
ause lupus, experts say that laboratory experiments suggest a
possible link.
At a recent medical conference in the Czech Republic, French
researchers
announced that two of their patients developed lupus soon after
starting
Enbrel.
o Warnings that the FDA issued earlier on anti-TNF drugs continue to
show up
in the latest reports, including nervous system disorders and deadly
infections like sepsis. Disturbing new cases of tuberculosis show up
as well.
Officials say that as many as 60 patients worldwide have developed
tuberculosis while taking Remicade, and nearly a dozen while taking
Enbrel.

HARD TO TELL: Experts familiar with these reports say that it nearly
impossible to
tell how dangerous Enbrel and Remicade might be. Arthritis patents
are sick
to begin with, and they are likely to take various immune-suppressing
treatments, which could be the real trouble.
"A lot of times when you get these reports, it just has very
incomplete
data," says Leslie Garrison, senior vice president of clinical
research for
Immunex, the company that markets Enbrel. "We've been doing our
homework and
it appears that all these rare events are not outside the expected
rates."
Long-term clinical trials show that TNF agents are overwhelmingly
safe for
the 5 years they have been looked at. But experts say that such
studies may
give an incomplete picture as well.
"You only use the healthiest patients for a study," says one
researcher who
took part in a TNF drug trial and asked not to be named. Stacking the
deck
may make it hard to tell how others will do, especially if they are
elderly
or suffer from other conditions besides arthritis. It's left to
random
adverse event reports to fill in the blanks.
"Any death is a concern," the researcher says.
And there is reason to suspect that there may be more problems than
what is
recorded.
"Most doctors don't report this stuff," says Cush. "It's a pain in
the ass."
He estimates that the real number of adverse events related to these
drugs
could be ten times as high as the FDA suggests. Caryn Goldstein, for
one,
says authorities were not told about her bad reaction to Remicade.
"I didn't know you could do this in cases like mine," she says.

SETBACK: Should Enbrel and Remicade be withdrawn? Hopefully not,
experts say.
All drugs come with an inherent risk, and rheumatologists have toiled
for
years with dodgy treatments because they had little else. Anti-TNF
agents
offer a more precise way to attack arthritis and they show a
startling
potential to turn the disease around.
"These drugs are having profound effects on the joints," say Jack
Klipple,
the scientific advisor for the Arthritis Foundation.
Unless TNF agents are more dangerous than expected, experts urge
doctors and
patients to keep an open mind.
"It's really an individual decision," say Cush. "Are they willing to
accept
the known and unknown risks for a better quality of life?"

ARE TNF DRUGS BETTER? With the discovery of how TNF goes about its
dirty
work, researchers could finally hone in on a major cause of
inflammation and
shut it down. But is the high-tech approach necessarily better?
Studies both completed and in the works suggest that methotrexate,
the
long-time favorite for treating rheumatoid arthritis, has so far held
its
ground when measured head-to-head against anti-TNF drugs. And
researchers say
they have 20 years of experience in judging methotrexate's safety,
compared
to 5 years with Enbrel and Remicade.
"Here at Johns Hopkins, and I think at many other institutions, we
still use
methotrexate first," says Joan Bathon, MD, who led a major study that
compared this drug to Enbrel. She says doctors will quickly move
patients to
anti-TNF drugs if methotrexate fails, but the cost and long-term
safety
questions make them cautious. "You have to be careful whom you use
these
drugs on," she says.
There are plenty of doctors who say that anti-TNF drugs should be the
first
choice, contending that the new understanding of rheumatoid arthritis
demands
swift attention. But a recent study from Australia suggests that TNF
is not
always the enemy.
"We tested the idea that TNF is essential for rheumatoid-arthritis-
like
disease in mice and found that it wasn't," says Ian Wicks, MD, a
rheumatologist at the Royal Melbourne Hospital who helped out on the
study,
which was published in the Journal of Clinical Investigation this
June. "At
the moment, we can't predict who or who will not respond" to anti-TNF
drugs.
A little bad news may not dampen sales. Unlike other arthritis drugs,
doctors
can make extra money by providing shots of anti-TNF treatments in
their
offices. "Not all doctors do this," says Cush. But many like the
arrangement,
he adds--from the patients who get a treatment they need, to the
financial
analysts who are happy with the drug's stock price.
"Everybody wins," says Cush.

Eric Sabo is a staff writer for CBSHealthWatch by Medscape. His work
has
appeared in Johns Hopkins Health After 50, Newsday, and Men's Health.

I always welcome your comments and suggestions. Thanks and good
health to
all.

Jack Nicholas
Cornishpro@a...
Issue 2001 11/07-4