Chapter 110
Maintaining the Joints
The rash with blisters can be very painful and leave scars or disrupted pigmentation, but it usually disappears on its own after a few weeks. About 30 to 50 percent of shingles patients suffer from “postherpetic neuralgia,” persistent pain that can last a year or longer and in some cases can debilitate patients. Nerves in the torso area are usually affected, but in 10 to 25 percent of cases the disease breaks out on the face and leads to permanent facial muscle weakness, hearing loss, or blindness. As if all that weren’t bad enough, shingles quintuples the likelihood of having a stroke in the following weeks, a risk that gradually declines over the next six to twelve months.
It is astonishing that not more people know about it, because the lifetime risk of getting shingles is 30 percent, meaning that nearly one in three people will develop it at some point in their lives. In young adults, the annual likelihood of developing it is only about 1 in 1000, whereas in older adults it rises more to 1 in 100 per year. That corresponds to a million cases of shingles per year in the United States. Fortunately, you can be vaccinated against it.
The first vaccine (Zostavax) has been available since 2006 and uses a live, attenuated viral strain. Its effectiveness, however, was only about 50 percent, and it could not be administered to people with weakened immune systems, such as those infected with HIV or individuals receiving immunosuppressants such as chemotherapy. In 2017, however, a recombinant shingles vaccine (Shingrix) was approved that prevents an outbreak with 90 to 97 percent probability. It requires two separate injections two to six months apart and is expensive, about 280 dollars, but in the US most private insurance plans cover it. In about 10 percent of cases, temporary systemic symptoms occur such as muscle aches, fatigue, headaches, fever, and chills, but Shingrix is considered so much more effective that in the US it is recommended for everyone age 50 and up, even if they have already been vaccinated with Zostavax. Since the new vaccine is only about five years old, there are not yet any data on its long-term safety and effectiveness—they are still being collected—but so far everything looks good. I recently turned 50 and immediately signed up for the vaccination.
Maintaining the Joints
Osteoarthritis (arthrosis), the most common joint disease in the world, arises when the cartilage—the cushioning of the joints—wears away faster than the body can rebuild it. More than 20 million Americans are affected by osteoarthritis, making it the most common cause of physical disability in older people. The average age at diagnosis is 55 years, and the most common symptom is pain, usually in the knees, hands, hips, and the spine. In the US, 40 percent of men and 47 percent of women develop osteoarthritis over the course of their lives.
Pills
Acetaminophen (Tylenol) is generally recommended as the first-choice pain reliever for osteoarthritis, but wrongly. Why? Because it doesn’t work. Although acetaminophen works statistically significantly better than a placebo for pain and for mobility, the clinical benefit is not significant—on a 100-point pain scale, Tylenol is only 3 points better than a placebo. For clinical relevance, it has to be at least 10 points. That doesn’t mean Tylenol doesn’t seem to do anything—it can lower pain by up to 26 points. But a placebo, a sugar pill, lowers pain by 23 points.
An acetaminophen overdose is the most common cause of sudden liver failure, but even the recommended dose can damage the liver. Acetaminophen is definitely safer than most over-the-counter and prescription pain pills, but among those who took it for osteoarthritis pain, the likelihood of developing liver function disorders was almost four times higher than with placebo.
Osteoarthritis has so far been viewed as prototypical wear and tear, but we now know that inflammation plays an essential role in the course of the disease. So can anti-inflammatory medications help? In the United States, most osteoarthritis patients are prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil), naproxen (Aleve), or the prescription drug celecoxib (Celebrex). Unfortunately, primary care doctors are often unaware of the risks that come with these medications, affecting the digestive tract, the cardiovascular system, and the kidneys.
The fact that people with osteoarthritis tend to live shorter lives could be due to the side effects of NSAIDs. They do in fact help with arthritic pain, but 10 to 30 percent of those who take NSAIDs regularly develop stomach ulcers. NSAIDs also increase the likelihood of a heart attack by around 50 percent, which means one additional heart attack per 100 to 200 users each year, and they double the risk of acute kidney failure in those over age 50. The risks in older age are considered so great that the American Geriatrics Society recommends opioids instead of NSAIDs for chronic pain in those over age 75.
Similar risks to the cardiovascular system, the kidneys, and the digestive tract also exist with ibuprofen and naproxen. The cardiovascular risks are similar with the prescription drug celecoxib, but it appears to cause fewer kidney problems than ibuprofen and has a significantly lower risk to the digestive tract than the two over-the-counter drugs.
Given the large risks of this class of medication, there is consensus that they should be taken only at the lowest possible dose and for as short a time as possible, if their use is deemed necessary.
Gels
The best pharmacologic option might be topical NSAIDs, which have been available over the counter in the US since 2020. They appear to be similarly analgesic to oral NSAIDs and carry fewer risks, since less gets into the system. They can cause (mostly) mild skin reactions, but they do not appear to pose a greater risk to the digestive tract than a placebo. They also appear to be safer for the kidneys and the cardiovascular system.
Injections
The “nonsteroidal” in NSAIDs serves to distinguish them from anti-inflammatory steroids like cortisone, which can be injected directly into the joint. The data analysis of half a million Medicare patients with knee osteoarthritis found that about a third of them had received at least one injection of corticosteroids. That can relieve pain in the short term, but in the long term it worsens the condition.
The steroid injections can ultimately worsen pain, stiffen the joint, and accelerate its wear to the point that an artificial knee joint is eventually required. And that in addition to complications such as osteonecrosis (death of the bone) and rapid joint destruction. In a randomized controlled trial, steroid injections for osteoarthritis in the knee led, within two years, to a significantly greater loss of cartilage mass in the subjects—and ironically not even to less pain—than a placebo injection with saline solution (that is, water). The study may have been the “last nail in the coffin” of this practice.
At see.nf/injections you can learn more about other injections, but the bottom line is: Both hyaluronic acid and PRP (platelet-rich plasma—or perhaps better, profit-rich placebo) “cannot be recommended.”
Surgeries
In 2003, a bold study was published in the New England Journal of Medicine that examined the most common orthopedic surgery—knee arthroscopy. Billions of dollars are spent drilling endoscopes into knee joints and cutting out tissue damaged by osteoarthritis and knee injuries, but does the procedure actually help? Knee-pain patients were randomized to actually be operated on or only as a pretense, in a so-called sham surgery in which the doctors cut open the knee and pretended to perform the procedure, filled it with saline solution, but did not change anything in the joint.