EAU CLAIRE - People will see Vicki Iverson-Wolter and say she looks good. They don't see the debilitating effects of arthritis.
"Just because people look good on the outside, sometimes we don't always understand what's going on in the inside," Iverson-Wolter said.
The 55-year-old Eau Claire woman deals with chronic pain, stiffness and fatigue from rheumatoid arthritis.
But she said determinedly, "I'm not going to let it beat me."
On Valentine's Day, she arrived at Mayo Clinic Health System in Eau Claire with her reddish-brown hair curled, her nails painted and a bright pink and purple scarf dressing up her outfit.
She came to Mayo for an intravenous injection of a new drug called Rituxan. She had received a six-hour treatment two weeks prior; this time the injection took four hours.
She hopes the Rituxan will reduce her joint discomfort and fatigue -- and she has good reason to think positively. Treatment for rheumatoid arthritis -- which can severely hamper physical movement -- has advanced in the past 20 years or so.
Previously people with rheumatoid arthritis found little relief. Doctors commonly prescribed aspirin. Surprisingly, gold injections have been used for more than 70 years but fell out of favor because of toxicity problems.
Iverson-Wolter recalled her great-grandmother, who had severe rheumatoid arthritis and a large family to care for, would soak her feet as she stood and ironed clothes so she wouldn't waste time.
Today there are better medications and a better understanding of arthritis, said Dr. Richard Misischia, who is Iverson-Wolter's rheumatologist at Mayo.
Not only are there more effective medications, but there are many more drugs available to help patients, he said.
Living with pain
Thirty-three years ago, Iverson-Wolter's battle with an autoimmune disease began.
She was diagnosed with systemic lupus erythematosus, or SLE, in which the body's immune system mistakenly attacks healthy tissue, leading to long-term inflammation.
She also developed rheumatoid arthritis.
Ten years ago her health took a turn for the worse, she said. She was in so much pain that she couldn't walk and had to use a wheelchair. Her rheumatologist at the time, Dr. Gina Adel, referred her to Mayo Clinic in Rochester, Minn.
She was started on an immunosuppressant to control inflammation. Enbrel worked well until last summer.
Iverson-Wolter was taken off the treatment for several weeks when she had a hysterectomy, so her immune system could "kick up" and fight infection. When she went back on the drug, her body no longer responded to it.
She was switched to another immunosuppressant. Humira didn't work either.
About a month ago she was started on Rituxan, a biologic antineoplastic agent, to try to put her rheumatoid arthritis and SLE back in remission.
Rituxan, Misischia explained, depletes certain B cells integral in the inflammation process in diseases such as rheumatoid arthritis. These cells are part of the immune system that, when malfunctioning, can stimulate inflammation.
Iverson-Wolter also takes an oral corticosteroid medication, prednisone, that she might be able to discontinue with the new drug.
If the Rituxan works, Iverson-Wolter will come every six months to Mayo Clinic Health System for a series of two treatments.
Iverson-Wolter described the pain of arthritis as so severe that a finger can hurt just from being touched.
"It's like your insides are bigger than your skin there's so much pressure inside," she said.
Iverson-Wolter has days when she can't get out of bed and nights when she keeps waking because she can't get comfortable.
Many people experience joint pain as they grow older. They may feel stiff when they get up after lying or sitting for a while.
But arthritis differs from mere arthralgia, or joint pain.
"Arthritis by definition means inflammation in a joint, Misischia said.
The caveat is osteoarthritis is more a degeneration of a joint, he said. While it likely involves some inflammation, it involves wear and tear on a joint, while rheumatoid arthritis is an inflammatory condition.
Typical symptoms of true arthritis are joint swelling, stiffness, redness and heat, said Dr. Marlon Navarro, a rheumatologist with Marshfield Clinic in Eau Claire.
Inflammation might wax and wane, or be constant, Navarro said.
Arthritis is a term used for more than 100 disorders affecting the musculoskeletal system and specifically the joints, where two or more bones meet, according to the national Arthritis Foundation.
Many forms -- including rheumatoid arthritis -- also can damage bodily organs or systems. The inflammation can affect the heart, lungs, eyes and nervous system, Misischia said.
"I always tell my patients that I am treating not only what I see on the outside, but also what I know is going on in the inside," he said.
Rheumatoid arthritis and osteoarthritis are common forms of arthritis.
Doctors don't know the cause of rheumatoid arthritis, but there is a genetic component that many believe makes people more susceptible to environmental factors, such as infection, that may trigger it. Osteoarthritis occurs when the cartilage that cushions the ends of bones in joints deteriorates over time.
About 1 percent of the U.S. population has rheumatoid arthritis, with three times as many women as men affected, Misischia said. In women, onset is typically between ages 30 to 60, while men tend to get it later in life.
Typically it affects multiple joints. It can cause damage to cartilage, bone, tendons and ligaments.
Although rheumatoid arthritis has a genetic component, many families can have only one member with the disease, he said.
At this time there is no way to effectively predict who will get it but this is being researched, he added.
Osteoarthritis is the most prevalent form of arthritis. Affecting nearly 27 million people in the United States, it is more common with age, Navarro said.
While people can get some inflammation with osteoarthritis, it is not to the degree of rheumatoid arthritis, he said.
Risk factors for osteoarthritis include, in addition to heredity, being overweight, having a joint or nerve injury and aging.
Diagnosing the problem
There are several ways to diagnose arthritis, Misischia explained, starting with a clinical exam.
Blood tests can detect the presence of an antibody called rheumatoid factor that may indicate rheumatoid arthritis, he said. However, RF also is found in a small percent of the unaffected population.
Other lab tests and X-rays also are used to diagnose arthritis.
Treatment depends on the type of arthritis, Navarro said. "It is all individual."
Treatments can help relieve symptoms, reduce inflammation and even put arthritis in remission.
There have been treatment breakthroughs for rheumatoid arthritis with new biological agents over the past 15 to 20 years, the doctors said. The new drugs can control symptoms to halt joint destruction, Misischia said.
Analgesics are medications that help with pain. Aspirin used to be the most common one, but now there are others, such as Tylenol and ibuprofen.
Navarro steers away from aspirin, which must be taken in high quantities to relieve the pain of arthritis. "It really irritates the stomach," he said.
Aspirin and ibuprofen also are among nonsteroidal anti-inflammatory drugs used to treat arthritis.
Corticosteroids can help relieve rheumatoid arthritis symptoms, but they also have a lot of side effects. They are not a good long-term treatment, Navarro said.
Potential complications include diabetes, osteoporosis, high blood pressure, glaucoma and increased risk of infection.
Among the new and improved medications are disease-modifying drugs, or DMARDs. These drugs, often taken orally, suppress the immune system and can help slow or halt the progress of rheumatoid arthritis, Misischia said.
The other advance is biologic agents, taken by patients as injections or infusions.
"These are much more potent medicines," he said, adding that researchers are working to develop these in a pill form.
The biologics do a good job of decreasing inflammation in the joints, Navarro said. They alleviate symptoms and may help prevent further joint damage.
To treat degeneration of joints caused by osteoarthritis, options include surgical joint repairs and physical therapy, which strengthens muscles and allows joints to function better, Misischia said.
Often people with rheumatoid arthritis deal with depression, Navarro said.
"Having a chronic disease like that really brings out your vulnerability, and people don't like to feel vulnerable. When you have a chronic disease, it changes you. It changes the way you think about the world and the way you think about yourself. It makes you feel mortal," he said.
People may fear becoming disabled, but this is happening less and less with the new medications, Navarro said.
"Most people get good relief with the treatments, maybe not 100 percent, but they get some kind of relief," he said.
"We are doing so much more ... for all of these diseases," Misichia agreed.
He encouraged people to not delay going to their doctor if they have symptoms because early detection "may help them lead a more normal life."
To lessen the risk of osteoarthritis, Navarro advises people who are overweight to lose extra pounds. Being overweight affects the joints, he said.
He recommends maintaining a healthy lifestyle by eating nutritious foods, exercising and relieving stress -- which affects the immune system -- by doing activities such as meditation and tai chi.
An active lifestyle also helps those who have arthritis, he said. If people don't use their muscles, they get weaker.
"Once you give in to something with this illness, you can't get it back," echoed Iverson-Wolter. She still mourns the day she no longer could water-ski.
"I push every day, but if I don't push every day, it will beat me," she said.
Along with traditional medicine, she has had chiropractic and acupuncture treatments. She visited Hippocrates Health Institute in Florida, which provides natural and alternative health care. She also has practiced yoga and tai chi.
She realizes the importance of staying on top of her arthritis.
"I could be sitting in a wheelchair and I'm not," said Iverson-Wolter, who added she believes in the power of being positive.
She credits great family support from her two sons and their families for helping her deal with arthritis and SLE. Her sons also have severe joint pain, she said, but they have not been diagnosed with SLE.
She also finds support through a network of friends and acquaintances. She is lead scheduler in the endocrinology department at Mayo Clinic Health System.
"I need the people interaction. I need that for me to be healthy," she said.
Taking walks, swimming and soaking in a hot tub all help Iverson-Wolter feel better. She wants to go to a gym and lift weights to regain muscle strength once she gets on an effective drug regimen for her rheumatoid arthritis.
"I'm too young to feel this darn old. There is a lot of life in me," she said. ___
Image courtesy of flickr user Pictoscribe