Osteoarthritis Discussion with Dr. Joanne Jordan: Part One

Part One: Osteoarthritis Care and Current Studies at UNC

Dr. Falk: Hello, this is Ron Falk for the Department of Medicine at the University of North Carolina. Welcome to the Chair’s Corner.

Here, we have a chance to discuss and highlight people, programs, and important things happening in our Department. Today we are talking with Dr. Joanne Jordan. She is the Joseph P. Archie, Jr. Eminent Professor of Medicine and Chief of the Division of Rheumatology, Allergy, and Immunology. She is also the Director of the Thurston Arthritis Center. Welcome, Dr. Jordan.

Dr. Jordan: Thank you.

Dr. Falk: You have had a long career in thinking about arthritis. Tell us about where arthritis care is today.

Dr. Jordan: Certainly as you’ve mentioned I have had a long career in rheumatology. We’ve seen complete revolution in the way we take care of inflammatory arthritis. Like rheumatoid arthritis, psoriatic arthritis- and that has happened with the use of new medications. Biologics, which actually get at some of the causative inflammatory mediators of those diseases. These types of therapies will continue to evolve and bring better care for our patients with those diseases.

We have also been focused on the most common kind of arthritis—osteoarthritis. And we don’t really have a disease-modifying medication at this point in time. With rheumatoid arthritis we can do more than just stop inflammation, we can actually stop the damage with these newer therapies. We don’t have that in osteoarthritis and we are striving to find that magic bullet. With osteoarthritis it’s going to be much more of a multi-factorial type of approach. That is, dealing with inflammation, dealing with the biomechanics that get altered in the joint when the cartilage breaks down, when the bones react and become too big for the joint—all of those things will have to continue to be worked upon as we go into the next 25 years.

Dr Falk: If I’m a patient listening out there, how do I know what kind of arthritis I have? How do I know if I have osteoarthritis or rheumatoid arthritis? Osteoarthritis is by far and away the most common.

Dr. Jordan: Osteoarthritis certainly is the most common, and that is the type of arthritis that people tend to get as they get older. You can get it younger, particularly if you’ve had long-standing obesity, or if you’ve had a joint injury, and we’re very involved in looking at what happens to the joint that’s injured, what happens to that joint that makes it more susceptible to get arthritis later.

The interesting thing about how we diagnose as rheumatologists, how we diagnose what type of arthritis someone has, is we actually talk to the patient. This is one of the areas where really talking to your patient, understanding what joints are involved, that’s a huge clue for us. Which joints are involved, do they get better and then get worse again? Are you fine in between flare-ups, and so on? So the best way, of course is to talk to your physician, and potentially see a rheumatologist. The joints that are involved in inflammatory arthritis, like rheumatoid arthritis are usually different than the ones that are involved in osteoarthritis. Osteoarthritis gets the large joints—knees, hips, it can get the finger joints as well. Rheumatoid arthritis tends to hit more the small joints of the hands and feet, and then can also involve other joints.

Dr. Falk: You’ve described a really beautiful multidisciplinary and almost holistic approach to somebody with osteoarthritis. Can you describe that in greater detail?

Dr. Jordan: Absolutely. It’s one of the things that really drives what we do at the Thurston Arthritis Research Center and drives the care that we deliver for patients with osteoarthritis. What I like to think about is really, everyone, everyone is at risk for osteoarthritis. So we may take care of people who have lupus, or who have rheumatoid arthritis, or who have other types of conditions—diabetes, heart disease, kidney disease. But we’re all at risk for osteoarthritis, particularly with the obesity epidemic, and joint injuries as I mentioned earlier, but particularly with the obesity epidemic. Some of the things that we do to help other types of arthritis or other medical conditions, cause them to gain weight, putting them at risk for osteoarthritis.

One of the holistic types of things we do in our rheumatology clinic is really think of everyone who comes to see us as someone we need to be thinking about, not just what can we do right now to help this person, but how can we preserve those joints from osteoarthritis later? Osteoarthritis is one of those things where drugs alone are not the answer. We need to alter the biomechanics, weight loss, physical activity, strengthening, and what we would call non-pharmacologic things have to be the mainstay, in addition to whatever other types of therapies we may come up with.

Dr Falk: You’ve learned a tremendous amount about this disorder and you’ve learned about it from a number of different perspective. Let’s walk through those different approaches. Is there a genetic predisposition to osteoarthritis?

Dr. Jordan: Absolutely. We’ve done a lot of work in genetics and osteoarthritis. Joint injury and obesity are clearly very important risk factors, but we all know people who get osteoarthritis who have neither of those risk factors. One of the things I think we need to remember and teach our residents and fellows is to ask about a history of arthritis in the family, and particularly a history of joint replacement. Very, very telling as far as whether that family may have osteoarthritis.

Women tend to get osteoarthritis in the hands, finger joints around the time of menopause, and those changes are very predictive of the development of osteoarthritis elsewhere. That is a highly hereditary condition.

But there are lots of different types of osteoarthritis, depending upon what joints are affected, and the genetics may be different for each one.

Dr. Falk: You’ve learned a lot about osteoarthritis from your studies in Johnston County. Can you tell us about that experience? How did it start, where is it now, what have you learned from it?

Dr. Jordan: Sure. The Johnston County Osteoarthritis Project is now coming up on its 25^th anniversary. It is unique in the sense that it was founded in the early 1990’s for the specific purpose of understanding how common osteoarthritis is in the population. Not in your medical clinics, because that’s just how many people get to the doctor. But how common is it in the population, and specifically, are there differences between African-Americans and whites, so really focusing from day one on the health disparities that we knew occur in many different areas of health care, but particularly in arthritis.

We recruited people straight out of the population in a door-to-door exercise—3,200 people in fact, about a third of them African-American. And we have followed them over time, repetitively, about every five years. We were interested in knowing: What’s different about the ones who don’t have arthritis at the beginning of the study, but by ten years into the study, they do? How are they different from the people who don’t develop arthritis?

That’s how you try to tease out causation-what is the underlying cause? In addition, we wanted to know for the people who already had arthritis-what makes that arthritis get worse? Some people have arthritis and have barely a symptom at all, and others may become significantly disabled, may need a joint replacement, may progress very rapidly and others much more slowly. These are all things that we had no idea about in the early 1990’s. That’s what this study has been about. It’s really been about multiple chronic conditions because osteoarthritis is one of those conditions that just does not happen on its own, by itself. It frequently occurs in people who have hypertension, high blood pressure, people who have heart disease, people who have diabetes. So it is not one of those conditions that happens all by itself, so you have to look at the whole person.

Dr. Falk: What have you learned? What are the findings?

Dr. Jordan: We were predominately focusing on the knee and hip in the initial studies, and the reason for that was that there was a myth that folks of African ancestry did not get osteoarthritis, and this was based upon old studies that compared people living in Africa and the Caribbean to people living in Europe. What we found was that in fact African Americans did have osteoarthritis in their hip, but over time we recognized that they were less likely to get it but just as likely, if not more likely, as the Whites to have it progress. So that probably has to do with genetics as well as basic differences in joint anatomy. This is really cutting-edge stuff that we’re just coming to know now.

We also found that women, particularly African-American women are more likely to have knee osteoarthritis, and it’s more likely to be worse. We’ve learned some of those things, but perhaps one of the most stark differences that we saw, was the fact that in hand osteoarthritis, African-Americans were hardly ever having the particular kind of hand osteoarthritis that we saw in the white participants. The white participants tended to have that hand arthritis that occurred also with knees and hips, whereas the African-Americans were much more likely to have that in multiple large joints: knees and hips. What does that translate into? That translates into a lot of difficulty with disability, walking, mobility—getting around.

Real ethnic differences in both frequency of arthritis, the joints affected, as well as its outcomes.

Dr. Falk: Where are these studies headed now?

Dr. Jordan: Right now we’ve got a lot of really exciting things going on. One of our investigators, Dr. Amanda Nelson, has been very interested in the imaging of these joints and assessing and analyzing with very sophisticated computer technology, looking at differences in the joint shapes, and the differences between knees, hips, hands, ankles, and how that whole kinetic chain works together in the lower extremity to give people arthritis in different joints.

We also are very interested in looking at how we can really intercede, identify people early, so that we can do things about their arthritis to keep it from progressing. One of the things that we’re very interested in, is not just waiting for the laboratory to come up with a magic bullet for us. While all those wonderful things are happening in the lab, we’re also excited about testing new drugs and medications.

We’re wanting to get to people where they are right now. A cure that comes ten years from now is not going to help that patient sitting in the chair who can’t walk on that knee. So we have several big studies that are looking at diet and exercise interventions across the state of North Carolina. We know these things work, but can they work in the real world?

Dr. Falk: You have a fun name for that study.

Dr. Jordan: It’s called the WE-CAN study (Weight Loss and Exercise for Communities with Arthritis in North Carolina.) In Johnston County where we have a community laboratory, a community-based resource, that will be one of the sites. We’re also collaborating with people in the western part of the state, in the mountains, to see if we can bring these things to the people of North Carolina. Of all the things that make us tick, we’re passionate about our research, about the care that we deliver to our patients, about the education for our residents and fellows, but we are also passionate about the service that we deliver to the people of this state.

Dr. Joanne Jordan is the Joseph P. Archie, Jr. Eminent Professor of Medicine and Chief of the Division of Rheumatology, Allergy and Immunology. She is the Director of the Thurston Arthritis Research Center and is Executive Associate Dean for Faculty Affairs and Leadership Development.