A CLOSER LOOK AT

Arthritis
One in six Americans
suffers from arthritis, and
the CDC projects that
number will grow to one
in five by 2020.

A C O L L A B O R AT I O N B E T W E E N
T H E A R T H R I T I S F O U N DAT I O N A N D
THE N AT I O N A L P H A R M AC E U T I C A L C O U N C I L
O
ne in six Americans suffer the pain and joint stiffness
associated with arthritis, and the CDC projects that
number will grow to almost one in five by 2020.
Arthritis is one of the most prevalent chronic health problems
and the leading cause of disability among Americans over the
age of 15. Seven million Americans experience limits on
everyday activities like walking, dressing, and bathing due to
arthritis. Contrary to common belief, arthritis is not simply a
disease of the elderly. More than half of those with arthritis
are under age 65; nearly 300,000 American children
have a form of juvenile arthritis.1
There are more than 100 different types of arthritis
that affect areas in or around joints, but the disease
can also affect other parts of the body. The two most
common types of arthritis are rheumatoid arthritis
(RA) and osteoarthritis (OA). RA is a chronic disease
affecting approximately 2.1 million individuals in the
United States, 1.5 million of whom are women.2,3 In
fact, women suffer from arthritis almost twice as often
as men, particularly rheumatoid arthritis and
fibromyalgia.1 RA is a progressively destructive
disease leading to irreversible joint damage,
permanent deformity and functional disability.4
Although the cause is not known, it is an autoimmune
disease in which the immune system attacks
otherwise healthy joint tissue resulting in inflammation of
the membrane lining the joint.5,6 OA, the most common form
of arthritis, affects 21 million Americans with symptoms
generally more common among the middle-aged and
elderly.7,8,9 OA is a progressive disease characterized by the
breakdown of cartilage in the joints, most commonly the
hands, spine, knees, and hips, leading to pain, restricted
movement, and functional limitations.5,10
The direct medical costs for treating arthritis and the lost
wages that result from the disease currently total more than
$82 billion annually.7 Earlier estimates of the cost of arthritis
found that the employment-related economic costs are
estimated at more than three times the direct medical
costs.11,12 This is not surprising since 60 to 70 percent of RA
patients who had been working at the onset of the disease
reported work disability after five years.13 OA is second only
to chronic heart disease as the principal reason why adults
receive Social Security Disability payments and has a great
effect among older Americans.2 As the baby boom
generation enters the prime years for arthritis, the number
of people affected will surge and the impact on individuals
and the nation’s health will grow dramatically.1 Lifetime
direct costs of RA are estimated at up to $14 billion per year,
comparable to the costs of coronary heart disease.14,15 One
study estimates that medications alone may account for as
much as 17 percent of the costs of treating RA.16 And because
of the clinical complexities of RA drug therapy, monitoring
drug effects and treating drug side effects can be as much as
40 to 70 percent of drug costs in some cases.17 The impact of
new therapies and their potential to prevent costly
hospitalizations and surgeries has yet to be determined.
The Arthritis Foundation currently estimates that OA results
in more than 7 million physician visits annually.7 In
addition, 80 percent of those with OA report at least some
disease-related limitation of movement or activities.7 One
study suggests that under a managed care plan, OA added
between $1,963 and $2,827 annually in costs per patient,
accounting for five percent of total health plan charges.18
Hospitalizations account for about 46 percent of total
spending for OA, with medications accounting for nearly
one-third of the costs and ambulatory care contributing the
remaining 22 percent.19
Unfortunately, half of all Americans who suffer from arthritis
are under the mistaken impression that nothing can be done
to help them when in fact there are a number of effective
treatments to help relieve the pain and inflammation of
arthritis.1 In 2000, the American College of Rheumatology
(ACR) published updated guidelines for treatment of OA of
the hip and knee. The outlined therapy begins with a
variety of non-drug components, with drug therapy
introduced if these methods alone fail to relieve
symptoms.20 The recommended non-drug components in RA
management are similar to those described for OA, including
support groups, physical activity and weight management,
and even surgery.3 However, the timing of diagnosis is a
more important factor in management of RA than it is for
OA. There is evidence that joint damage or destruction can
both occur and be detected early in the RA disease process.
Therefore, optimal management requires early diagnosis
and timely adoption of treatment strategies that have the
potential to reduce, delay or prevent joint damage.3 New
evidence and the availability of new therapies, such as
biologic response modifiers that actually neutralize a key
factor in RA disease progression, have shifted the emphasis
for treatment of RA to the use of drug therapies.21
Initial drug treatment of RA commonly involves the use of
nonsteroidal anti-inflammatory drugs (NSAIDs), many of
which are available over the counter, to reduce joint pain
and swelling. However, these drugs do not have an effect
on the underlying disease process or progression of joint
destruction, and are often associated with gastrointestinal
complications including upset stomach, ulcers, and
elevated blood pressure.22,23,24 Studies of the gastrointestinal
(GI) effects of traditional or “non-selective” NSAIDs suggest
the following:25,26,27,28,29
• NSAID users have approximately three times greater
relative risk of developing GI complications compared to
non-users.
• The relative risk of GI side effects is greatest during the
first three months of therapy.
• Age is strongly correlated with increased risk. The relative
risk for NSAID users older than 60 years was three times
that of those age 60 and younger.
• A history of GI events independently increases the risk of
an NSAID-related GI event, as does the simultaneous use of
corticosteroids or anticoagulants.
• Risk increases with higher NSAID doses.
• Other independent factors exerting more moderate effects
on the risk of GI events include prolonged NSAID use, the
presence of other GI conditions (e.g., esophageal disorders,
gastritis), certain chronic illnesses, and alcohol use.
Despite the benefits associated with NSAIDs, therapy
exclusively with these agents is not recommended for more
than three months except in patients with mild RA and no
disease progression.30 Disease-modifying antirheumatic
drugs (DMARDs) are often introduced early in treatment and
have the potential to reduce or prevent joint damage and
preserve joint integrity and function.31 Over the past several
years, research has highlighted the potential for and
importance of using both more aggressive initial therapeutic
approaches and combination therapy to manage RA.32 As a
result, combination therapy early in the course of RA has
become the accepted standard of treatment.3,30,31
For osteoarthritis that is not manageable with non-
pharmacological means, the currently recommended
approach involves pain relievers, such as acetaminophen
and prescription NSAIDs if necessary.33 The relatively new
COX-2 products (selective NSAIDs) provide therapeutic
effects similar to those of the non-selective NSAIDs.34,35 As
with the non-selective NSAIDs, the COX-2 inhibitors do not
have any significant effect on altering the underlying disease
process; their primary action is to relieve pain and swelling.
Evidence from the literature also points to fewer adverse
gastrointestinal effects associated with COX-2 use.34 Recently
published studies have examined the evidence regarding
cardiovascular effects of the COX-2s and noted variable
protective effects among the NSAIDs, but more research is
needed on such effects.36,37,38,39

M
ORE THAN HALF OF THOSE
WITH ARTHRITIS ARE UNDER
AGE 65.

THE BENEFITS OF PHYSICAL ACTIVITY

IN MANAGING ARTHRITIS
If you think that physical activity and arthritis don’t go hand in hand, you’re
wrong. Research has shown that physical activity is an essential tool in managing
arthritis. It can:

• Reduce joint pain and stiffness; • Control your weight;

• Build strong muscle around the joints; • Decrease depression;
• Increase flexibility and endurance; • Improve self-esteem; and
• Give you more energy; • Stave off other health problems such as osteoporosis and heart disease.
• Help you sleep better;

Physical activity can include anything from walking around the block to taking a yoga or tai chi class or playing a round of
golf. If you are reluctant to exercise because of pain, you may want to start with a water exercise program because your
body’s buoyancy in the water reduces stress on your hips, knees, and spine. Whatever physical activity you decide on,
you should always consult with your doctor before starting out.40
L
IFETIME DIRECT COSTS OF RHEUMATOID ARTHRITIS ARE COMPARABLE
TO THOSE OF CORONARY HEART DISEASE.

FACTORS INFLUENCING DRUG SPENDING

METHODOLOGY
This study separately analyzed
prescription drug spending
growth for two large national
claims databases, one
representing managed care
plan enrollees and the other
representing those covered by
large employer-provided
health benefit plans. The study
defined and assessed several
factors affecting the price per
day of therapy and the volume
of therapy — the number of
days of therapy received and
the number of patients
receiving drug therapy. The
analysis also examined the
effects of price and volume
changes for established drugs
on the market during the entire
period of analysis and for new
drugs that were first marketed
during this period.
FOR ARTHRITIS 1997-1999
1997 and 1999 pharmaceutical expenditures
were analyzed for individuals in private
Price
managed care plans. The sample included
Factors
individuals who had at least two arthritis
diagnoses during the calendar year. The
diagnoses did not have to be the same, but
this method ensured a better focus on
patients with confirmed arthritis diagnoses.
Volume Factors Overall, drug expenditures per health plan
member for arthritis patients rose 87 percent
during the two-year period from 1997 to 1999.
Volume factors were responsible for 78
percentage points of the total 87 percent
increase in spending. The increase in the
percentage of people in the covered
population being treated for arthritis
accounted for 56 percentage points of the
overall 87 percent expenditure growth. Price
factors had only a small influence on total
expenditure growth. Together, the three
factors contributed nine percentage points of
the 87 percent growth.

Factors Influencing Growth in Rx Expenditures: % Positive Impact % Negative Impact

Total Growth in Expenditures +87
Growth Due to Volume Factors +78
Changes in the Number of Prescriptions per Person for Established Drugs -4.3
Changes in the Number of Prescriptions per Person for New Entrants +21.5
Changes in Days of Therapy for Established Drugs +2.7
Changes in Days of Therapy for New Entrants +2.6
Patients per 1000 Health Plan Enrollees +55.6
Growth Due to Price Factors +9
Inflation +4.8
Changes in Mix of Established Drugs -20.5
Price of New Entrants +24.8

Source: Protocare Sciences managed care database

Seven million Americans experience
limits on everyday activities like
walking, dressing, and bathing
due to arthritis.

A sequencing analysis was performed for seven types of arthritis therapy to examine
the order in which the various drug therapy classes were used within the arthritis
population. Sequencing was based on the date the first prescription was filled for each
of the classes and therefore shows the therapies and therapy combinations used.
Sequencing was performed for the calendar year 1999 using data from the 1997-1999
analysis, and separately for the first six months of 2000 using additional data.

In 1999:
• More than 34 percent of arthritis patients received non-selective NSAIDs as their initial therapy, and
30 percent of that group received no other arthritis-related therapy during the year.
• Only 1.6 percent of arthritis patients received COX-2s as initial therapy, and 40 percent of this group
received no other arthritis-related therapy during the year.
• Seventy-three percent of arthritis patients received more than one type of arthritis-related therapy
over the course of the calendar year.

During the first six months of 2000:

• Almost 39 percent of arthritis patients received non-selective NSAIDS as their initial therapy, and 56
percent of that group received no other arthritis-related therapy during the next six months.
• Only 5.1 percent of arthritis patients received COX-2s as initial therapy, and 53 percent of this group
received no other arthritis-related therapy over the next six months.
• Seventy percent of arthritis patients received more than one type of arthritis-related therapy over
the course of the six months.

REFERENCES:
1
Arthritis Foundation Fact Sheet: Arthritis Prevalence:
A Nation in Pain; Arthritis Foundation, National Office
- Atlanta, GA, 1998
2
Lawrence RC, Helmick CG, Arnett FC, et al. Estimates
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3
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4
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12
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14
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18
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(continued on back panel)

ABOUT THIS
PUBLICATION:
"A Closer Look at Arthritis" is a
collaborative publication of the Arthritis
Foundation and the National
Pharmaceutical Council.
The mission of the Arthritis Foundation is
to prevent and cure arthritis, and to
improve the lives of all people affected
by arthritis. To fulfill this mission, the
Arthritis Foundation funds research,
publishes scientific findings, provides
information and other services to people
with arthritis, their families, health care
professionals and the public and
advocates for scientific research and for
the rights of people with arthritis.
Since 1953, the National Pharmaceutical
Council (NPC) has sponsored and
conducted scientific, evidence-based
analyses of the appropriate use of
pharmaceuticals and the clinical and
economic value of pharmaceutical
innovation. NPC provides educational
resources to a variety of health care
stakeholders, including patients,
clinicians, payers and policy makers.
More than 20 research-based
pharmaceutical companies are members
of the NPC.
For more information about NPC or for
additional resources, please contact:
The National Pharmaceutical Council
1894 Preston White Drive
Reston, VA 20191-5433
Phone: 703-620-6390
Fax: 703-476-0904
www.npcnow.org
FOR MORE INFORMATION ABOUT
ARTHRITIS, PLEASE CONTACT:
Arthritis Foundation
www.arthritis.org
1-800-283-7800
National Institute of Arthritis and Musculoskeletal
and Skin Diseases (NIAMS)
www.niams.nih.gov
1-877-22-NIAMS
Centers for Disease Control and Prevention (CDC),
National Center for Chronic Disease Prevention and Health Promotion
www.cdc.gov/nccdphp/bb_arthritis/index.htm
770-488-5464
American College of Rheumatology/
Association of Rheumatology Health Professionals
www.rheumatology.org
404-633-3777
19
Lanes SF, Lanza LL, Radensky PW, et al. Resource
utilization and cost of care for rheumatoid arthritis
and osteoarthritis in a managed care setting: the
importance of drug and surgery costs. Arthritis Rheum.
1997;40(8):1475-81 (abstract).
20
American College of Rheumatology Subcommittee
on Osteoarthritis Guidelines. Recommendations for
the Medical Management of Osteoarthritis of the Hip
and Knee. 2000:43:1905-15.
21
Arthritis Foundation (2002). Conditions and
Treatments [Online]. http://www.arthritis.org/
conditions/DrugGuide/dmards_about.asp. (accessed
8/12/02).
22
Bradley JD, Brandt KD, Katz BP, et al. Comparison of
an anti-inflammatory dose of ibuprofen, an analgesic
dose of ibuprofen, and acetaminophen in the
treatment of patients with osteoarthritis of the knee.
N Engl J Med. 1991;325:87-91.
23
Smalley WE, Ray WA, Daugherty JR, et al.
Nonsteroidal anti-inflammatory drugs and the
incidence of hospitalizations for peptic ulcer disease
in elderly persons. Am J Epidemiol. 1995;141:539-45.
24
Wolfe MM, Lichtenstein DR, Singh G. Gastrointestinal
toxicity of nonsteroidal anti-inflammatory drugs.
N Engl J Med. 1999;340(24):1888-99.
25
Van Schaardenburg D. Rheumatoid arthritis in the
elderly: prevalence and optimal management. Drugs
and Aging. 1995;7:30-37.
26
Crofford LJ. COX-1 and COX-2 tissue expression:
implications and predictions. J Rheumatol.
1997;49(suppl):15-19.
27
Simon LS. Role and regulation of cylooxygenase-2
during inflammation. Am J Med. 1999;106:37S-42S.
28
Fung HB, Kirschenbaum HL. Selective
cyclooxygenase-2 inhibitors for the treatment of
arthritis. Clin Ther. 1999;21:1131-1157.
29
Simon LS, Weaver AL, Graham DY, et al. Anti-
inflammatory and upper gastrointestinal effects of
celecoxib in rheumatoid arthritis: a randomized
controlled trial. JAMA. 1999;282:1921-8.
30
Pincus T, O’Dell JR, Kremer JM. Combination therapy
with multiple disease-modifying antirheumatic drugs in
rheumatoid arthritis: a preventive strategy. Ann Intern
Med. 1999;131:768-774.
31
Drugs for rheumatoid arthritis. The Medical Letter.
2000;42(1082):57-64.
32
Fries JF, Williams CA, Morfeld D, et al. Reduction in
long-term disability in patients with rheumatoid
arthritis by disease-modifying antirheumatic drug-
based treatment strategies. Arthritis Rheum.
1996;39:616-622.
33
American Pain Society. Guideline for the
management of pain in osteoarthritis, rheumatoid
arthritis, and juvenile chronic arthritis. 2002.
34
Watson DJ, Harper SE, Zhao PL, et al. Gastrointestinal
tolerability of the selective cyclooxygenase-2 (COX-2)
inhibitor rofecoxib compared with nonselective COX-1
and COX-2 inhibitors in osteoarthritis. Arch Intern Med.
2000;160(19):2998-3003.
35
Silverstein FE, Faich G, Goldstein JL, et al.
Gastrointestinal toxicity with celecoxib vs. nonsteroidal
anti-inflammatory drugs for osteoarthritis and
rheumatoid arthritis: the CLASS study: a randomized
controlled trial. JAMA. 2000;284(10):1247-1255.
36
Dalen JE. Selective COX-2 inhibitors, NSAIDs, aspirin,
and myocardial infarction. Arch Intern Med.
2002;162:1091-1092.
37
Solomon DH, Glynn RJ, Levin R, Avorn J.
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38
Watson DJ, Rhodes T, Cai B, Guess HA. Lower risk of
thromboembolic cardiovascular events with naproxen
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Med. 2002;162:1105-1110.
39
Rahme E, Pilote L, LeLorier J. Association between
naproxen use and protection against acute myocardial
infarction. Arch Intern Med. 2002;162:1111-1115.
40
Arthritis Foundation. (2002) Exercise and Arthritis
[Online]. Available: http://www.arthritis.org/
conditions/Exercise/default.asp. (7/10/02)