Sunday, June 28, 2009


Not a pretty sight, and certainly not one you want to see below your knee on a trans-Atlantic flight. On average, it's a bad thing that airplane seats on such journeys are so close together that you can hardly reach your feet to pull off your shoes, but a good thing insofar as inspecting your ankles is difficult. But when I finally got my lower leg into viewing range on the leg of the trip from Madrid to Philadelphia, it was strictly Exhibit B for me!

This would be a good time to review venous return from the lower leg and all that might interfere with it during a summer flight. Consider blood and its journey from toe back to heart after its load of oxygen has been delivered to these nether regions. Each heartbeat sends a surge of blood through the elastic arteries which expand as the blood pushes by and then contract in a springy sort of way to amplify its forward progress. By the time the blood passes through the teeny weeny capillary bed back to the leg veins, however, it's a different story.

The veins which carry blood back to the heart are neither elastic nor springy. When the blood arrives in the venous system, that pulsing kick from the heart's action is much diminished. In the upright or seated position, gravity is tugging that old deoxygenated blood downwards. The veins have valves on their inner walls that open to partially prevent this gravitational backwash, and activation of the leg muscles helps to further squeeze venous blood in its upward course.

Think for a moment, then, about a middle-aged lady(MAL) stuck in a seat for 9 hours watching "Bride Wars" and "Marley and Me" and eating salty airline meals. Actually, the movie choices have nothing to do with our cankle tale here, but believe me, these were dismal ways to pass time. So the MAL has already walked too much through the hot Spanish sun with her venous system dilated from the heat and saggy with age. She's retaining water from the high salt food. Furthermore, as she sits motionless in steerage, two 90 degree turns in her leg veins (at the knees and the hips) further slow the flow.

Oh gad, methought, those are NOT my ankles (or more precisely, where are my ankles?). For those of you wondering when your ankle bones will re-emerge from the inflight edema, mine took two days and I've seen it take up to two weeks in some of my patients.

Monday, June 08, 2009

Limbrel--new option for osteoarthritis

I wrote some time ago about licofelone, a new analgesic for osteoarthritis (OA) that was then in Phase III clinical trials. Not only does this new agent decrease pain and inflammation from OA without stomach irritation (a la ibuprofen, naproxen, etc.) or cardiovascular complications (a la Vioxx and Bextra), it also demonstrates potential in actually slowing down joint destruction. Alas, while new reports on its dual action efficacy--analgesia AND disease modification--continue to appear, I can find no information on a release date.

I was pleased, therefore, to learn today about a new drug for osteoarthritis--a medical food actually--from a patient. Limbrel is all phytochemicals which should delight the aging hippies in all of us that search for the natural in the drugs we take to keep old body hooked to mellowing soul. It's made from those two lovely plants pictured above: Scutellaria baicalensis and Acacia catechu.

So here's the scoop. Arachidonic acid(AA) is a polyunsaturated fat that's necessary to body functions when it is appropriately converted to chemicals that protect your stomach lining, dilate blood vessels, promote proper blood clotting, and repair tissues. Too much AA in the wrong place at the wrong time is a bad thing whether it's derived from cellular injury or diet (think twisting your ankle as you eat a Big Mac for a double load of AA). Per Dr. Barry Sears: "...if you inject arachidonic acid into... rabbits they are dead within three minutes. "

As you get older, injured, have an inherited predisposition to arthritis, and eat too much fatty red meat or egg yolks, all that piled up AA gets churned along by the COX-1, COX-2, and 5-LOX enzyme systems into a world of inflammatory molecules and reactive oxygen species which set off a process by which your cartilage is destroyed and your bone overgrows into treacherous spurs.

You can inhibit COX-1 by aspirin or NSAIDs or inhibit COX-2 by Celebrex, but unless you turn down your 5-LOX as well, the resultant imbalance creates other problems. Scientists have sorted through more than a thousand plant-derived molecules looking for flavonoids with favorable suppressive action on these inflammatory pathways. Apparently those pretty posies posing above won the competition, proving both safe and efficacious in decreasing the pain of osteoarthritis.

While licofelone has been shown to slow down the cartilage destruction that leads to permanent joint deformities in osteoarthritis, Limbrel makes no such claims. Whether this is due to a lack of research supporting this function, or simply that it doesn't work in that way is not clear. Limbrel, however, is available here and now whereas licofelone is still churning along on the slow train to FDA approval. I've requested samples from the company, and look forward to working with those of you with the gnarly hands and aching knees of osteoarthritis to see what we think about this one.