Osteoarthritis and Its Treatment - American Council on Science and

Osteoarthritis and Its Treatment:
What You Need to Know
This booklet is based on a paper written for ACSH by
Gary W. Williams, M.D., Ph.D.
Chairman, Department of Medicine
Scripps Clinic Medical Group
Vice President for Medicine Services
and Academic Affairs
the Scripps Clinic Foundation, La Jolla, CA
January 2004
AMERICAN COUNCIL ON SCIENCE AND HEALTH
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Phone:. (212) 362-7044 • Fax: (212) 362-4919
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E-mail: acsh@acsh.org
KATHLEEN MEISTER, M.S., WROTE THIS BOOKLET, BASED ON AN EARLIER PAPER
WRITTEN FOR ACSH BY GARY W. WILLIAMS, M.D., PH.D., WHICH WAS
REVIEWED BY:
Steven Abramson, M.D.
NYU School of Medicine
Hospital for Joint Diseases
Karl E. Anderson, M.D., FACP
University of Texas Medical
Branch
Peter Barland, M.D.
Albert Einstein College of
Medicine
George E. Ehrlich, M.D.
University of Pennsylvania/
NYU/WHO
Allan Gibofsky, M.D., J.D., FACP,
FCLM
Joan and Sanford Weill Medical
College of Cornell University
Michael Kirsch, M.D., FACP
Highland Heights, OH
Joseph Markenson, M.D.
Joan and Sanford Weill Medical
College of Cornell University
Roland W. Moskowitz, M.D.
Case Western Reserve University
School of Medicine
Dennis L. Sprecher, M.D.
Cleveland Clinic Foundation
William B. White, M.D., FACP
University of Connecticut School
of Medicine
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Copyright © 2004 by American Council on Science and Health, Inc.
This book may not be reproduced in whole or in part, by mimeograph or any other
means, without permission.
Ta b l e o f C o n t e n t s
Osteoarthritis Basics
5
How Doctors Diagnose Osteoarthritis
7
Self-Treatment of Osteoarthritis
7
Forms of Treatment for Osteoarthritis
8
Glucosamine and Chondroitin
11
Future Drug Therapies for Osteoarthritis
12
Summary
12
Arthritis and other “rheumatic” (joint-related) conditions are the leading
cause of disability in the United States. Between one sixth and one third
of American adults — that is, somewhere between 40 and 70 million
people — have some type of arthritis or chronic joint problem.1 The
most common type of arthritis is osteoarthritis; more than 20 million
Americans have this condition.2
At the present time, osteoarthritis cannot be cured. However, much can
be done to control its symptoms and maintain joint function. This report
from the American Council on Science and Health provides a brief summary of the symptoms and causes of osteoarthritis and explains experts’
current views on the best ways to treat this disease.
Osteoarthritis Basics
The word arthritis literally means joint inflammation. In practice, the
word is used to refer to a group of more than 100 diseases and conditions3 that can cause pain, stiffness, and swelling in the joints, including
some conditions — such as osteoarthritis — in which inflammation is
not necessarily apparent.
The word osteoarthritis refers to a group of disorders that affect the cartilage of the joints. Cartilage is the slippery tissue that covers the ends
of the bones in a joint. When cartilage is healthy, it allows bones to
glide over one another easily. It works as a shock absorber, helping to
cushion the joint against damage from physical movement. When cartilage breaks down and wears away, however, as it does in osteoarthritis,
the joint does not function well. The bones rub against each other
directly, causing pain, swelling, stiffness, and difficulty in movement.
Over time, the joint may lose its normal shape, bits of bone (bone spurs)
may grow on the edges of the joint, and small pieces of bone or cartilage may break off and float inside the joint. All of these changes contribute to additional pain, loss of function, and joint damage.
1
2
3
CDC Press Release, “Arthritis and Chronic Joint Conditions More Common Than
Previously Thought,” 10/24/02.
NIAMS fact sheet, “Handout on Health: Osteoarthritis” (referred to later as NIAMS
2002).
Lewis, C, Arthritis: timely treatments for an ageless disease, FDA Consumer, MayJune 2000 (referred to later as FDA Consumer 2000).
5
Osteoarthritis and Its Treatment: What You Need to Know
Like other tissues in the body, cartilage is continually remade. Every
day, some cartilage is broken down, and some new cartilage is formed.
In osteoarthritis, there is an imbalance between the formation and
breakdown of cartilage, so that the synthesis of new cartilage does not
keep up with the wearing away of old cartilage. This is why the amount
of cartilage in the joint decreases and the functioning of the joint
becomes impaired.
Scientists have learned that the process by which cartilage deteriorates
in osteoarthritis is very complex, involving multiple steps and the
actions of many different body chemicals. Although this complexity
makes the process difficult to understand, it also offers hope for the
development of more effective treatments; drugs that inhibit any stage
in the destructive process might be useful in relieving symptoms or
slowing the progress of joint damage.
The joints most often affected by osteoarthritis are in the hands, knees,
hips, and spine.4 The problem usually develops gradually; joint pain is
the first symptom, and the pain is made worse by repetitive use of the
joint.5 Some people have osteoarthritis in only one joint; in other individuals, many joints may be affected.
Older people are most at risk for osteoarthritis. The joints in the human
body are under a great deal of stress, and cartilage has only a limited
ability to repair itself. Thus, as people get older, the accumulation of
many years of wear and tear on the joints increases the chances that
osteoarthritis will develop. Aging is also associated with decreases in
muscle mass and strength and with changes in bone, which may put
additional stress on the cartilage of the joints.
Age is not the only risk factor for osteoarthritis, however. The disease can
occur even in young people as a result of injury to a joint — generally from
repeated trauma from recreational or other activities. Obesity is a major
contributing factor in osteoarthritis of the knee, especially in women.
Genetic factors are also believed to play a role. Osteoarthritis runs in some
families. In addition, some people have hereditary conditions, such as
hemochromatosis (an inherited disorder in which excessive amounts of iron
accumulate in the body) that predispose them to osteoarthritis.
4
5
6
NIAMS 2002.
FDA Consumer 2000.
How Doctors Diagnose Osteoarthritis
When patients go to a doctor because of concern about joint pain or
other joint symptoms, the doctor will need to determine whether the
problem is due to osteoarthritis or to other causes. Many different conditions can cause joint pain; because these conditions require different
types of treatment, it is important to distinguish among them.
There is no specific diagnostic test for osteoarthritis, but the physician
can usually diagnose the problem through a physical examination and
medical history (asking the patient about the symptoms and when they
occur). X-rays are often taken. In some instances, particularly in
patients who have inflammation (swelling of or fluid in the joint, and/or
redness, and/or heat) along with joint pain and stiffness, blood tests or
other diagnostic tests may be needed to distinguish osteoarthritis from
other diseases such as rheumatoid arthritis. In patients with osteoarthritis, the results of the tests will be normal; in those with other diseases,
they may not be.
Self-Treatment of Osteoarthritis
Most of the rest of this report will discuss the ways in which doctors
treat osteoarthritis. It’s important to note, though, that before patients
see a doctor, they have usually been aware of their joint problems for
some time and have taken steps to deal with the symptoms by using
nonprescription medicines, devices, and/or dietary supplements. Many
patients do not discuss their joint problems with a doctor until they
reach the point where nonprescription remedies no longer relieve their
symptoms.
Although self-treatment can be an appropriate way to deal with minor,
occasional health problems, it is important for patients to realize that
remedies available without a prescription are not necessarily risk-free.
Also, people who use nonprescription products to treat joint symptoms
may be delaying obtaining a correct diagnosis and thus appropriate
medical care — joint pain may be caused by a number of illnesses other
than arthritis — so an accurate diagnosis is important.
Those who decide to continue self-medicating should take the following
precautions:
7
Osteoarthritis and Its Treatment: What You Need to Know
1. Always read and follow the directions on the product label.
2. If you take prescription medication or have any type of medical
problem (even something unrelated to arthritis), consult your doctor
before using any over-the-counter drug or dietary supplement. Some
products sold without a prescription may not be safe for you or may
interfere with your medications. For example, recent research indicates that ibuprofen (sold under many brand names including Advil
and Motrin), which is commonly used to relieve mild arthritis pain
and is available over the counter, may interfere with the protective
effect of low-dose aspirin against heart attacks.
3. Be aware that, unlike over-the-counter drugs, dietary supplements do
not need to be proven safe or effective before they can be sold.
Many of these products have received little formal scientific scrutiny,
and their risks and benefits may be uncertain. Dietary supplements
may also be inconsistent in quality and purity.
4. If you need to treat yourself for joint symptoms frequently, it would
be a good idea to consult your doctor even if you are still obtaining
satisfactory results from nonprescription remedies. Your doctor may
be able to recommend or prescribe treatments that are safer or more
effective than those that you have been using on your own.
Forms of Treatment for Osteoarthritis
The currently available forms of treatment for arthritis do not cure or
modify the course of the disease. Instead, the goal of therapy is to control pain and maintain or improve joint function.
Two professional organizations, the American College of
Rheumatology (the organization of U.S. physicians who specialize in
arthritis care) and the American Pain Society (an organization of scientists and physicians specializing in research on and treatment of pain),
have issued treatment guidelines for osteoarthritis. The goal of these
guidelines is to ensure that the safest treatments are used first, with
forms of therapy that are most likely to produce troublesome side
effects reserved for cases in which the preferred treatments did not produce adequate relief of symptoms.
Both sets of guidelines begin by recommending non-drug therapies,
8
such as weight loss (particularly valuable for patients with osteoarthritis
of the knee) and appropriate exercises to strengthen muscles. These
forms of treatment are safe when performed properly, and they may
allow patients with mild or intermittent joint symptoms to avoid the use
of drugs (and therefore the potential side effects of drug therapy).
Drug Therapy
If non-drug therapies don’t produce sufficient relief, the use of drugs is
the next step in osteoarthritis therapy. For patients with mild joint pain,
the first drug recommended in both sets of guidelines is acetaminophen
(the active ingredient in Tylenol and many other brands of non-aspirin
pain reliever). The advantages of this drug include its relatively low
cost, widespread over-the-counter availability, and general safety.
For patients whose arthritis pain is too severe to be relieved by acetaminophen, the recommendations are more complex. To understand the
reasoning behind them, it is helpful to take a brief look at the types of
drugs used to treat osteoarthritis and how they work.
The drugs most commonly used to treat osteoarthritis are non-steroidal
anti-inflammatory drugs (NSAIDs). These drugs work in the body by
inhibiting the actions of enzymes called cyclooxygenases (COX), which
contribute to pain and inflammation. There are at least two kinds of
COX enzymes in the body: COX-1 and COX-2. Research indicates that
the COX-2 enzyme is the one that’s important in causing pain and
inflammation. COX-1 is more of a “housekeeping” enzyme; it plays
roles in the normal functioning of several body organs and, in particular,
seems to have a protective role in the digestive tract.
Traditional NSAIDs, such as ibuprofen (Advil, Motrin, etc.), naproxen
(Anaprox, Aleve, Naprosyn), ketoprofen (Orudis, Oruvail), and
indomethacin (Indocin), inhibit both COX-1 and COX-2. These drugs
are effective against pain and inflammation, but they also tend to have
side effects in the digestive tract, especially when they’re used on a regular basis, as they often are by patients with osteoarthritis. The side effects
sometimes include serious problems, such as ulcers and bleeding.
Some newer drugs, called COX-2–selective agents, are also used in the
treatment of osteoarthritis. This group of drugs includes celecoxib
(Celebrex), rofecoxib (Vioxx), and valdecoxib (Bextra). These drugs are
NSAIDs, but they inhibit COX-2 only; they don’t affect COX-1.
Research has indicated that they work as well as the traditional
9
Osteoarthritis and Its Treatment: What You Need to Know
nonselective NSAIDs do in reducing pain and inflammation. Apparently, COX-2 is the important enzyme when it comes to pain; whether or
not a drug inhibits COX-1 seems to be irrelevant in terms of the drug’s
effectiveness against arthritis pain.
The COX-2–selective agents have fewer gastrointestinal side effects
than do traditional nonselective NSAIDs, suggesting that the side
effects of the traditional drugs are due primarily to their impact on
COX-1. COX-2–selective agents are not entirely free from side effects
(no drug is), but they do have a safety advantage over traditional nonselective NSAIDs in terms of their most common adverse effect, bleeding
in the stomach and related areas. The lower risk of stomach effects is
not absolute. These drugs should also be used with caution in those
who have had any episode of internal bleeding. Kidney and liver damage can also be made worse by COX-2–selective drugs.
One recently-approved COX-2–selective agent, rofecoxib, was found in
one large study to have a negative effect on the risk of heart attack,
especially in those using a higher dose. Thus, practitioners have been
advised by the FDA to bear this in mind before prescribing this agent to
patients with cardiovascular disease.
Because COX-2–selective agents work as well as traditional nonselective NSAIDs do but produce fewer troublesome side effects, both sets
of official guidelines recommend the COX-2–selective agents as the
preferred drugs for patients who need something stronger than acetaminophen to treat their osteoarthritis. When expense is not an issue —
the newer COX-2 selective agents are more expensive — traditional
nonselective NSAIDs should be used only if the newer agents are not
effective. In that instance, patients who are judged to be at risk for
digestive tract problems may need to take an additional drug to protect
the stomach and GI tract along with the traditional nonselective NSAID
to reduce the risk of these problems.
It should also be noted that those patients taking aspirin to protect
themselves against heart disease must continue to take it if they are also
prescribed any of the NSAIDs discussed here, since none of the antiarthritis drugs (COX-2 selective or not) offer that same protection.
While taking both aspirin and a NSAID the risk of stomach or other
internal bleeding is increased — thus, it is most important that the
patient’s doctor be informed if this is the case.
10
Other Drugs and Therapies
In addition to the drugs discussed above, several other forms of therapy
are sometimes used in patients with osteoarthritis. These include:
• Topical agents — A few creams, rubs, or sprays that are applied
directly to the skin may be helpful in relieving mild pain due to
osteoarthritis. However, these should be discussed thoroughly with
your doctor as there are many so-called “alternative” remedies that
come in these forms and are of no value whatsoever.
• Hyaluronates — This is a substance that can be injected into an
arthritic joint. It has a lubricating effect and may have other beneficial effects as well. It is usually used to treat osteoarthritis of the
knee, and it may work well enough to allow patients to discontinue
oral medication for a period of time.
• Corticosteroids — This is another type of medication that may be
injected into an arthritic joint. Corticosteroids take effect more quickly and cost less than hyaluronic acid does, but there has been some
controversy about possible harmful effects if they are used too often.
• Narcotics or a non-narcotic pain reliever called tramadol (Ultram) —
These strong pain relievers may be used to relieve osteoarthritis pain
when other drugs fail, but they are considered only a last resort
because they pose a serious risk of becoming habit-forming.6 As a
rule, narcotic drugs should only be used in the short period while
surgery is being contemplated.
• Surgery — When other measures fail, joint replacement surgery is
often performed in patients with advanced osteoarthritis. Since the
first such procedures were performed around 40 years ago, the techniques have improved to such a degree that the large majority of
patients who undergo joint replacement surgery are largely relieved
of pain while experiencing improved function and mobility.
Glucosamine and Chondroitin
Two dietary supplements usually used in combination, glucosamine sulfate and chondroitin sulfate, are probably the most widely used alterna6
NIAMS 2002.
11
Osteoarthritis and Its Treatment: What You Need to Know
tive therapy for osteoarthritis. Glucosamine and chondroitin are important constituents of cartilage, and the basis for their use is the hope that
taking them as dietary supplements might help to replenish and restore
cartilage.
The results of several scientific studies suggest that glucosamine may
indeed be helpful in relieving symptoms of osteoarthritis. This agent
seems to work better than inactive placebos do, and may even produce
results as good as those seen with NSAIDs in some patients. However, it
is important to remember that glucosamine is a “dietary supplement,”
not an FDA-approved drug, and therefore is not subject to the stringent
safety, efficacy, and quality standards applied to drugs. Further scientific
study of glucosamine (and chondroitin) is needed. Patients with
osteoarthritis who plan to try these products should tell their doctors that
they intend to do so. As with all drugs and dietary supplements, side
effects and interactions with other agents are possible, so it is important
for the physician to be aware of all substances that the patient is using.
Future Drug Therapies for Osteoarthritis
At the present time, drugs that actually modify the course of
osteoarthritis are not available. However, efforts are being made to
develop drugs of this type. It seems reasonable to assume that such
drugs can be developed; in fact, disease-modifying drugs have long
existed for another major form of arthritis, rheumatoid arthritis. If drugs
that modify the course of osteoarthritis come onto the market, they
might drastically alter the treatment of this disease, making joint preservation, rather than symptom control, the principal goal of therapy.
Summary
Osteoarthritis, a type of arthritis caused by breakdown of cartilage in
the joints, is a very common medical problem, affecting more than 20
million Americans. The joints most often affected are the hands, knees,
hips, and spine. Older people are most at risk, but even young people
can develop osteoarthritis as a result of joint injury. The disease is usually diagnosed on the basis of the patient’s symptoms and medical history; no specific diagnostic test exists, although X-rays are often highly
suggestive, but various tests may be conducted to rule out other diseases of the joints.
12
It is common for people with mild or occasional joint symptoms to treat
themselves using nonprescription remedies. While this is not necessarily
inappropriate, ACSH urges people with persistent or frequent joint problems to consult a physician. People who take prescription medication or
have any type of medical problem should consult a doctor before using
any over-the-counter drug or dietary supplement to treat joint symptoms.
Two major professional organizations, the American College of
Rheumatology and the American Pain Society, have issued treatment
guidelines for osteoarthritis. These guidelines state that:
1. Non-drug therapies such as exercise and weight loss should be tried
first.
2. Acetaminophen is recommended as a first-choice drug for mild joint
pain.
3. For moderate or severe joint pain, the COX-2–selective agents are
the first-choice drugs. The effectiveness of these drugs is comparable
to that of traditional nonselective NSAIDs, but the COX-2–selective
agents have the advantage of a lower risk of gastrointestinal side
effects. In addition, they may also be less likely to interfere with the
protective effect of aspirin against heart attacks.
4. COX-2–selective agents are expensive, however.
5. In instances in which COX-2–selective agents do not produce sufficient relief of symptoms, traditional nonselective NSAIDs may be
used, but patients should be evaluated for the risk of digestive tract
side effects, and additional medications to reduce the risk of such
side effects may be needed.
6. Other forms of therapy that may be used in selected cases include
topical agents, hyaluronic acid joint injections, glucosamine, corticosteroid joint injections, narcotic pain relievers, tramadol, and surgery.
7. The treatments currently available only relieve symptoms of
osteoarthritis without modifying the course of the disease. However,
efforts are currently being made to develop disease-modifying drugs.
13
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Raymond Gambino, M.D.
American Cancer Society
Philadelphia, PA
Quest Diagnostics Incorporated
Dwight B. Heath, Ph.D.
Randy R. Gaugler, Ph.D.
Brown University
Rutgers University
Robert Heimer, Ph.D.
J. Bernard L. Gee, M.D.
Yale School of Public Health
Yale University School of Medicine
Robert B. Helms, Ph.D.
W. Lawrence Beeson, Dr.P.H.
Loma Linda University School of Public
Health
Barry L. Beyerstein, Ph.D.
Simon Fraser University
Steven Black, M.D.
Kaiser-Permanente Vaccine Study Center
Blaine L. Blad, Ph.D.
University of Nebraska, Lincoln
Hinrich L. Bohn, Ph.D.
University of Arizona
Ben Bolch, Ph.D.
Rhodes College
Joseph F. Borzelleca, Ph.D.
Medical College of Virginia
Michael K. Botts, Esq.
Ames, IA
St. Luke’s Roosevelt Hospital Center
Gerald F. Combs, Jr., Ph.D.
Cornell University
Michael D. Corbett, Ph.D.
Omaha, NE
Morton Corn, Ph.D.
John Hopkins University
Michael P. Elston, M.D., M.S.
Rapid City Regional Hospital
William N. Elwood, Ph.D.
Nancy Cotugna, Dr.Ph., R.D., C.D.N.
Center for Public Health & Evaluation
Research
K. H. Ginzel, M.D.
American Enterprise Institute
University of Delaware
James E. Enstrom, Ph.D., M.P.H.
University of Arkansas for Medical Sciences
Zane R. Helsel, Ph.D.
Ronald W. Brecher, Ph.D., C.Chem.,
DABT
Roger A. Coulombe, Jr., Ph.D.
University of California, Los Angeles
William Paul Glezen, M.D.
Rutgers University, Cook College
Utah State University
Donald A. Henderson, M.D., M.P.H.
H. Russell Cross, Ph.D.
Stephen K. Epstein, M.D., M.P.P.,
FACEP
Baylor College of Medicine
GlobalTox International Consultants, Inc.
Robert L. Brent, M.D., Ph.D.
Future Beef Operations, L.L.C.
Beth Israel Deaconess Medical Center
Medical College of Wisconsin
Alfred I. duPont Hospital for Children
James W. Curran, M.D., M.P.H.
Myron E. Essex, D.V.M., Ph.D.
Allan Brett, M.D.
Emory University
Harvard School of Public Health
University of South Carolina
Charles R. Curtis, Ph.D.
Terry D. Etherton, Ph.D.
Kenneth G. Brown, Ph.D.
Ohio State University
Pennsylvania State University
KBinc
Ilene R. Danse, M.D.
R. Gregory Evans, Ph.D., M.P.H.
Gale A. Buchanan, Ph.D.
Novato, CA
St. Louis University Center for the Study
of Bioterrorism and Emerging Infections
George A. Bray, M.D.
Pennington Biomedical Research Center
University of Georgia
Jay A. Gold, M.D., J.D., M.P.H.
Roger E. Gold, Ph.D.
Texas A&M University
Reneé M. Goodrich, Ph.D.
University of Florida
Frederick K. Goodwin, M.D.
The George Washington University
Medical Center
Johns Hopkins University
James D. Herbert, Ph.D.
MCP Hahnemann University
Gene M. Heyman, Ph.D.
McLean Hospital/Harvard Medical School
Richard M. Hoar, Ph.D.
Williamstown, MA
Theodore R. Holford, Ph.D.
Yale University School of Medicine
ACSH
BOARD
OF
SCIENTIFIC
AND
POLICY
ADVISORS
Robert M. Hollingworth, Ph.D.
Brian A. Larkins, Ph.D.
Ian C. Munro, F.A.T.S., Ph.D., FRCPath
Bill D. Roebuck, Ph.D., D.A.B.T.
Judith S. Stern, Sc.D., R.D.
Michigan State University
University of Arizona
Cantox Health Sciences International
Dartmouth Medical School
University of California, Davis
Edward S. Horton, M.D.
Larry Laudan, Ph.D.
Kevin B. Murphy
David B. Roll, Ph.D.
Ronald D. Stewart, O.C., M.D., FRCPC
Joslin Diabetes Center
National Autonomous University of Mexico
Merrill Lynch, Pierce, Fenner & Smith
University of Utah
Dalhousie University
Joseph H. Hotchkiss, Ph.D.
Tom B. Leamon, Ph.D.
Harris M. Nagler, M.D.
Dale R. Romsos, Ph.D.
Martha Barnes Stone, Ph.D.
Cornell University
Liberty Mutual Insurance Company
Beth Israel Medical Center
Michigan State University
Colorado State University
Steve E. Hrudey, Ph.D.
Jay H. Lehr, Ph.D.
Daniel J. Ncayiyana, M.D.
Joseph D. Rosen, Ph.D.
Jon A. Story, Ph.D.
University of Alberta
Environmental Education Enterprises, Inc.
University of Cape Town
Cook College, Rutgers University
Purdue University
Susanne L. Huttner, Ph.D.
Brian C. Lentle, M.D., FRCPC, DMRD
Philip E. Nelson, Ph.D.
Steven T. Rosen, M.D.
Michael M. Sveda, Ph.D.
University of California, Berkeley
University of British Columbia
Purdue University
Northwestern University Medical School
Gaithersburg, MD
Robert H. Imrie, D.V.M.
Floy Lilley, J.D.
Malden C. Nesheim, Ph.D.
Kenneth J. Rothman, Dr.P.H.
Glenn Swogger, Jr., M.D.
Seattle, WA
Amelia Island, FlF
Cornell University
Boston University
Topeka, KS
Lucien R. Jacobs, M.D.
Paul J. Lioy, Ph.D.
Joyce A. Nettleton, D.Sc., R.D.
Stanley Rothman, Ph.D.
Sita R. Tatini, Ph.D.
University of California, Los Angeles
UMDNJ-Robert Wood Johnson Medical
School
Aurora, Co
Smith College
University of Minnesota
John S. Neuberger, Dr.P.H.
Edward C. A. Runge, Ph.D.
Steve L. Taylor, Ph.D.
Texas A&M University
University of Nebraska, Lincoln
Alejandro R. Jadad, M.D., D.Phil.,
F.R.C.P.C.
William M. London, Ed.D., M.P.H.
University of Kansas School of Medicine
University of Toronto, Canada
Walden University
Gordon W. Newell, Ph.D., M.S.,F.-A.T.S. Stephen H. Safe, D.Phil.
James W. Tillotson, Ph.D., M.B.A.
Rudolph J. Jaeger, Ph.D.
Frank C. Lu, M.D., BCFE
Palo Alto, CA
Texas A&M University
Tufts University
Miami, FL
Thomas J. Nicholson, Ph.D., M.P.H.
Wallace I. Sampson, M.D.
Dimitrios Trichopoulos, M.D.
Stanford University School of Medicine
Harvard School of Public Health
Environmental Medicine, Inc.
William M. Lunch, Ph.D.
Western Kentucky University
Loma Linda University
Oregon State University
Steven P. Novella, M.D.
Harold H. Sandstead, M.D.
Murray M. Tuckerman, Ph.D.
Michael Kamrin, Ph.D.
Daryl Lund, Ph.D.
Yale University School of Medicine
University of Texas Medical Branch
Winchendon, MA
University of Wisconsin
James L. Oblinger, Ph.D.
Charles R. Santerre, Ph.D.
Robert P. Upchurch, Ph.D.
Purdue University
University of Arizona
William T. Jarvis, Ph.D.
Michigan State University
George D. Lundberg, M.D.
North Carolina State University
Michigan State University
Medscape
Deborah L. O’Connor, Ph.D.
Herbert P. Sarett, Ph.D.
Mark J. Utell, M.D.
P. Andrew Karam, Ph.D., CHP
Howard D. Maccabee, Ph.D., M.D.
University of Toronto/The Hospital for
Sick Children
Sarasota, FL
University of Rochester Medical Center
Sally L. Satel, M.D.
Shashi B. Verma, Ph.D.
University of Nebraska, Lincoln
John B. Kaneene,Ph.D., M.P.H., D.V.M.
University of Rochester
Radiation Oncology Center
Janet E. Macheledt, M.D., M.S., M.P.H.
John Patrick O’Grady, M.D.
American Enterprise Institute
Pennsylvania State University
Houston, TX
Tufts University School of Medicine
Lowell D. Satterlee, Ph.D.
Willard J. Visek, M.D., Ph.D.
John G. Keller, Ph.D.
Roger P. Maickel, Ph.D.
James E. Oldfield, Ph.D.
Oklahoma State University
University of Illinois College of Medicine
Purdue University
Oregon State University
Jeffrey Wyatt Savell
Donald M. Watkin, M.D., M.P.H., F.A.C.P.
George Washington University
Philip G. Keeney, Ph.D.
Olney, MD
Delta Toxicology
George Mason University Law School
Stanley T. Omaye, Ph.D., F.-A.T.S.,
F.ACN, C.N.S.
Texas A&M University
Miles Weinberger, M.D.
George R. Kerr, M.D.
Karl Maramorosch, Ph.D.
University of Nevada, Reno
Marvin J. Schissel, D.D.S.
Roslyn Heights, NY
University of Iowa Hospitals and Clinics
Rutgers University, Cook College
Michael T. Osterholm, Ph.D., M.P.H.
Lawrence J. Schneiderman, M.D.
Lynn Waishwell, Ph.D., CHES
University of California, San Diego
Edgar J. Schoen, M.D.
University of Medicine and Dentistry of
New Jersey
Kaiser Permanente Medical Center
Janet S. Weiss, M.D.
David Schottenfeld, M.D., M.Sc.
University of California at San-Francisco
University of Michigan
Simon Wessley, M.D., FRCP
Joel M. Schwartz, M.S.
Reason Public Policy Institute
King’s College London and Institute of
Psychiatry
David E. Seidemann, Ph.D.
Steven D. Wexner, M.D.
Kathryn E. Kelly, Dr.P.H.
University of Texas, Houston
Henry G. Manne, J.S.D.
Judith A. Marlett, Ph.D., R.D.
University of Minnesota
Progress and Freedom Foundation
University of Wisconsin, Madison
M. Alice Ottoboni, Ph.D.
Michael Kirsch, M.D.
James R. Marshall, Ph.D.
Sparks, NV
Roswell Park Cancer Institute
Michael W. Pariza, Ph.D.
Margaret N. Maxey, Ph.D.
University of Wisconsin, Madison
Emmaus, PA
University of Texas at Austin
Stuart Patton, Ph.D.
Ronald E. Kleinman, M.D.
Mary H. McGrath, M.D., M.P.H.
University of California, San Diego
Massachusetts General Hospital
Loyola University Medical Center
James Marc Perrin, M.D.
Leslie M. Klevay, M.D., S.D.in Hyg.
George A. Keyworth II, Ph.D.
Highland Heights, OH
John C. Kirschman, Ph.D.
Brooklyn College/Yale University
Cleveland Clinic Florida
Patrick J. Shea, Ph.D.
Joel Elliot White, M.D., F.A.C.R.
Alan G. McHughen, D.Phil.
Mass General Hospital for Children
University of North Dakota School of
Medicine
University of California, Riverside
Timothy Dukes Phillips, Ph.D.
James D. McKean, D.V.M., J.D.
Texas A&M University
David M. Klurfeld, Ph.D.
Iowa State University
Mary Frances Picciano, Ph.D.
Wayne State University
John J. McKetta, Ph.D.
National Institutes of Health
Kathryn M. Kolasa, Ph.D., R.D.
University of Texas at Austin
David R. Pike, Ph.D.
East Carolina University
Donald J. McNamara, Ph.D.
University of Illinois, Urbana-Champaign
James S. Koopman, M.D, M.P.H.
Egg Nutrition Center
Thomas T. Poleman, Ph.D.
University of Michigan
Michael H. Merson, M.D.
Cornell University
Alan R. Kristal, Dr.P.H.
Yale University School of Medicine
Charles Poole, M.P.H., Sc.D
Fred Hutchinson Cancer Research Center
Patrick J. Michaels, Ph.D.
David Kritchevsky, Ph.D.
University of Virginia
University of North Carolina School of
Public Health
The Wistar Institute
Thomas H. Milby, M.D., M.P.H.
Gary P. Posner, M.D.
Princeton University
University of Illinois, Urbana-Champaign
Stephen B. Kritchevsky, Ph.D.
Walnut Creek, CA
Tampa, FL
James J. Worman, Ph.D.
Wake Forest University Health Sciences
Michael S. Simon, M.D., M.P.H.
Joseph M. Miller, M.D., M.P.H.
John J. Powers, Ph.D.
Wayne State University
Rochester Institute of Technology
Mitzi R. Krockover, M.D.
University of New Hampshire
University of Georgia
Russell S. Worrall, O.D.
Humana, Inc.
S. Fred Singer, Ph.D.
William J. Miller, Ph.D.
William D. Powrie, Ph.D.
Science & Environmental Policy Project
University of California, Berkeley
Manfred Kroger, Ph.D.
University of Georgia
University of British Columbia
Robert B. Sklaroff, M.D.
Panayiotis M. Zavos, Ph.D., Ed.S.
Pennsylvania State University
Dade W. Moeller, Ph.D.
C.S. Prakash, Ph.D.
Elkins Park, PA
University of Kentucky
Laurence J. Kulp, Ph.D.
Harvard University
Tuskegee University
Steven H. Zeisel, M.D., Ph.D.
University of Washington
Anne M. Smith, Ph.D., R.D., L.D.
Grace P. Monaco, J.D.
Kary D. Presten
The Ohio State University
The University of North Carolina
Gary C. Smith, Ph.D.
Michael B. Zemel, Ph.D.
University of Nebraska, Lincoln
John Muir Comprehensive Cancer Center
Michael B. Shermer, Ph.D.
Carol Whitlock, Ph.D., R.D.
Skeptic Magazine
Rochester Institute of Technology
Sidney Shindell, M.D., LL.B.
Christopher F. Wilkinson, Ph.D.
Medical College of Wisconsin
Burke, VA
Sarah Short, Ph.D., Ed.D., R.D.
Mark L. Willenbring, M.D.
Syracuse University
Veterans Affairs Medical Center
A. J. Siedler, Ph.D.
Carl K. Winter, Ph.D.
University of Illinois, Urbana-Champaign
University of California, Davis
Lee M. Silver, Ph.D.
Lloyd D. Witter, Ph.D.
Sandford F. Kuvin, M.D.
Medical Care Management Corp.
U.S. Trust Co.
University of Miami
Brian E. Mondell, M.D.
Marvin P. Pritts, Ph.D.
Colorado State University
Nutrition Institute, University of Tennessee
Carolyn J. Lackey, Ph.D., R.D.
Baltimore Headache Institute
Cornell University
Ekhard E. Ziegler, M.D.
North Carolina State University
John N. Sofos, Ph.D.
Eric W. Mood, LL.D., M.P.H.
Daniel J. Raiten, Ph.D.
Colorado State University
National Institute of Health
Roy F. Spalding, Ph.D.
Pagona Lagiou, M.D., DrMedSci
Yale University School of Medicine
University of Athens Medical School
John W. Morgan, Dr.P.H.
David W. Ramey, D.V.M.
University of Nebraska, Lincoln
J. Clayburn LaForce, Ph.D.
California Cancer Registry
Ramey Equine Group
University of California, Los Angeles
Leonard T. Sperry, M.D., Ph.D.
W. K. C. Morgan, M.D.
R.T. Ravenholt, M.D., M.P.H.
Barry University
James C. Lamb, IV, Ph.D., J.D.
University of Western Ontario
Population Health Imperatives
Blasland, Bouck & Lee
Robert A. Squire, D.V.M., Ph.D.
Stephen J. Moss, D.D.S., M.S.
Russel J. Reiter, Ph.D.
Johns Hopkins University
Lawrence E. Lamb, M.D.
Health Education Enterprises, Inc.
University of Texas, San Antonio
San Antonio, TX
Ronald T. Stanko, M.D.
Brooke T. Mossman, Ph.D.
William O. Robertson, M.D.
University of Pittsburgh Medical Center
William E. M. Lands, Ph.D.
University of Vermont College of Medicine
University of Washington School of Medicine
College Park, MD
James H. Steele, D.V.M., M.P.H.
Allison A. Muller, Pharm.D
J. D. Robinson, M.D.
University of Texas, Houston
Lillian Langseth, Dr.P.H.
The Children’s Hospital of Philadelphia
Georgetown University School of Medicine
Robert D. Steele, Ph.D.
Lyda Associates, Inc.
Pennsylvania State University
The opinions expressed in ACSH publications do not necessarily represent the views of all ACSH Directors and Advisors.
ACSH Directors and Advisors serve without compensation.
University of Iowa