Readers sent more than 100 questions to Dr. Vivian P. Bykerk about rheumatoid arthritis, a disease that often starts in middle age and is more common in women. Dr. Bykerk, a rheumatologist who has practiced for more than 20 years, is the director of research at the Inflammatory Arthritis Center at the Hospital for Special Surgery in Manhattan and a researcher at Weill Cornell Medical College. Her focus is the early detection of rheumatoid arthritis and the adoption of optimal treatment strategies. She was chairwoman of the Therapeutics Committee of the Canadian Rheumatology Association for four years and was the lead author of Canada’s rheumatoid arthritis treatment recommendations. Dr. Bykerk is currently working in collaboration with the Inflammatory Arthritis Center to develop a clinical research program in early rheumatoid arthritis. Because of the volume of questions, not all may be answered. More answers will appear next week on Booming. INTRODUCTION Thank you to all of you who wrote in with questions. I’m sorry I cannot answer each of you individually; however, I chose to answer questions with themes that you frequently addressed. Rheumatoid arthritis is one of the most destructive forms of arthritis. Unlike the more common osteoarthritis, R.A. is an autoimmune disease in which the immune system attacks and inflames the joints. It can cause serious damage to large and small joints and to many other organs in your body. I have found that early diagnosis with frequent early follow-up, along with an initially more intensive treatment strategy, is crucial in optimizing the best outcomes in this disease. MEDICATION Q. I am 66, recently given a diagnosis of R.A. Was put on methotrexate/prednisone/folic acid. Am currently being weaned off prednisone. What are the long-term effects of methotrexate on the body? — globro, New York A. Globro: This is a common question people ask with any medication, and it is often asked about methotrexate, given original fears 20 years ago about the liver. Prednisone probably has more significant long-term effects on the body in terms of negatively impacting bone health, causing skin thinning for some, weight gain for some, and increasing the risk for hypertension and diabetes, so I am glad you are weaning off this. Prednisone is very effective to use for flares and between other treatments while you are waiting for them to work. Long-term effects of methotrexate are for the most part positive. Methotrexate has proved to be a good drug to help to control the inflammation of R.A. and other rheumatic diseases. Studies also show that patients whose R.A. is being controlled on methotrexate experience less cardiovascular disease. Your doctor should be monitoring blood tests every three or so months while on methotrexate. We like to see that liver, kidney and blood tests are normal. If this is the case, our experience with methotrexate over the last 30 years is that there are almost no significant long-term consequences and that benefits clearly outweigh risks. There is no doubt that a few patients (fewer than 10 percent) don’t feel well on methotrexate; usually the dose needs to be adjusted. We do recommend that patients taking methotrexate also take folic acid. Your doctor will advise you on this recommendation. Q. I was given a diagnosis in December 2012 of mild-mod R.A., and started methotrexate in January 2013. In June I stopped methotrexate and began taking low-dose naltrexone (LDN). I discovered LDN on the Web after searching for infectious causes of R.A. I had heard an interview with Dr. Ewald on the People’s Pharmacy radio show about infections as the cause of some cancers and autoimmune disorders. It made perfect sense to me and reflected my experience (sudden onset of full blown RA after sinus infections and flu vaccine). I now take 4.5 milligrams of LDN per day and I feel better than I have in years. If I feel stiffness or pain late in the day ibuprofen helps but I rarely need it. LDN works by supporting the immune system and increasing the availability of endorphins. It is safe and F.D.A. approved (opiate addiction) at 50 milligrams per day (the max dose for R.A. is 4.5 milligrams per day). I try not to be cynical but it’s hard not to believe that big pharma plays a role in why this drug is not well known in the medical world. Another aspect of R.A. for many people, I believe, are intestinal issues. I had a diagnosis of leaky gut syndrome six months prior to onset of R.A. I have eliminated dairy and nightshade vegetables and take probiotics and other supplements to support my intestinal tract. LDN is helping with that, too, as it is effective for treating Crohns (and M.S.). Could you please comment on LDN, infections as a cause of R.A., the importance of diet and why most rheumatologists are so resistant to this approach? — Melissa, N.C. A. Melissa has asked a number of questions. The first relates to low-dose naltrexone, which has helped her. This is a medication currently approved for use in alcohol and narcotic dependence, suggesting it plays a role at the level of the central nervous system. There have also been some recent, very small studies concluding that it has had some benefit in fibromyalgia. This suggests it might benefit central nervous system-mediated pain. In addition, there are many publications looking at whether it helps inflammation. Hopefully, this will be explored soon in a well-studied F.D.A.-approved clinical trial where both safety and benefits are better explored. The second question relates to infection as a cause of rheumatoid arthritis. Again, this is an issue that is not well understood. It would seem for classical R.A., the role of infection may be only one aspect of why R.A. occurs (environment, genetics, smoking, oral health being others). Other forms of arthritis, like reactive arthritis, are set off by infection but a person needs to have certain susceptibility factors for this to occur. It is even less clear whether treating infection substantially improves arthritis. This is particularly because some antibiotics used to treat infection, like doxycycline, minocycline or tetracyclines, also have anti-inflammatory effects, so it is not known what these medications are actually achieving. Antibiotics are not without their own risks. Rheumatologists tend to be cautious and stick to therapies in proven scientific studies and approved by the F.D.A. Having said that, I am aware of rheumatology colleagues who have tried therapies targeted against infection, and too many noted their patients did not substantially improve; some developed side effects like lupus and problems with skin and teeth, and they abandoned these for treatments where they are more certain of a positive benefit to risk profile. Please see comments regarding diet in the response to CJ. Q. I have psoriatic arthritis (but no psoriasis). I take 200 milligrams of Celebrex every day, which works quite well for me, and I also take over the counter Claritin for my dust allergy. I’ve noticed that if I run out of Claritin (while continuing the Celebrex), my arthritis will flare after a few days. Seems to me that there is a clear connection between allergies and arthritis. Do you think arthritis research is finding a connection between the two? My mother had untreatable rheumatoid arthritis and died after becoming bedridden in the last year of her life (2003). I’ve always wondered if she had been tested/treated for allergies, perhaps she would have had a better outcome. —belong, Mercer, Pa.
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