Ask Dr. White
Q. How therapeutic is the use of an Abilify/cymbalta medication regime used in conjunction with Gabapentin and Tramadol for the control of arthritis/rheumatoid pain? I don't understand the relationship of psychiatric medications with the others.
A. You ask an interesting question. Pain is the most common problem for people with arthritis and pain is a complex symptom with many pathways that lead to what you actually feel. Similarly, the therapies that assist you with your pain can affect these different pathways.
For example, some pain is centrally amplified in the brain and other pain originates from the distant sites in the joint itself. As more than one pathway may be playing a role in your pain, more than one type of medication may be needed. I encourage you to talk with your rheumatologist and your pain specialist to understand what is the purpose of each of your pain medications and how they work to decrease your pain. The Arthritis Foundation has programs that can assist you with managing your pain. Call your local Arthritis Foundation chapter to learn about the Life Improvement Series and the Arthritis Foundation Self Help program.
Q. I was diagnosed with Juvenile Arthritis at age 13. I am now 52. Am I still considered a JRA patient?
A. Your diagnosis is based on the age you were and the symptoms you had during the first several weeks of your arthritis. Thus, if your arthritis onset was before age 16, you will always have juvenile arthritis. If your arthritis onset was after age 16, your arthritis would be called rheumatoid arthritis.
Q. I have an eight year old daughter who has had systemic juvenile arthritis for 4.5 years now. She has been on Humira and MTX for 2 1/2 years now. She is doing fairly well, but still has some inflammation in her hips and ankles. I am wondering if we should be moving on to Kineret. I have read that it works well for those with systemic juvenile arthritis, and I fear that even a little inflammation can cause joint damage over time. I know I need to consult with her doctor, but I am just looking for advice as to how to determine when and if to switch biologics.
A. Central to making the decision about changing any therapy is the careful monitoring by an arthritis specialist, like a pediatric rheumatologist, of the activity of the arthritis and consequences of that activity along with balancing that information with the potential side effects of the treatment. In addition, it is important to take any therapy for enough time to see if it has or has not been effective before moving on to another approach. The goal of treatment is to decrease pain and any disease activity that results in changing one’s ability to have a good quality of life. The Arthritis Foundation suggests that you ask how your arthritis specialist is monitoring the disease activity to learn if the residual inflammation you mention is resulting in any decreased joint function or joint damage.
Q. I have an 11 year old son who was diagnosed with systemic juvenile arthritis in 2001. He started taking Kineret in 2003 and is currently taking 1/4 the adult dose of Kineret daily, and is doing well. From the research I have done, it sounds like Kineret blocks Interluken 1. My question is, if everybody's body produces Interluken 1 naturally and children with systemic juvenile arthritis produce too much of it, what is the purpose of Interluken 1? Why do we need it, and, if it's blocked, what are the short and long term consequences of not having it in our bodies?
A. You ask an interesting question, as medicine does not fully understand all the functions of the many proteins in the body that are a part of your immune system such as Interluken 1, Anti TNF a and IL6 to name a few. These proteins are part of a larger system that protects the body from insults such as infection. The Arthritis Foundation supports many researchers who are actively trying to understand what each of these many proteins do. They have learned that some of these protein functions overlap, but have much to more learn. Through research studies, the researchers have found that if you block only one of these proteins, you body’s ability to fight off infection is not completely disrupted, but is partially effected, as is the case for people taking Kineret. People taking Kineret have a greater susceptibility to infection and need to be monitored carefully to avoid the consequences of infection.
Q. I was wondering if Osgood Schlatter’s disease is considered a form of or precursor to arthritis. I had this in both of my knees when I was 8 or 9 years old and have always had trouble with my knees. When I was 37, I developed osteoarthritis and at age 47 was told that I had no cartilage left in my right knee (an arthroscopy confirmed this). I am now 51 and have been told to wait to have knee replacements because I am still "too young".
A. Osgood Schlatter’s disease is a painful knee condition where there is inflammation of the tendon where it makes contact with the bone below the knee. This tendon assists in bending and straightening the knee. This is a condition that affects the structure around the joint and does not affect the inside of the joint that results in arthritis. To date there is no convincing evidence that Osgood Schlatter’s can lead to early osteoarthritis of the knee.
Q. Is a patient diagnosed with juvenile arthritis in their early teens, with resolution of the symptoms occurring after about one year, likely to have rheumatoid arthritis emerge later in life?
A. The outcome of juvenile arthritis is not completely understood. Studies have been done looking at a group of youth who were diagnosed with juvenile arthritis in childhood and then they were followed up 10 to 20 years later. In general, when all subtypes of juvenile arthritis were combined, approximately 50 percent had a recurrence.
The chance of recurrence of juvenile arthritis seems related to the type of arthritis the youth had in the first 6 weeks of their disease. For example, those youth who had pauciarticular onset had the least chance of recurrence and those with polyarticular onset with rheumatoid factor in their lab tests rarely had a remission. Talk with your rheumatologist to understand what the chances are for your daughter.
Q. My eight year old daughter was diagnosed with juvenile arthritis when she was two-and-a-half-years old. She had joint injections in her knees and ankles and took almost every oral medicine they had at the time. Due to the recurrent uveitis, she started weekly Methotrexate injections. She has been almost four years without a flare so in February, we tapered, then stopped the Methotrexate. Now, in June, she has a sore, swollen knee. She is devastated at the thought of going back on the injections.
She sees an excellent Rheumatologist at University of San Francisco and we are waiting on a call back from him. Are there any new oral meds that maybe weren’t around four years ago? I worry about the long term effects of Methotrexate.
Also, I have one other question. My daughter has eye exams every three months. We have seen several different specialists since we move every couple of years. One was a corneal specialist, one a retina specialist, one we were lucky to have was a uveitis specialist. All claimed to have special training in uveitis. What is the best type of Ophthalmologist for her condition? And are there any reputable alternative treatments to help keep the flares at bay? So many people tell me to try a more holistic approach as I am putting “poison” into my daughter’s body with the meds.
A. The most important question about your daughter’s swollen knee is to learn if this is a recurrence of her juvenile arthritis or if it is caused by something else, as the treatment would be different depending on the cause of the swollen knee. Your rheumatologist will help in making that determination. The most recent medications that have come on the market to treat inflammatory arthritis are the newer biologic medications and they are given either intravenously or by subcutaneous injection.
The Arthritis Foundation has an informative publication called the Drug Guide that reviews all the arthritis medications and is updated yearly. It can be obtained from your local Arthritis Foundation chapter or on the Foundation’s Web site.
As far as your question about the Ophthalmologist, generally when trying to decide what type of physician to treat a condition, one should ask if and how many people they have treated with a similar condition. Ophthalmologists may all be trained in the condition, but some will obtain extra training or have had experience treating the condition. Thus talk with your rheumatologist who often knows the eye specialists in their area and can help you find the best one to treat your daughter’s eye problem.
Last but not least, you brought up the question if one should try “natural” or “complementary” or “holistic” treatments. It is difficult to answer this because there is not a great deal of information about these treatments as they have not been subjected to the rigorous study like the drugs that have been released by the US Federal Drug Administration.
Often these natural therapies are not all made the same way and there is no regulation of how they are made, like there is for FDA-approved treatments. Drugs released by the FDA are put through controlled trials where populations with similar diseases are put into groups; half receive the medication and that group is compared to those not taking the medication. Side effects are followed closely. This kind of investigation is not required for “natural” treatments so little is known about the efficacy or side effects. Remember just because it is “natural” does not mean it is safe. Aspirin is considered natural because it comes from the bark of a tree and we know now it can have many side effects. You might also try the Arthritis Foundation’s Supplement Guide to learn more. Just be sure to let your physician know what you are learning and thinking about trying. They can assist you in evaluating the information offered about these natural or complementary treatments.
Q: I am an 18-year-old female college student who was just diagnosed as having arthritis in my spine between the bottom of my lumbar (L5) and the top of my Sacrum (S1). I didn't even realize that arthritis was a possibility at my age! I'm a dancer and would like to treat this issue in order to continue dancing. What are the best ways to treat my arthritis and get rid of it?
A. Arthritis in the back can have many causes (congenital, injury, inflammation, etc.), so first learn what kind of arthritis you have by seeing a rheumatologist or orthopedist that specializes in back disorders. It is important to keep the muscles strong and balanced, so after learning the type of arthritis, ask for a referral to a physical therapist that can give you exercises to assist you in keeping your arthritis under control.
Q: My 9 year old nephew was recently diagnosed with Ankylosing Arthritis. His physician has introduced the idea of starting him on Enbrel. I understand there are risks associated with this type of treatment and would like to help my sister make an informed decision about starting her son on this medication. Any help or insight into drug studies with children would be beneficial and appreciated!
Also, if you have suggestions on alternative treatment options for this type of arthritis (i.e. heat therapy, exercise, etc.), that would also be quite appreciated!
A. In making a decision about taking a medication, a careful discussion with an arthritis specialist should cover not only the risks and benefits of the medication, but also the risks of not treating the condition. You may find that the risk of disability from arthritis is much greater then the published side effects of the treatment.
Enbrel has been used in children for over 10 years now and has shown the ability of stopping the progression of Juvenile arthritis in many trials. In considering taking Enbrel, start by discussing with an arthritis specialist if there is anything in your family history that would exclude your nephew from taking Enbrel. If not, your nephew should be monitored for potential side effects, such as increased susceptibility of infection while taking the medication. The arthritis specialist should be able to give you some of the literature on Enbrel. Also, look at the package insert that comes with the drug that summarizes many of the drug trials.
You can also look at the Drug Guide published by the Arthritis Foundation to learn more about Enbrel. Last but not least, it is important for joint health to keep the muscles and tendons around the joint strong and flexible so seeing a physical therapist for a series of exercises and learning how to use heat and cold is very helpful.
See question's about juvenile arthritis from a previous Ask the Expert feature. Visit the home of the Juvenile Arthritis Alliance.
