Ask Dr. Klippel l John H. Klippel, MD l Rheumatologist l Rheumatoid Arthritis

Created on: 06/09/07 - Email to friend - Print Page

Q. I was diagnosed with rheumatoid arthritis (RA) earlier this year. I was put on methotrexate and always felt bad after taking it. I got to the point that I was having back pain and constant headaches. My joint pain was increasing and my memory was getting bad. I also was having trouble concentrating at work. I forgot to take the methotrexate for a couple of weeks and all of the symptoms went away. I am wondering if this was a rare reaction or it was caused by something else.

A. My experience suggests that many patients don’t feel quite right for a couple days after taking methotrexate. Common symptoms that occur – some of which you mention – include excess fatigue, headache, and feeling "spaced out" or not being able to think clearly. I often tell people starting methotrexate that this may be a problem and, in fact, some people will even choose particular days of the week they are taking the drug to try and work around the problem. For instance, I’m aware of people who work during the week and opt to take methotrexate on Friday night so as to not interfere with their work (but it then cuts into their enjoyment of the weekend). One thing you might consider with your doctor is adding low dose folic acid, which can reduce the side effects of methotrexate in some people. For more side effects, cautions and "need to know" information about arthritis medication, visit the 2007 Drug Guide.

Q. How effective are antibiotics in the treatment of rheumatoid arthritis?

A. The use of antibiotics in rheumatoid arthritis has a very checkered history and remains controversial. Antibiotics were originally considered (and used) with the notion that rheumatoid arthritis MIGHT be caused by an infection and thus treatment of the infection would then lead to improvement of the RA. It is important to recognize that there is NO convincing evidence linking RA to an infection. However, some people appeared to improve with antibiotic treatment. As far as I know, most of the current interest in antibiotic treatment of RA involves the use of tetracycline drugs, particularly minocyline, and a number of clinical studies have shown that the drug does improve joint pain, swelling and stiffness in rheumatoid arthritis. How it works isn’t exactly clear but it most likely has an effect on interfering with enzymes or other molecules responsible for joint inflammation and not because of any effect on infectious agents.

Q. I am 51 and was diagnosed with RA two years ago. I was put on sulfasalazine to control the inflammation, as my hands showed no bone erosion. The latest MRIs of my hands now show some damage and my physician wants me to start serious medications. The list of medications he suggested I research is Enbrel, Humira, Remicade and methotrexate. The side effects that he listed were reduced immunity to infection, possible increased susceptibility to lymphoma and the possible reactivation of symptoms for multiple sclerosis (MS) and tuberculosis (TB). He also said that once I start the drugs I will likely need to continue them throughout my life.

I have two concerns: My mother recently died from non-genetic amyotrophic lateral sclerosis (ALS) and I am wondering if there is any link between RA and ALS, and the possible initiation of ALS from any of these drugs (and which ones was he referring to). My other concern is that I would need to take medication continuously forever. I am not one for medications, and I am wondering if it is possible to go on and off the medication as the disease flares up and down.

A. If your rheumatoid arthritis is progressing (and it sounds like it is if you have developed joint damage while on drug treatment) then it is certainly a good idea to discuss what other options might be available with your doctor. It also is good that you are thinking about possible side effects of drugs since you need to weigh the benefits versus the risks when making a decision. As to your questions, I’m not aware of any link between rheumatoid arthritis and ALS nor of any risk of developing ALS from any of the drugs used to treat rheumatoid arthritis. Tumor necrosis factor (TNF) inhibitors such as Enbrel, Humira and Remicade can be associated with neurological complications which can resemble multiple sclerosis. In most – if not all – people rheumatoid arthritis is a chronic, life-long disease which requires continuous drug treatment forever. Treating the disease only when the disease flares and then stopping never gets the inflammation in control so as to limit joint damage. Moreover, even stopping most medications when the disease is fully under control leads to eventual return of joint disease. For more information on arthritis medications, visit the 2007 Drug Guide.

Q. Can RA cause seizures?

A. Seizures CAN occur as a result of rheumatoid arthritis, but they would certainly be considered a very, very rare complication. Most rheumatologists (including me) have never actually seen an RA patient with seizures caused by the disease. Seizures might occur from several different causes – inflammation of vessels within the brain (vasculitis), the development of rheumatoid nodules within the brain, or deposits of a protein called amyloid within the brain. These are all very rare conditions that would likely only occur in someone with severe, long-standing rheumatoid arthritis.

Q. I have RA that affects my lungs as well as my joints. How does RA affect the lungs, and what can I expect in the future?

A. Lung involvement in rheumatoid arthritis is uncommon, but can actually occur as a result of several different things. All of these things can produce the same set of symptoms – typically cough and shortness of breath – and if not recognized and treated appropriately can become both progressive and severe. The same inflammation that develops within the membranes of joints in rheumatoid arthritis also can occur within lung tissues. In addition, the nodules that typically occur beneath the skin in RA can also form within lung tissue. Two of the most serious forms of lung disease in RA actually occur as a complication of drugs used to treat the disease. Methotrexate can be associated with a rapidly and potentially very severe, progressive lung disease, and patients on this drug should be aware of this potential complication and be advised to notify their physician promptly should they develop shortness of breath. Many of the disease-modifying antirheumatic drugs (DMARDs) – but in particular the biologic response modifiers (BRMs) – increase the risk of infection and can cause pneumonia. Individuals taking these drugs also need to be cautioned about notifying the physician immediately should they develop shortness of breath and fever.

Q. I was wondering whether any studies are being done to ask RA patients about their onset or course of RA? Example: RA and female connection – Did you ever contract a sexually transmitted disease or experience fever blisters repeatedly? Did the onset of menses or menopause influence your symptoms? Were you ever intimate with someone who had active immune related diseases (MS, diabetes, shingles) or in very close contact with them? Other smoking connections: How long of a period and how many cigarettes/cigars/pipes did you smoke (if applicable – regular or menthol)? Did you have double joints in fingers and thumbs? Any other popping or cracking of joints when movement was involved? How many of the childhood diseases did you actually have? Which ones did you not have but received immunizations for? Did you ever get some of the same ones twice? These are just some of the connections that I personally have questions about that I have often wondered their relationship to RA.

A. On behalf of every arthritis epidemiologist in the country – thanks for this important question! These kinds of studies are extremely important in learning more about what might actually cause RA and factors which influence the disease. There is a definite need for more of these studies, but the few that are available have yielded interesting clues about RA. For example, smoking has been shown to clearly increase the risk of developing RA. Patients who develop RA hold the answers to all the fundamental questions about the disease, and it’s just a matter of time before we ask the right research questions to learn the answers.

Q. My previous doctor tested an "RA/lupus gene" and said I was "borderline." Should I be tested again? Does this mean I might get RA or Lupus? I have fibromyalgia and minimal osteoarthritis.

A. We’re still in the very early stages of identifying and learning about genes that are associated with RA (and related diseases like lupus). I believe that most rheumatologists are in agreement that genetic testing isn’t YET really of any practical use in screening patients. The few genes that we know about that are associated with RA occur commonly in the general population and the vast majority of people who have these genes don’t have and will never get rheumatoid arthritis. So for now I don’t see any reason for you to be retested. But as we learn more about genes in RA, there is no question that in the future genetic testing will become increasingly important to identify patients at risk for disease, confirm the diagnosis early, be used to predict the course and prognosis of the disease and help determine the response and risk of side effects from drug treatment.

Q.My question, along with everyone else, is how did I get this illness? My aunt has RA very severe and is crippled. She is 74. Could this genetic connection be the answer?

A. Genetics are an important piece to the puzzle of what causes RA, but as best we understand the disease there are other – yet unidentified – things involved. We know from families like yours that genes are passed along which predispose some individuals in the family to develop RA (or other interesting "related" autoimmune diseases). Identifying and learning about these genes is an area of great research interest by the Arthritis Foundation and others, and progress is being made daily. It is quite likely that more than one gene is associated with the disease and, in fact, combinations of genes likely have to fall in place before RA actually develops. This would help explain why not everyone in a family known to have someone with RA gets the disease. Moreover, it is believed that there are likely different genes which might determine whether someone is prone to get the disease, when it might begin, how severe it will be, and how it will respond to treatment. If we stay focused on research in this area, we’ll someday know about the genes and will be able to use this information in physician offices to prevent, better treat, and hopefully cure the disese.

Q. My father was diagnosed with rheumatoid arthritis (RA). We are looking for alternative methods in additional to the medications for him. He is in so much pain because the current doctor just brought down his prednisone to 10mg. Any suggestions?

A. For most people with RA, controlling pain is the single most important priority in approaching treatment. It sounds as if your father is experiencing a common clinical problem when prednisone is used – high doses very effectively control the pain (and typically the swelling and stiffness) but as the dose is gradually reduced the symptoms can reappear. Increasing the dose of prednisone isn’t generally a good option since the risk of side effects from the prednisone become substantially increased the longer high doses of the drug are used. Choices that he needs to consider with his doctor would be adding nonsteroidal anti-inflammatory drugs (NSAIDs) (and he may have to try several different ones to see which one might be best) or disease-modify antirheumatic drugs (DMARDs) to the low dose of prednisone.

Q. Can rheumatoid arthritis be reversed or arrested?

A. The simple answer is yes to both, however it is a little more complicated. The joint disease of rheumatoid arthritis is actually two separate, but related, problems. The first is inflammation of the membranes of the joint, which is responsible for the joint pain, swelling and stiffness. Certainly this can be stopped and reversed with drugs – particularly disease-modifying antirheumatic drugs (DMARDs) and biologic response modifiers (BRMs). The inflammation over time can lead to damage to the joint cartilage, bone and other joint structures, which is what causes joint deformity and disability. Certainly damage can be stopped (and even prevented) by DMARDs and BRMs, however once damage has occurred, this can’t be reversed or repaired. So one of the important goals of RA treatment is to get the inflammation under control as quickly and completely as possible to reduce the risk of permanent joint damage.

Q. I have been diagnosed with seronegative RA. I have pain and swelling primarily in my wrists, hands and feet. Lately, I have noticed a pain in my right hip that occurs without warning after sitting, standing or at times while I am walking. It feels almost as if my hip "gives out" or dislocates. Could this be related to the RA? Since it is not a constant pain or ache, but rather sporadic, I never considered it to be part of this disease.

A. It is difficult to be entirely certain what is responsible for your right hip problem, but since RA can affect virtually any joint, I think there is a more than reasonable chance that RA is causing your problem. In fact, seronegative RA has a slightly greater tendency to involve the hips that seropositive RA. However, by far the most common form of arthritis, which might also explain the hip problem, is osteoarthritis (OA) – and yes, people can get both RA and OA. The development of pain after sitting or standing is very characteristic of hip OA. Finally, if by chance you have ever been treated with corticosteroids (like prednisone) for your RA, another possibility is a form of arthritis affecting the hip called osteonecrosis. An X-ray might be helpful to determine which of these forms of arthritis might be causing the hip pain.

Q. My husband was diagnosed in January with rheumatoid arthritis. He has arthritis in his hands, feet, hips, shoulders, and back. All his blood work came back normal. He has tried every type of medication there is to try without success. One symptom I am concerned about is he has been sick on his stomach since he has started all the medications. He has not taken any medication in three weeks but the sickness is still there. I was wondering is this normal for him to be sick on his stomach?

A. Unfortunately many of the medications used to treat arthritis are associated with stomach upset, nonsteroidal anti-inflammatory drugs (NSAIDs) in particular can cause this problem. The symptoms can vary and include nausea, heartburn, indigestion and abdominal pain to frank vomiting. It is unusual to have this problem persist if he’s not taken any medications for three weeks (which certainly isn’t good for his rheumatoid arthritis) so one would have to be curious whether there isn’t another explanation for the problem. One possibility that would need to be considered would the development of ulcers from one of the drugs which he has taken. I would think it would be important to have the problem evaluated, perhaps by a GI specialist (a gastroenterologist). Read more about GI problems caused by medications.

Q. I was diagnosed with rheumatoid arthritis about a year ago. We got it early, but now I have been diagnosed with bicep tendonitis. Is there any relation to the arthritis and tendonitis? I also am developing calcium deposits in my shoulder, which need to be shaved. Is that also related?

A. It is good to hear that your rheumatoid arthritis was recognized and treated early. This is a very much the goal for all patients, which should pay dividends in the future by reducing both the risk and severity of disability. Certainly inflammation of tendons (tendonitis) can occur in rheumatoid arthritis so it wouldn't be all that unusual for you to develop bicipital tendinitis. However, calcium deposits in the shoulder – particularly requiring surgery for removal – would be distinctly uncommon in RA. Crystal deposits in joints is actually a hallmark of another form of arthritis – so-called CPPD arthropathy – and I am curious if this might be responsible for your shoulder disease.

Q. What can I do for the stiffness, pain and grating in my neck?

A. Involvement of the neck (cervical spine) is common in RA, and there are a number of things you can do to help relieve the pain and improve neck movement. Certainly using drugs such as nonsteroidal anti-inflammatory drugs (NSAIDs) or disease-modifying antirheumatic drugs (DMARDs) to get your RA under the best control as possible is important. In addition, simple analgesic (pain) medications such as acetaminophen, codeine or even stronger drugs may be needed to control the pain. Muscle relaxants may also be helpful. Physical therapy measures including the use of hot compresses (towels) or immobilization (neck collar) are useful. Finally, many people find that neck problems are troublesome during the night while sleeping and in the morning. In those instances, the use of a firm, formed pillow can be very helpful.

Q. I was diagnosed with RA a year and a half ago. I do not show the rheumatoid factor in my lab samples. I also have “atypical” symptoms. However, as I understand, there is no typical pattern for RA. It is unique to each person. My rheumatologist seems sure in his diagnosis, however, I would like to know if there is some test or some way to determine if this is in fact RA or are we possible misdiagnosing (and therefore not properly treating) my condition?

A. Although every case of rheumatoid arthritis is slightly different in the way it first presents, how it evolves, what joints are affected and the course of the disease over time, there is generally enough that is common to allow your rheumatologist to make an accurate diagnosis. The involvement of many joints – particularly affecting joints of the hands, wrists, and feet, a "symmetrical" pattern of joint disease (i.e., both the right and left wrist, knee, etc., are affected), and other signs such as morning stiffness and fatigue are characteristically found in the vast majority of patients. Unfortunately, there is no "specific" test that is universally positive in all patients with rheumatoid arthritis. About 20 percent of people with rheumatoid arthritis never develop rheumatoid factor so I wouldn’t be concerned about that test in particular. The other blood tests that are commonly abnormal in rheumatoid arthritis is an elevation in tests that measure inflammation such as the erythrocyte sedimentation rate or the C-reactive protein.

Q. Along with the usual joint pain and swelling and being diagnosed with RA, I also have a pain in my neck, perhaps a gland. It was part of the rest of the pain I had in July that started all this. It was very painful to swallow with pain going from my jaw to my eardrum. I have been to an ENT specialist and can't find anything. My prednisone and methotrexate are working on the joints but the neck pain continues, sometimes worse than other times. Sometimes on the right side, sometimes on the left. It hurts to swallow.

A. Neck pain is fairly common in people with RA, but I’m not certain how, or even if, this is related to symptoms of your pain with swallowing which involves both the jaw and ear. A very rare complication of neck involvement in RA is displacement of vertebrae in the cervical spine, which certainly could lead to swallowing difficulties. However, this generally occurs after many years of RA and is commonly associated with recurrent and severe headaches (or even other neurological complications), which you didn’t mention. Arthritis of the jaw joint – the tempromandibular joint (TMJ) – can cause jaw or more commonly ear pain, but this typically occurs with chewing and not swallowing per se.

Q. I was diagnosed with temporal arteritis four and a half years ago. Now, I've been diagnosed with RA and told that it was the aftermath of the temporal arteritis. All my RA factors are negative, my CRP test is normal and my SED rate is normal. I would like to know if this is possible or could my symptoms be RA-like and possibly something else?

A. It is certainly possible that you been unfortunate enough to have developed both temporal arteritis and rheumatoid arthritis, however I’m not aware that the two diseases are in any way linked. Temporal arteritis is actually associated with another form of arthritis that is "RA-like" called polymyalgia rheumatica (PMR), although the fact that your CRP and SED isn’t elevated would be distinctly uncommon in that disease (and for that matter in RA as well).

Q. I am a 36-year-old male who has been battling joint pain for over seven years. I get excruciating pain in both knees and they get hot and red often. I have also pain in my knuckles, mainly the upper big knuckles, hip pain (both hips) and back pain. I take 3000 mg/day of sulfasalazine, among other meds, to keep it at bay, but lately, it has been getting worse. Now I know you can't diagnose me but any information would be appreciated.

A. Battling sounds like the right word to use here, and I can only begin to imagine the challenges you have had to face. A safe bet would to say that you have "inflammatory joint disease," which is both chronic and unfortunately, severe. But whether this is rheumatoid arthritis or probably more likely something called "seronegative spondyloarthropathy" isn’t clear, or for that matter all that important. Seronegative spondyloarthopathy occurs more often in men than women and many of your symptoms (recurrent knee pain and swelling and hip back pain are very typical of that form of arthritis. Additional things which can occur with this form of arthritis are skin rashes (including psoriasis), mouth sores, or even eye problems – none of which you mentioned. The most important thing is to rethink your medicines with your doctor to get the inflammation under control and prevent damage to your joints.

Q. I have had RA over a year, I'm an registered nurse, plus my father had RA in his 40s also. It’s been aggressive, and I’m on prednisone, methotrexate and Humira. Now I’m experiencing carpal tunnel syndrome on my right fingers, hand and wrist. Any correlation that you know of?

A. There are many possible causes of carpal tunnel syndrome and certainly rheumatoid arthritis is one of them. Carpal tunnel syndrome occurs as a result of pressure on the median nerve in the wrist in a very narrow and confined space called the "carpal tunnel." In rheumatoid arthritis, the thickened, inflamed synovium in the wrist fills the space, puts pressure on the median nerve, which then leads to the pain, numbness and tingling in the fingers, hand and wrist.

Q. My blood pressure has gone very high since I have been taking Enbrel. My doctor says that the Enbrel is causing this but he doesn't want to take me off this drug. Should I be concerned?

A. There is a risk of side effects with virtually all drugs, and it is important that you learn about the side effects which MAY occur with the drug when you are first consider taking the drug. This will help you be on the lookout for early signs of potential complications. In some instances, regular monitoring by your doctor will need to be done to check for these side effects. I’m not aware that etanercept (Enbrel) causes high blood pressure so I would think it would be important to consider other possibilities. Both nonsteroidal anti-inflammatory drugs (NSAIDs) and prednisone – both commonly used in the treatment of rheumatoid arthritis (RA) – can occasionally cause high blood pressure. If you are by chance taking either of these medications, then this might be a consideration. If the blood pressure is at levels that require treatment (and you and your doctor are not able to easily figure out what is causing the problem), then it is best to simply start treatment to get your blood pressure down.

Side effects which are possible and most common with etanercept (Enbrel) include skin reactions and pain at the injection site and headache. Infection and blood disorders are two of the more serious RARE complications which MAY occur with etanercept (Enbrel). It is important that you discuss the risk of these complications with your physician and, in particular, steps that will be taken to monitor for them or things that you need to look for as early signs of the complications. For tips on talking about treatment options with your doctor, see Let's Talk RA.

Q. I have had rheumatoid arthritis of the eyes for the past 40 years or so. I take eye drops when I feel the pain coming on. I have arthritis in my hands, neck, shoulders, back and knee. Is there anything out there I should take to slow down my problem?

A. Many people aren’t even aware that rheumatoid arthritis can cause eye problems and, in fact, there are several different types of eye complications which can occur. The most common – and presumably what you are dealing with – is called Sjögren’s syndrome (or the keratoconjunctivitis sicca). The main symptom of Sjögren’s syndrome is extreme dryness of the eyes and the best form of treatment involves the use of regular eye drops so you are doing exactly the right thing. Sjögren’s syndrome also can be responsible for dryness elsewhere like the mouth and skin. Very rarely rheumatoid arthritis can cause intermittent redness and irritation of the surface of the eye (episcleritis) or a more serious inflammation of the deeper layers of the eye surface (scleritis). If you aren’t entirely certain what type of eye problems you are experiencing – seeing a rheumatologist or ophthalmologist would be a good idea.

Q. I was just diagnosed by my primary doctor with rheumatoid arthritis. I made an appointment with a rheumatologist, but the earliest appointment I could get is over two months from now. What can I do in the mean time for the pain? Will my rheumatoid arthritis progress and get worse while I am waiting to see a rheumatologist?

A. It is good to hear you have an appointment with a rheumatologist, but certainly not good news that you have to wait two months. Because of the shortage of rheumatologists and the high demand to see them, delays of two months (or in many cities more) to see a rheumatologist are unfortunately common. It is very important to get the inflammation of RA under control as quickly and completely as possible. However your options are limited to nonsteroidal antinflammatory drugs or pain medications – either prescribed by your primary care physician or over-the-counter medications. In most people, there is a need to begin a disease modifying antirheumatic drug (DMARD), but you’ll need to wait to discuss this with the rheumatologist and decide if this is the right decision and which one would be best for you.

One of the key – and perhaps most important – strategic goals of the Arthritis Foundation is to work with primary care physicians and rheumatologists to recognize people with possible RA as early as possible and reduce the wait time to see a rheumatologist.

Q. I have recently been diagnosed with RA and have been treated with a high dose of prednisone this winter. I was extremely ill and the prednisone worked miracles. The symptoms returned and worsened as my prednisone was reduced. I am a 22-year kidney recipient who had a vasculitis diagnosis about 24 years ago and have been on a maintenance dose of 5mg prednisone continuously over the years. Now the RA is totally disabling and I am on 10mg of prednisone a day until blood tests will determine if I can take methotrexate. I understand this medication may take 6 weeks to work. In the meantime, what can I expect. Also I understand there are a lot of undesirable side effects with methotrexate. Any help would be appreciated.

A. As you have learned, high doses of prednisone can have a profound effect on the signs and symptoms of RA, but they can be the cause of major side effects if used for long periods and unfortunately joint pain and swelling often return as the dose is reduced. If your symptoms aren’t being controlled with maintenance steroids (10 mg or less of prednisone daily), then starting a disease modifying drug (DMARD) is important. Methotrexate is the most commonly used DMARD in this country, but there are many others that you may want to consider. The time it takes these drugs to work varies from person to person, but it does take four to six weeks before improvement is seen with methotrexate. Methotrexate – like all drugs – has the potential for adverse side effects, which you need to be aware of and consider when making the decision to take the drug. Among the side effects which ARE POSSIBLE with methotrexate, mild nausea, diarrhea, and loss of appetite are perhaps the most common. Liver and lung damage are extremely rare complications of methotrexate, and your doctor will likely monitor you closely for these should you decide to take the drug.

Q. I have rheumatoid arthritis (RA) and a family history of multiple sclerosis (MA). My doctor says I can't take any of the newer biologic medications because of the increased risk of MS. What kind of treatment options will I have in the future if my RA progresses? What is the research community doing right now to help people who have multiple autoimmune diseases?

A. The occurrence of different "autoimmune" diseases within families isn’t all that unusual, and there are a number of research studies underway to identify whether this is a result of autoimmune genes within the family (likely the case), environmental triggers the family is exposed to, or something else. The rare complication that has been reported with the use of tumor necrosis factor (TNF) inhibitors has been neurological disease which resembles multiple sclerosis. I would agree with your doctor that given your family history of multiple sclerosis you would likely be at greater risk for this complication with TNF inhibitors. I’m not aware of the risk of neurological complications from disease modifying drugs used in RA such as methotrexate or leflunomide or the "newer" biologic agents such as abatacept and rituximab. If your RA progresses – and let’s hope that it won’t – these drugs would be considerations. (See the 2007 Drug Guide for more about arthritis medications you can discuss with your rheumatologist.)

Q. Does RA ever remit permanently?

A. The short answer is YES, RA does go into remission. There is no agreed upon definition or understanding of what remission means exactly. Is it remission without medication where disease completely goes away and doesn’t require any further medications or treatment, or remission with medication where symptoms are completely or mostly gone with medications? As a result, it isn’t entirely clear how often this actually happens, but a good guess might be that 10 to 20 percent of people with RA achieve a complete or partial remission during the course of their disease. There is a general belief that there is a much greater likelihood of remission if RA is recognized and treated as early as possible with disease-modifying drugs. (See a summary of the PROMPT study.) In addition, the number of people who achieve remission would appear to have increased since the availability of effective disease modifying drugs and biologic agents.

Q. Since being diagnosed with RA, I have become increasingly sensitive to the sun to the point that even reflective sunlight, after a few hours, will make me feel very ill. Is this the RA or is it a side effect of my treatment which is a combination of prednisone, methotrexate and Enbrel.

A. Increased sensitivity to the sun (photosensitivity) can lead to severe sunburns or rashes, or, in some individuals, "systemic" symptoms, including extreme fatigue or a feeling of general illness. I’m not aware of photosensitity occurring as a result of RA (however it is common of lupus). The drugs you are taking could certainly be one possibility to explain your symptoms. In addition, nonsteroidal inflammatory drugs (NSAIDs), including over-the-counter medications and some "alternative medications," have been associated with photosensitivity reactions. If you are taking any of these drugs, they, too, might be causing the problem.

Q. My dad developed rheumatoid arthritis when he was 26 years old. Why would anyone get arthritis at such a young age? I'm 26 years old right now. Should I worry? He's had many joint surgeries and including open heart triple bypass surgery.

A. Rheumatoid arthritis has absolutely no respect for age and, in fact, the majority of cases first begin in people between the ages of 20 and 40 years. The development of the disease in your father at age 26 is, therefore, rather typical and comes at a time of enormous family and career responsibilities. Once it begins, it becomes chronic and, in many cases, causes serious joint damage requiring surgeries. Many people don’t realize that there is an increase in serious coronary artery disease in people with RA so it is quite likely that your father’s triple bypass is the result of his rheumatoid arthritis.

Because your father has rheumatoid arthritis, you are at increased risk of developing the disease compared to someone who doesn’t have RA in their family. However, the risk is still small and you shouldn't worry about it as long as you are healthy. If, however, you do develop joint problems – particularly in your hands, wrists or feet – it is important that you see a rheumatologist promptly for an evaluation.