Rheumatoid Arthritis Questions
Arthritis Today Medical Experts Answer Your Questions About Rheumatoid Arthritis
One of the most popular features in Arthritis Today, "On Call" finds answers to your most puzzling arthritis questions by asking a variety of healthcare experts. Just click on the question or title you'd like to see.
Safety of shingles vaccine in people with RA
How long does a flare last?
Is minocycline safe for long-term use?
If I'm in remission, can I stop my medications?
What if I want to get pregnant?
Is It RA Or Gout?
Aneurysm-RA Association?
Combining medications
Explaining Felty's Syndrome
A More Comfortable Splint
Relief for Neck Pain
Breathless with Arthritis
Fighting Fatigue
Sore Tongue Relief
A Cure In My Lifetime?
Allergies And Arthritis
Rheumatoid Arthritis: Blame It On El Nino?
Scared By Side Effects
Less Painful Fluid Removal?
How Can I Get Butazolidin?
Skin Ulcers: Cause and Treatment
Is My Daughter at Risk for RA?
Safety of Shingles Vaccine in People with RA
Q: I’ve heard and read that those of us with RA and other autoimmune disease should not have the new shingles vaccine. Can you explain why we shouldn’t?
A: Shingles is a reactivation of the chickenpox virus, which lies dormant in the body for years. Reactivation may be triggered after the immune system weakens, which can happen with age, or after taking immunosuppressant drugs. Several of the medications given to people with autoimmune diseases, such as rheumatoid arthritis, suppress the immune system. These include corticosteroids, such as prednisone, some disease-modifying anti-rheumatic drugs (DMARDs) such as azathioprine or methotrexate; and the biologics – abatacept (Orencia), rituximab (Rituxan), and the TNF inhibitors (Enbrel, Humira and Remicade).
Because people who take these medications are at higher risk of shingles, a vaccine might be helpful. But Zostavax, the shingles vaccine, is a live vaccine, so doctors remain very cautious about giving it to any patients whose immune systems are even slightly suppressed. We avoid giving the vaccine to patients who take methotrexate, and even to those on low-dose prednisone.
It is possible to get the vaccine safely, if it is given before you start a biologic. If you are already taking a biologic agent and want to receive the Zostavax vaccine, you would need to stop taking the biologic for a period of time before the vaccination is given, and wait to start the biologic again for a time afterward. The length of time varies substantially, depending upon the particular biologic. For etanercept (Enbrel), some doctors recommend stopping for one month before and withholding for one month after.
Whether it is worth discontinuing your treatment simply to administer the vaccine is something you and your doctor need to discuss, based on the likelihood and consequences of a disease flare, as well as your concern about shingles.
John H. Stone, MD, Rheumatologist
Q: I was diagnosed with rheumatoid arthritis (RA) three months ago, so learning to recognize a flare is new to me. I realize the length of a flare can vary, but what is the experience of most people? Months? Years?
A: People usually know a flare is getting under way when morning stiffness increases. That is, they wake up in the morning feeling their joints are stiffer than usual, and it takes longer until the joints loosen up sufficiently for daily activities to be performed. With bad RA flares, morning stiffness and fatigue may last all day and greatly interfere with people’s lives. They can persist for weeks or months unless there is a change in treatment.
Changes in bloodwork may indicate an increase in inflammation. For example, both the erythrocyte sedimentation (“sed”) rate or the blood level of C-reactive protein may rise. Although these test results don’t change only when there is an RA flare, they may provide supporting evidence of worsened disease activity for the doctor and often are helpful in tracking improvement of the disease flare after treatment. Usually your symptoms are reliable indicators of a flare, so it is important to keep tabs on them, as well as what you are doing to treat your arthritis.
It’s crucial to suppress inflammation during flares, especially so soon after your diagnosis, when initial damage to your joints can occur. How long it takes to suppress a flare depends upon the medications you take. One strategy for severe flares is to control symptoms quickly with low-dose prednisone, which can improve symptoms within days, while simultaneously starting methotrexate and other medications designed to suppress RA disease activity within weeks or months.
John H. Stone, MD, Rheumatologist
Is minocycline safe for long-term use?
Q: I have been taking the antibiotic minocycline as a disease-modifying drug for the past two months to treat my RA. Is it safe for long-term use? Will it affect my health or my liver?
A: Minocycline, a drug similar to the antibiotic tetracycline, generally is considered to be one of the safer disease-modifying anti-rheumatic drugs (DMARDs). The most common side effects with using minocycline for three months or so are upset stomach, dizziness, discolored fingernails and rashes or dark pigmentation of the skin – especially on sun-exposed areas. It can cause liver damage, but only in very rare cases. Your doctor should be examining you every few months and sending you for lab tests to make sure minocycline is working for your RA and not causing any side effects.
Minocycline is effective in about 60 percent of people with RA who use it. However, it often is not prescribed because it does not have FDA labeling approval for this use, and it is a relatively weak DMARD compared with methotrexate, leflunomide (Arava) or the biologics (Enbrel, Humira, Kineret, Orencia, Remicade and Rituxan). It isn’t the antibiotic properties, but the effects on the immune system and the ability to inhibit enzymes that break down cartilage and connective tissue that make minocycline (and other tetracycline drugs) so effective.
Don Miller, PharmD, Pharmacist
If I'm in remission, can I stop my medications?
Q: With taking injections of methotrexate and Humira, along with naproxen and folic acid, I have had very little joint pain, swelling or morning stiffness for at least three months. Does that mean my RA and psoriatic arthritis are in remission, and I can stop at least the injections temporarily?
A: You may well be in remission, but you should not stop taking your injections. The combination of an immunosuppressant (methotrexate) and a biologic agent (Humira) can result in a near-complete cessation of symptoms in a high percentage of people. Your excellent response with very little pain in the joints and no morning stiffness or swelling for the past three months could be classified as a “clinical” remission.
But without the injections, the diseases most likely will come back within four to eight weeks as strongly as before you started taking those medications. Most importantly, if the disease becomes more active, you will have an increased risk of damage to the joints. I certainly understand your desire to use less medication, but you must balance it with the need to keep the RA and psoriatic arthritis under control, in order to halt the progression of your diseases.
Once a clinical remission is achieved, we attempt to lower the amount of medications while maintaining the remission. I recommend you talk to your rheumatologist about first reducing your dose of naproxen, which is an NSAID. People in clinical remission usually can discontinue their NSAID; because it does not halt the progression of RA or psoriatic arthritis, stopping it does not increase the risk for disease-related damage. Once the NSAID is discontinued, sometimes the methotrexate dose can be lowered next, but this is an individual decision to be made with your rheumatologist. Rarely can a person stop a biologic agent and maintain a clinical remission.
Paul Howard, MD, Rheumatologist
What if I want to get pregnant?
Q: I was diagnosed with RA one year ago. I chose not to start medication because I am trying to have a child and my rheumatologist informed me the medications could cause birth defects or miscarriage. Another doctor said I should be on medication, however, because RA is degenerative. What should I do?
A: I am glad you are discussing pregnancy plans with your doctor. Any patient thinking about having a child should talk about medications and risks with their rheumatologist before discontinuing birth control measures. With careful planning, most patients with RA can have a successful pregnancy. Some patients actually will improve during pregnancy, but, in others, RA can flare after delivery.
During attempted conception, throughout pregnancy and after delivery, you should be assessed continually by your rheumatologist for signs of inflammation in the joints on examination or in the blood, so you can be treated if a flare occurs.
Some medications should not be used before or during pregnancy. For example, I recommend patients stop methotrexate and wait three menstrual periods prior to attempting conception. Patients who take NSAIDs and are having difficulty getting pregnant should stop these medications because they can affect ovulation. Once they are pregnant, NSAIDs can be used, but only until the third trimester because they can cause problems with lung and kidney development if used late in pregnancy.
Prednisone has been considered the safest of the corticosteroid options, although there is a risk of low birth weight if high doses are needed to control arthritis. The DMARD hydoxychloroquine (Plaquenil) is used during pregnancy and appears to carry a very low risk. There is limited data on the DMARD sulfasalazine (Azulfidine) in pregnant women with RA, but risks are low in patients with Crohn’s disease who take it. Women of childbearing age who are taking sulfasalazine also must take folic acid to reduce the risk of neural tube defects. For the newer biologic drugs, such as adalimumab (Humira), etanercept (Enbrel) and infliximab (Remicade), the risk is not yet known, but early findings suggest they may be relatively safe during pregnancy for patients with severe RA. There is little information on other biologic drugs.
Leslie Crofford, MD, Rheumatologist
Is it RA or Gout?
Q: I am a 50-year-old man recently diagnosed with rheumatoid arthritis (RA). But based on some previous, isolated joint problems, I suspect I have had RA for some time. Two years ago, after a day of vigorous exercise, I experienced swelling and excruciating pain in my left toe, which lasted a few days. Then, while recuperating from a heart attack last year, I had a similar problem in the opposite foot and knee. My doctor suspected an infection and prescribed antibiotics, which seemed to clear up the problem. Three months later, though, the problem returned in the same knee. It soon went away, but later returned in both feet and knees and now my wrists. Do you think these incidents were early signs of RA?
A: I definitely think these events are related, but they probably were not due to RA. It sounds to me like you have gouty arthritis, or gout, an inflammatory disease that occurs when excess uric acid (a bodily waste product) circulating in the bloodstream is deposited as sodium urate crystals in certain joints. The excess uric acid may be caused by genetic factors or kidney disease. The condition may be aggravated by certain drugs such as diuretics and low doses of aspirin or by consuming too much alcohol or foods rich in purines, which are broken down into uric acid.
If your physician didn't know about your previous problems, it's not surprising that he diagnosed your condition as RA, probably without even suspecting gout. In its later stages gout can look a lot like RA, causing pain and inflammation in multiple joints. In some cases, untreated gout can be associated with a positive rheumatoid factor, an antibody often detected in the blood of people with rheumatoid arthritis. And build-ups of sodium urate can form lumps under the skin that resemble the nodules that are fairly common in RA.
But that's pretty much where the similarity ends. The causes and treatments are entirely different. Unlike gouty arthritis, RA is caused by an abnormality of immune function that causes the immune system to attack the membrane lining the joints. RA may begin acutely in many joints or may start gradually, involving several joints and progressing. Initially, the involved joints are the knuckles, middle joints of the fingers, wrists, and joints that attach the toes to the feet.
Gout, on the other hand, often starts as your problem did -- with excruciating pain and swelling in the big toe -- and often follows a trauma such as an illness or injury. Subsequent attacks may occur off and on in other joints -- primarily those of the foot and knee -- before becoming chronic. In its chronic stage, gout can affect many joints, including those of the hands. But this can take a few years to happen.
Unlike rheumatoid arthritis, gout is a well-understood and highly treatable disease -- and it has been for almost three decades. Medications are available to stabilize uric acid levels and relieve acute pain and inflammation. With appropriate treatment gout can be controlled and future attacks can be prevented. The biggest obstacles in controlling gout are improper diagnosis and noncompliance. If a doctor doesn't diagnose it properly, he cannot treat it properly. Like some other forms of arthritis, gout requires a medical regimen all its own. Taking the proper medications and taking them faithfully -- even during periods that you feel absolutely fine -- is essential to controlling gout. Maintaining a reasonable weight and limiting alcohol consumption can help control gout as well.
If you haven't already had a joint fluid sample examined for urate crystals, I would recommend that you speak to your doctor about having one at your next visit. Or if the medication he has prescribed for your RA (and I assume he has prescribed one or more) doesn't seem to be helping, schedule a visit sooner. If, in fact, you have gout, the sooner you know and begin proper treatment, the sooner you will experience relief.
Doyt Conn, MD, Rheumatologist
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Aneurysm-RA Association?
Q: In 1970 I had an aneurysm, which caused paralysis of my right side. Seven years later I developed rheumatoid arthritis. Is it possible these two problems could be related?
A: There is no known relationship between aneurysms or strokes and the later development of rheumatoid arthritis. In people who have RA and are paralyzed, however, there is generally less joint involvement on the paralyzed side. Arthritis is not likely to involve joints that are inactive or not used. I don't know whether that's true in your case.
Doyt Conn, MD, Rheumatologist
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Combining Medications
Q: I have rheumatoid arthritis (RA), for which I take both prednisone and methotrexate. Now my doctor wants to prescribe hydroxychloroquine (Plaquenil) for me. Have you ever heard of someone taking three drugs at once? Is this safe?
A: It is common for physicians to prescribe a combination of low doses of prednisone and drugs like methotrexate for patients with rheumatoid arthritis. In selected cases, as in your case, physicians are adding on additional drugs. These combinations of drugs are used for patients with RA whose disease has not responded well to a single drug or to two drugs. A number of clinical studies have shown that patients treated with certain drug combinations do better with no greater incidence of side effects than those taking individual drugs. In these situations, it's important to have your disease managed by a physician experienced in the arthritic diseases.
Doyt Conn, MD, Rheumatologist
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Explaining Felty's Syndrome
Q: My husband has had rheumatoid arthritis for 18 years, and just recently he learned he also has Felty's syndrome. Can you please tell me what this condition is, if it's related to rheumatoid arthritis, and how it is treated?
A: Felty's syndrome is defined as rheumatoid arthritis in combination with a low white blood cell count (leukopenia) and an enlarged spleen. It often occurs in people who, like your husband, have had longstanding rheumatoid arthritis. Because of the low white blood cell counts, people with Felty's syndrome may be more susceptible to infections. The treatment of the arthritis with disease-modifying drugs like gold or methotrexate may actually raise the white blood cell count and decrease the chance of infection. Removing the spleen rarely helps, except in extreme cases.
Bernard Rubin, DO, Rheumatologist
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A More Comfortable Splint
Q: I am a high school senior with rheumatoid arthritis, and in the past I have worn a plastic splint on my elbow to straighten it. However, the splint is large and heavy and a pain to wear, especially at night. Are you aware of splints made out of lighter, easier-to-wear materials?
A: Good news! There's a good chance you can get a lighter-weight splint. First I would recommend that you speak to your doctor to find out the purpose of the splint he has prescribed, because there are basically two different types. One, which is relatively light to begin with, is designed to increase the joint's range of motion. It works by adjusting to progressively straighten the joint to keep it from becoming fixed in one position. The second type, which is often made of heavier molded plastic, is designed to hold the joint in one particular position. By doing so, the splint serves as kind of a "bed" to allow the joint and muscles surrounding it to rest.
Because you say your splint is heavy, I assume the second type I've mentioned is the type you have. In either case, there are some new lighter-weight versions on the market. Once you have learned from your doctor the type of splint you need, see an occupational therapist (OT), who will probably be able to make or order one for you. If your OT is unfamiliar with lighter-weight splints, a certified hand therapist may be able to help you.
Dena Slonaker, OTR, Occupational therapist
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Relief for Neck Pain
Q: After 30 years of rheumatoid arthritis and increasing neck pain, I learned from an X-ray that I have deterioration of the upper spine. My doctor warns that this could lead to paralysis. What can I do to minimize the danger of paralysis?
A: The neck, or cervical spine, is the only part of the spine that is commonly affected by rheumatoid arthritis (RA). RA causes inflammation of joints, which leads to cartilage damage, bone erosion and instability of the vertebrae (the bones that make up the spine). Usually associated with pain, RA of the neck can also cause damage to the spinal cord, resulting in weakness, nerve damage and paralysis. While paralysis is rare, X-ray findings of spine instability are common, especially in patients who have damage to other joints such as the hands, wrists, knees and elbows. Strategies for preventing further nerve damage are uncertain, although the use of a collar may help prevent excessive neck motion, especially when you're doing activities that would cause sudden or sharp neck movement. Using a cylindrical-shaped cervical pillow can help relieve neck pain at night. When there is evidence of progressive nerve damage, such as difficulty in walking or loss of control of bladder or bowels, surgery may be required to fuse the unstable joints.
David Pisetsky, MD, PhD, Rheumatologist
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Breathless with Arthritis
Q: Is it possible for arthritis to cause shortness of breath?
A: Yes. Shortness of breath can occur in people with rheumatoid arthritis for a number of reasons. For one, the disease process itself can cause inflammation and scarring in the connective tissue of the lungs. In a very small portion of patients, methotrexate use can cause pneumonitis -- inflammation of the lung tissue. Also in rare instances, rheumatoid arthritis may affect the heart and cause heart failure, which can be associated with shortness of breath. Much more often people with rheumatoid arthritis develop fatigue and dyspnea (breathlessness) on exertion simply because of the general disability associated with this inflammatory condition. It's important that your physician be aware of your concern about shortness of breath and carry out appropriate studies to determine its cause.
John Hardin, MD, Rheumatologist
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Fighting Fatigue
Q: I am a young woman with RA who is doing very well in general, except that I can't get enough sleep. I eat well, exercise religiously, meditate and get good medical care. I also sleep quite well - sometimes for as long as 12 hours at a stretch - yet I am still tired. What is going on? Is there anything that can help my fatigue?
A: Fatigue is a surprisingly common problem in people with RA. In many patients fatigue seems to parallel the course of arthritis and improves as the arthritis comes under better control with appropriate therapy. In other patients, however, the relationship between arthritis and fatigue is much less clear. In those cases, it is particularly important to exclude other causes of fatigue such as hypothyroidism, anemia or fibromyalgia. In addition to exploring the medical causes of your fatigue with your doctor, you might consider working with a physical therapist to review factors that may be contributing to your fatigue. Physical therapists often refer to the concept of energy conservation and assess lifestyle changes that make for a better balance between activities that use energy and those that restore it. For example, you may be exercising too much, at the wrong times of day, or not getting proper rest when it is actually needed, so that you feel exhausted all the time. A physical therapist might suggest simple changes in your daily routine that would help to relieve your fatigue.
John Klippel, MD, Rheumatologist
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Sore Tongue Relief
Q: For some time I have been experiencing a sore tongue, which my doctor says is caused by the medications I take for RA. Is there anything I can take to relieve this problem?
A: There are several reasons you may have developed a sore tongue or mouth, including - as your doctor told you - side effects from certain arthritis medications, such as methotrexate, gold salts and D-penicillamine. Less commonly, NSAIDs can cause mouth irritation. Dry mouth, from causes such as Sjögren's syndrome may also cause mouth soreness. To relieve the problem, try spraying your tongue with a topical anesthetic such as Chloraseptic or Cepastat. If your mouth is dry, frequently sipping water may help.
For more severe cases, your doctor may prescribe chlorhexidine gluconate 0.12 percent rinse to be swished in your mouth and spit out three times a day or a gel medication called lidocaine that will cause numbness of the tongue. If there are discrete sores in the mouth, a steroid medication in a sticky base called Orabase may be applied directly to the sores. If none of this helps, I would recommend asking your physician about other possible causes. Fungal infections or vitamin deficiencies can cause similar problems, and both of these can be corrected. If your pain persists or becomes severe, your only option might be to switch medications. Ask your physician about your options.
Timothy Lambert, MD, Family Physician
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A Cure In My Lifetime?
Q: I am 23 years old and have recently been diagnosed with rheumatoid arthritis (RA). When my doctor told me RA is incurable, I was devastated. But I am still hopeful. With all the research going on and the fact that I am so young, don't you think there will be a cure in my lifetime?
A: I can understand your distress over learning you have RA -- particularly since your doctor told you it is incurable. When we place ourselves in a doctor's care, it's only natural to want -- and even expect -- him to correct the problem. Indeed medical science has the tools to cure some conditions. There are others, however -- RA included -- that medical science can't yet fully fix, but can manage well.
It's hard to say if there will be a cure in your lifetime. Certainly a cure is the ultimate goal of scientists working in clinics and laboratories even as I write. But RA is a complicated disease. There are many factors that initiate and perpetuate it, and probably a combination of agents will be needed to stop it. Keep in mind, too, that if scientists one day find a way to stop the disease, it would not undo the damage that has already occurred in people with RA. That's why it's important to get proper treatment now.
For the person today with recent onset, newly diagnosed RA, we can be optimistic about controlling the disease and limiting its impact. This is due to the proven effectiveness of disease-modifying antirheumatic drugs. When used early in the disease process, often in combination with prednisone, these drugs can slow the process and prevent irreparable joint damage. As scientists learn more about the genetics of RA, the factors that trigger the disease, and people's individual responses to those factors, new treatments will emerge and we will be able to apply them earlier and with increasingly better control. For some people, this will equal a cure.
But drugs are not the whole solution. Appropriate exercise, rest, physical therapy (if needed), a healthful diet and other non-drug therapies can play a key role in arthritis treatment. If your doctor does not bring these non-drug therapies up, I would encourage you to ask him about them. Or call your local Arthritis Foundation office. I am glad to know that you are remaining hopeful. Maintaining hope and a positive attitude are important elements in managing your RA. At the same time, however, I urge you not to pin all your hopes on a cure. Doing so may ultimately set you up for disappointment. It could also make you vulnerable to unscrupulous practitioners with products and potions, promising to cure your disease, when in actuality following their advice -- and abandoning your prescribed treatment -- could cause you more harm than good.
Frankly, I am a bit surprised that your doctor referred to RA as "incurable." Instead, I like to think of it as manageable. Today, more than ever, the prognosis for a young person with RA is good. Remember that, remain hopeful, follow your prescribed treatment and do well.
Doyt L. Conn, MD, Rheumatologist
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Allergies And Arthritis
Q: I was diagnosed with RA last year. Since then I have tested positive for allergies to wheat and dairy foods as well as pollens, molds, grasses, etc. Is it possible for allergies to cause or exacerbate arthritis?
A: If your allergies predispose you to serious or chronic sinus infections or bronchitis, they may affect your RA. Many physicians believe that stress -- either physical (including illness) or emotional -- could influence the course or symptoms of RA. However, I feel it's unlikely that allergies caused your RA. Although both RA and allergies result from heightened activity of the immune system, the basis for these conditions is quite different. RA is caused by excessive activity of immune cells in the joints, while allergies are caused by the action of an antibody in the blood that usually leads to symptoms in the respiratory tract.
David S. Pisetsky, MD, PhD, Rheumatologist
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Rheumatoid Arthritis: Blame It On El Nino?
Q: Have you heard of any new cases of rheumatoid arthritis (RA), particularly among people in Southern California, due to El Nino? I have recently developed RA and have spoken with several people in my area who've developed similar problems.
A: It is probably just an odd coincidence that some people in Southern California experienced the onset of their arthritis during El Nino. Weather cannot cause a person to develop arthritis, but cool, humid weather may increase stiffness and joint discomfort in some people who already have the condition. In people with early, undiagnosed arthritis, it is possible that such weather might cause the first noticeable discomfort and lead them to seek medical attention. While this can make it seem that the weather is causing arthritis, it is simply exacerbating the symptoms.
James McKoy, MD, Rheumatologist
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Scared By Side Effects
Q: After reading the pharmacy sheets listing side effects of the medications I take for rheumatoid arthritis (RA), I can't help but wonder if the "cure" is worse than the disease. Is it possible I'd be better off skipping the medications and taking my chances with the RA?
A: I would really hate to see you - or anyone with a potentially disabling disease such as RA - completely give up medications. But I certainly can understand your concerns: No medication is completely safe, and the potential risk of side effects can be frightening. Anytime you interfere with one bodily process you may interfere with others - sometimes in undesirable ways. But the dangers of untreated RA, in most cases, far outweigh the risks of the drugs used to treat it. Each day, medications ease pain, prevent joint destruction and improve the lives of countless people with arthritis and related conditions. In some cases, medications can literally save lives.
The pharmacy sheets are provided as a service to make you aware of side effects that can occur with a certain medication. Keep in mind that the key word here is "can." You shouldn't assume that the listed side effects will necessarily occur in you. Even if you do experience one or more side effects, you may be able to reverse or halt them by stopping or changing medications. In most cases, no action is needed; the side effects resolve on their own.
Many factors can influence how your body reacts to a drug. Some are largely controllable - such as when and how you take your medicine. Factors that can't be changed, such as your age and other health problems, may be compensated for with choice of medication or a dosage adjustment. Life is full of risks. Sometimes we have to risk experiencing a side effect to gain a medication's benefits. The key is weighing risks against potential gain. Your doctor can help you weigh those risks and choose the drugs that provide the most help and do the least possible harm.
Let your doctor know about any other medications you are taking - even over-the-counter (OTC) ones- because some can add to the side effects of others. For example, taking aspirin along with a prescription nonsteroidal anti-inflammatory drug (NSAID) can increase your risk of stomach ulcers and other side effects.
Don't underestimate the power of nutritional supplements. Nutritional supplements, too, can affect the way a drug works. In some cases - such as taking folic acid along with methotrexate - vitamin supplements can reduce the risk of certain side effects. In other cases, taking nutritional supplements or herbs in addition to prescribed medications can interfere with the action of the medication or even enhance its potential side effects.
Find out if there are certain foods you should eat or avoid while taking a medication. Most drugs, including NSAIDs, should be taken with food to reduce the risk of stomach upset. For others - such as minocycline, an antibiotic that is being used increasingly to treat RA - taking with food can decrease the drug's absorption.
Forgo alcohol - it can add to the side effects of most drugs, from analgesics to antidepressants. If you can't or don't want to give up alcohol altogether, set a limit of two drinks (including beer) per week.
Ask your doctor to prescribe the lowest beneficial dose of a drug and never take more than the prescribed amount. Many side effects are related to dosage. High doses of glucocorticoids such as prednisone, for example, can cause a wide range of side effects, including fluid retention, fragile bones and increased susceptibility to infections. Low doses, which are often effective in managing inflammatory arthritis, have a low risk of side effects.
Take the drug at the time designated by your doctor. Timing, in some cases, can influence a drug's side effects. For example, taking the osteoporosis drug alendronate when you get up in the morning, rather than before lying down at night, can cut the risk of esophageal ulcers. Timing can also influence some drugs' wanted effects. By taking a drug at the optimum time, you may actually be able to reduce the dose and, thus, the risk of side effects.
Never stop taking any medication without consulting your doctor. A drug can't help you if you don't take it, but abruptly stopping a drug can hurt you. The dosage of drugs such as prednisone, for example, must be tapered to avoid serious adverse effects.
Let your doctor know if you suspect a side effect. He can determine whether the side effect requires treatment or if discontinuing a drug or perhaps educing its dose is in order.
Doyt Conn, MD, Rheumatologist
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Less Painful Fluid Removal?
Q: Is there anything that can be done to alleviate RA-related fluid buildup in the knee other than draining the fluid out with a big needle? If not, is there any way to make that procedure less painful?
A: In people with RA, fluid accumulates within the joint space in response to inflammation. Because the disease often strikes the knee and because the knee is a large joint, it is especially likely to develop large collections of joint fluid when inflamed. Although draining the fluid with a needle is effective, it is, as you say, painful. Furthermore, its effects may be only temporary, if efforts aren't made to stop the inflammation and keep any fluid from returning. Unfortunately, once fluid accumulates, there is no way to make its removal less painful.
Ideally, RA treatment should prevent the inflammation that causes fluid buildup in the first place. Systemic medications such as NSAIDs (ibuprofen and ketoprofen, for example), droxychloroquine (Plaquenil), gold or methotrexate are specific approaches to solving the problem of inflammation. Some other strategies include local injections of anti-inflammatory agents into the joint, resting the joint and applying cold packs.
John A. Hardin, MD, Rheumatologist
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How Can I Get Butazolidin?
Q: Several years ago, my previous physician prescribed a medication called Butazolidin -- the only medication that has helped me manage the pain of RA. That physician retired and my new one says Butazolidin is used only for horses. Is this true? Isn't there some way I can get this medication?
A: Butazolidin is the brand name of a NSAID called phenylbutazone. Currently, no U.S. manufacturer produces phenylbutazone for human use. Phenylbutazone, introduced in 1952, was the first NSAID -- aside from aspirin -- to be marketed and remained popular for many years. As other NSAIDs came out, however, its popularity diminished, due to increased competition as well as the drug's risk of side effects. In addition to having side effects common to NSAIDs, phenylbutazone also causes potentially life-threatening decreases in blood cell counts in some people. Consequently, in 1984 the FDA made its manufacturer add a warning to the drug labeling mandating that phenylbutazone not be used until other NSAIDs were found ineffective in a patient and that caution should be used in prescribing the drug to older people. Eventually, both Butazolidin and its generic versions were discontinued due to low sales. As your physician mentioned, phenylbutazone is still available in veterinary formulations, but severe side effects have been reported in people who ingested veterinary phenylbutazone.
I'm sorry that other drugs have not helped you the way phenylbutazone did, but with the high numbers of NSAIDs on the market -- and all the new drugs coming out shortly --I hope you and your doctor will find one that brings you relief.
Donald R. Miller, PharmD, Pharmacist
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Skin Ulcers' Cause and Treatment
Q: I have had rheumatoid arthritis (RA) for 35 years. About 10 years ago I developed open sores on my ankles, which my doctor says are caused by vasculitis. Can you tell me what vasculitis is? Is it related to arthritis? Is there a cure for it or for the sores it is causing?
A: Vasculitis, which may be associated with RA, is an inflammation of the blood vessels -- particularly those that supply the skin and supporting nerves. In people with RA-related vasculitis, the ulcers you describe are often caused by a combination of several factors: the blood vessels' inability to supply adequate amounts of blood to the skin due to inflammation; the effect of corticosteroid medications (such as prednisone) on the skin; having the legs below torso level, as when seated or standing, which causes pooling of the blood in the veins of the leg and poor healing; and the fact that the skin just above the ankles has a naturally limited blood supply.
Although ulcers that become particularly large or deep may require skin grafts to heal, most ulcers will heal on their own if you keep them clean, keep your feet raised as much as possible, and keep your arthritis under control. In severe RA, such as what you are likely experiencing, controlling the disease often requires some type of disease-modifying agent such as methotrexate.
Doyt Conn. MD, Rheumatologist
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Is My Daughter at Risk for RA?
Q: I have rheumatoid arthritis (RA), for which I take both prednisone and methotrexate. Now my doctor wants to prescribe hydroxychloroquine (Plaquenil) for me. Have you ever heard of someone taking three drugs at once? Is this safe?
A: It is common for physicians to prescribe a combination of low doses of prednisone and drugs like methotrexate for patients with rheumatoid arthritis. In selected cases, as in your case, physicians are adding on additional drugs. These combinations of drugs are used for patients with RA whose disease has not responded well to a single drug or to two drugs. A number of clinical studies have shown that patients treated with certain drug combinations do better with no greater incidence of side effects than those taking individual drugs. In these situations, it's important to have your disease managed by a physician experienced in the arthritic diseases.
Doyt Conn, MD, Rheumatologist
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