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Angelfire RA Treatment

The risk of serious side effects is low,generally speaking, in people without existing complications (some people cannot tolerate certain medications). E.g.,MTX promises early onset of action,usually within four to six weeks,and the liklihood of a sustained and prolonged effect. MTX is usually given as tablets,but can also be injected into muscles. the effective weeky dose for a patient my be as low as two 2.5-milligrams tablets,as high as ten ( subcutaneous inject is 25 mg)tablets (equivalent to 25 mg ) once a week. The effective range is so wide,it's best to start low ( 3 tablets a week ) and only slowly increase the dose by one tablet each time. Changes in dose should occur no more often (approximately) than every 3 weeks,once a month is the usual. All the pills should be taken together,at the same time,on the same day each week (There is some variations-changes in dose -longer, and sometimes, at hgher doses,split it up into two doses per day.)
 
It isn't unusual to notice a god response at a farly low dose at first,but then to require a higher dose later on to maintain that response. A complete blood count ( hemoglobin,white cell and platelet count ) is usually done every few weeks until the final dose is decided,then every 4 to 6 weeks. Liver function test should be checked at every second blood test (some use a different schedule).The impairment of kidney function increases the risk of any of the side effects. NSAIDs don't interact with MTX when MTX is taken at the recommended doses,however,sulfa-containing antibodies increase the risk of side effects and should be avoided. Side effects are often dealt with by decreasing the dose or temporarily stopping MTX and then restarting it.
 
Common side effects: A 12 hr.-24-hour reaction to the dose. Nausea is most common,but some patients report flushing or a temporry flare-up of arthritis. These reactions can be blocked by a small dose of a steriod called dexamethasone,taken with MTX Nausea with vomiting,very occasionally occurs. Mild anemia,and occasionally lower numbers of white blood cells or platelets,though not low enough to cause problems. Sometimes,small sores inside the mouth for a day or two after the weekly dose. Both these and anemia of the kind menthioned can be helped by a low dose of folic acid 5 days/week. A high dose of folic acid will counteract some of the good effects of the MTX. (researchers found 5 days better than 7days/week).
 
A small amount of hair loss,noticeable on the pillow each morning but not obvious to friends and neighbours. Temporary reduction in the sperm count in men may be caused by MTX. In women,MTX shold be avoided in pregnncy ( it can cause miscrrige ) and breast-feeding.Rare,if you encounter these,stop MTX and call the doctor; Significant lowering of blood counts (hemoglobin, white blood cells,platelets) with symptoms of tiredness, dizziness, infections, bruiseing or bleeding. cramps and diarrhea. Infection,including pneumonia and shingles. Skin rash (very uncommon ). Occasionally patients with RA who develop rheumatoid nodules will develo many new ones,even though the arthritis is under control.
 
Liver damage is very rare. To be on the side of safety,no use of alcohol (except at weddings,birthdays and Christmas-little ) since alcohol may combine with MTX to damage the liver. psoriasis,obesity and possibly diabetes may also increase the risk of MTX liver damage. Possible but not proved,Increased risk of infection after joint surgery ( doubtful but possible). A very few cases of lymphoma ( a type of lymph gland cancer ) have been discovered in patients treated with MTX. It was resolved when MTX was stopped,but it is so rare,mention this as a after-thought.
 
Although there is little difference in NSAIDs pharmacologically,individual NSAIDs will show signiificant difference in efficacy and side effects in different individuals. NSAIDs,DMARDs and Steriods are covered in other articles , therefore,we give give some updates and a review. Patients with RA are nearly twice as likely as patients with osteoarthritis from NSAID treatment Risk factors for the development of NSAID-associated gastroduodenal ulcers include advanced age ( 75 years and older ),history of ulcer,cocomitant use of corticosteriods or anticoagulants,higher doseage of NSAID,use of mutiple NSAIDs,or a serious underlying disease.
 
The following approaches may be considered for patients with RA who would benefit from an NSAID but who are are at increased risk of serious adverse GI effects: use of low-dose predisone instead of a NSAID,use of which are effective in decreasing NSAID-associated gastroduodenal ulceration,include high dose H2 blockers,proton-pump inhibitors and oral prostaglanden analogs (Cytotec etc).
 
While symptoms of dyspepsia are often improved by treatment with H2 blockers,one study showed that asymptomatic patients with RA who were receiving both NSAIDs and low-dose H2  blockers were at higher risk of GI complications than those receiving NSAIDs alone. Therefore,routine use of H2 blockers to prevent dypepsia or to protect against NSAID-induced gastropathy is not recommended--ACR.
 
In two recent large trials comparing highly selective COX-2 agents with traditional NSAIDs,the patients in the selective COX-2 agent group had significantly fewer GI events. There are several caveats,however. If anticipated therapy is indicated (e.g.,as risk reduction for cardiovascular disease),an agent such as a nonacctylated salicylate,use of a highly selective COX-2 inhibitor,or use of an combination of an NSAID and a gastroprotective agent. Gastroprotective agents,addition of low-dose aspirin may partially ameliorate the benefit of less GI toxicity associated with highly selective COX-2 agents. Morever,the use of a highly selective COX-2 agent has been reported to be associated with a higher rate of thrombotic events,compared with traditional NSAID. Use of NSAID and selective COX-2 inhibitors should be avoided in conditions associated with diminished intravascular volume or edema,such as congestive heart failure,nephrotic syndrome,or cirrhosis and in patients with unacceptable serum creatinine levels .
 
All patients with RA ar candidates for DMARD therapy. Although NSAIDs and glucocorticoids may alleviate symptoms,joint damage may continue to occur and to progress. DMARDs have the potential to potential to reduce or prevent joint damage preserve joint integrity and function and ultimately reduce the total costs of health care and maintain economic productivity of the patient with RA. The initiation of DMARD therapy should not be delayed beyond 3 months for any patient with an established diagnosis,who,despite adequate treatment with NSAIDs has ongoing joint pain,significant morning stiffness or fatigue,active synovitis,persistent elevation of the ESR or CRP level,or  radiographic joint damage. For any untreated patient with persistent synovitis and joint damage,DMARD treatment should be started promptly to prevent or slow further damage.
 
One of the real problems in treating RA is recognizing when it's time to change the regimen. It's too easy to check a patient breifly,mentally compare the present condition to what it was on the last visit,and continue the treatment Instead of words of encouragement and a prescription renewal,the patient often needs a change. Physician's memories,like anyone else,may not be the best,and patients who normally feel bad are often unaware of slow changes. for the worse.
 
It's esy to monitor the condition of some diseases like blood pressure,simply put on a blood pressure pad amd take a reading. There have been many attempts,criterias etc,to develop a similar progress test for RA,but no truly effective.fool-proof,answer has been found.
 
Some patients have resistant disease and experience a progressive course, despite exhaustive trials of DMARDs whether used alone or in combinations. While the utimate goal of treating RA is to induce complete remission,this occurs infrequently.
 
If complete remission is not achieved,the management goals are to control disease activity,alleviate pain,maintain function for activities of daily living and work,and maximize quality of life. Achieving these goals challenges the managerial skills of the rheumatologist to determine the the most efficacious combinations of pharmacological therapy,which may include NSAID,DMARD(s),low dose predisone,local injection of glucocortoid, rehabilitation support and anagesics.Although adequate pain relief is an important goal with a chronic disease such as RA,the ACR,does not recommend narcotic analgesic dependency.
 
Given the chronic waxing and waning course of RA,a longitudal treatment plan needs to be developed,and the patient should be involved in developing the plan. The discussion should address disease progression,prognosis and treatment options,taking into account adverse effects, expected time for response,the patient's risk factors and comorbid conditions, monitoringease activity (i.e., ongoing disease activity after 3 months of maximum therapy ),or progressive joint damage require consideration of significant changes in the DMARD regimen. If disease activity is confined to one or a few joints,then local glucocortoid injection may help. For patients with severe symptoms,systemic glucocortoids may need to be initiated,or the dosage may need to be incresed,for a short period of time.
 
Active joint disease may impair physical function and may also be aggravated by physical activity. Therefore, consultation with a physical therapist, occupational therapist and/or nurse-counselor familiar with rheumatic diseases should be considered early in the disease course. Periods of rest,job modification,time off from work,changes in occupation,or termination of work may be necessary. Reconstructive surgery should be considered for patients with end-stage joint damage that is causing unacceptable pain requirements of pharmacologic agents,and the patient's preference. Expectations for treatment and potential barriers to carrying out the recommendations should be discussed. Psychosocial factors,such as illness beliefs and perceived self-efficacy,have been shown to affect patient outcomes and treatment adherence Education and cognitive-behavioral interventions,such as the Arthritis Society Self-Management Program,can improve health status and decrease visits to the physician.
 
The initial evaluation of the patient with RA should document symptoms of active disease (i.e.,presence of joint pain,duration of morning stiffness,degree of fatigue}, functional status,objective evidence of disease activity (i.e., synovitis,as assessed by tender and swollen joint counts,and the ESR and CRP level) mechanical joint problems (i.e., loss of motion-joint instability, malalignment, and/ or deformity), the presence of extra-articular disease and the presence of radiographic damage. The presence of comorbid conditions should be assessed.
 
The patient's and physician's global assessment of disease activity and a quantitative assessment of pain using a visual analog scale or other validated measure of function or quality of life are useful parameters to follow during the course of the disease. This baseline information greatly facilitates assessment of these progression and response to treatment. Baseline laboratory evaluations should include a complete blood cell count (with white blood cell differential and platelet counts),rheumatoid factor (RF) measurement,and measurement of ESR or CRP. Evaluation of renal and hepatic functions is necessary, since many antirheumatic agents cause renal or heptic toxicity and may be contrainindicated if these organs are impaired. Since the hands and feet are so frequently involved in RA,radiographs of these joints as well as other affected joints establish a baseline for future assessment of structural damage. Arresting and preventing structural damge is the primary goal of therapy.and radiographic studies of major involved joints may be needed periodically.
 
Selection of the treatment regimen requires an assessment of prognosis. Poor prognosis is suggested by earlier age at disease onset,high titer of RF,elevted ESr,and swelling of >20 joints. Extra-articular manifestations of RA,such as rheumatoid nodules,Sjogren's syndrome,episcleritis and scleritis,interstitial lung disease,pericardial involvement , systemic vasculitis and Felty's syndrome,may also indicate a worse prognosis,but have not been widely adopted for clinical practise.
 
The ACR criteria for 20 % clinical improvement (the ACR 20 ) requires a 20 % improvement in 3 of the following parameters;patient's global assessment,physician's globl assessment,patient's assessment of pain,degree of disability,and level of acute-phase reactant. These criteria have been expanded to include criteria for 50 % and 70 % improvement measures (i.e.,ACR 50,ACR 70). Other criteria,such as Paulus criteria,have bee employed. More recently,radiographic progression (e.g., the Sharp score ) has been utilized as an outcome measure.
 
Optimal management of RA involves more than pharmacologic therapy. Early in the course of the disease the patient needs to know that polyarticular,RF positive have a >70 % probability of  developing joint damage or erosions within 2 years of onset of disease. Since studies have demonstrated that treatment with DMARDs may alter the disease course in patients with recent-onset RA,particularily those with unfavourable prognostic factors, aggressive treatment should be initiated as soon as the diagnosis has been established.
 
At each followup visit,the physician must assess whether the disease is active or inactive. Symptoms of inflammatory (as contrasted with mechanical ) joint disease,which includes prolonged morning stiffness, duration of fatigue and active synovitis on joint examination,and active synovitis on joint examination, indicate active disease and accessitate consideration of changing the treatment program. Occasionally,findings of the joint examination alone may not adequately reflect disease activity and structural damage, therefore,periodic measurement of the ESR or CRP level and functional status,as well as radiographic examinations of involved joints should be performed. Functional status may be determined by questionnaires such as the Arthritis Impact Measurement Scale or the Health Assessment Questionnaire.It is important to determine whether a decline in function is the result of inflammation,mechanical damage,or both, treatment strategies will differ accordingly.
 
The ACR has developed criteria for defining improvement and clinical remission in RA. These criteria have become accepted for outcome assessment in clinical trials. The patient will need to become involved in the process of making decisions about treatment. If treatment does not fully control the disease,the patient may struggle emotionally as well as physically in adjusting to this chronic disease,it's flares,and the concomitant loss of function.
 
Rheumatologists,other physicians and their office staff should play important roles in educating the patient and the patient's family about the disease and providing longitudal supportive care. Other health professionals, familiar with RA,including nurses,physical therapists, occupational therapists,social workers,health educators, health psychologists and orthopedic surgeons,may be involved in interdisciplinary  team approach in the comprehensive management of RA. Instruction in joint protection,conservation of energy,and a home program of joint range of motion and strengthening exercises are important and essential in achieving treatment goal of maintaining joint function. Physical therapy and occupational therapy should help the patient who is compromised in activities of daily living. Regular participation in dynamic and even certain selected,suitable aerobic conditioning exercise programs improve joint mobility,muscle strength,aerobic fitness and function and psychological well being without increasing fatigue or joint symptoms.
 

Considerations:

Many health professionals may be involved in your care, depending on your condition and whether they are available in your area. Some of the health care professionals you might meet are listed below. The first eight are medical doctors, and the next seven are arthritis health professionals.

  • Family physicians and general practitioners provide general medical care for adults and for children.
  • Internists provide evaluation and management for adult diseases.
  • Rheumatologists specialize in treating people with arthritis or any of the rheumatic diseases.
  • Orthopedists help evaluate and manage bone and joint problems and can perform surgical procedures such as joint replacement.
  • Physiatrists are physicians who may direct your physical therapy and rehabilitation.
  • Ophthalmologists are physicians who may provide eye care and treatment.
  • Pediatricians are physicians who treat childhood diseases.
  • Psychiatrists are physicians who may provide treatment if you have mental or emotional problems that need special attention.
  • Podiatrists are experts in the care of feet. If your arthritis affects your feet, podiatrists can prescribe special supports and shoes to help you.
  • Nurses trained in arthritis care assist your doctor with your treatment. They also help explain your prescribed treatment program and can answer many of your questions.
  • Physical therapists may show you exercises to maintain muscle strength and use of joints.
  • Occupational therapists may teach you how to reduce strain on your joints while carrying out everyday activities. They may provide you with splints and other devices to help protect your joints.
  • Psychologists help to solve emotional or mental problems.
  • Social workers can help you find solutions to the financial and social problems you may encounter.
  • Pharmacists will fill your prescriptions for medications and can explain the actions and side effects of these drugs. They also advise you about drug interactions and over-the-counter medications.

You are in charge

With so many skilled professionals involved, it's sometimes difficult to keep everything straight. You're the central focus of the efforts made by these experts. Therefore, you and your doctor need to make sure that your treatment program is understood by all the team members.

What to expect

In order to have a partnership with your doctor and other health care professionals, you should expect good medical care from them. Good medical care includes being told about your arthritis and the essential facts of your treatment. This information should include costs, medications, side effects, and other possible options for treatment.

In addition, you should be assured of privacy concerning your records, hospital stays, and finances. If you ask for a second opinion, your doctor should assist you by suggesting other physicians you can consult, and by making your medical records available to the person you select.

Every member of your health care team should contribute to your good medical care. If you don't feel that you're getting the right attention from one of the members, let that person and your doctor know how you feel. Remember, team members aren't mind readers. It is your responsibility to inform them of your concerns. Otherwise, they will probably assume that you are satisfied with the care you are getting.

It is important for you to understand that if you criticize a member of your medical team in a positive way, it does not hurt his or her feelings. Your comments won't be taken personally and you will probably be thanked for helping to improve your care. By letting the team members know your feelings, you can help foster the cooperative spirit that is necessary for the success of the whole team.

Many RA patients have other common,underlying diseases besides RA,and therefore they have a tendency to be more suceptible  to the side effects of RA medication,and less tolerable to a particular brand or type of medication or even therapy in general.
 
Most patients who develop liver problems  e.g., (which is rare) with methotrexate have underlying medical conditions that make them suceptible to this side effect,e.g., diabetes,alcoholism,liver disease,hepatitis,or obesity.
 
Steriods increase blood sugar levels. Although this effect (Diabetes Mellitus ) is usually short lived,if you're "prediabetic" your blood sugar may rise into a range usually seen only in diabetes patients. In early diabetes,steriods will increase blood sugar and make antidiabetic drugs seem ineffective. If you take insulin,steriods will elevate blood sugar. You may need to increase the insulin dose.
 
Usually,there is no long-term effect of repeated cortisone injections if the doseage is reasonable and the frequency is less then 4 times per year per joint and the phsician is skilled in this process. Bigger bone joints like the knee can not be injected more often, than smaller ones like the fingers,
 
There is some controversy as to whether or not too many injections may damage the joint (accebrated damage or (harcot joints ) or the local bone (avascular necrosis and osteoporosis),but other studies indicate that the injections can retard joint damage and preserve the joint. Frequent injection may weaken ligaments and tendons. Rarely calcification may form in the tissue of the injection site.but it is not considered serious.
 
Remember when they (the researchers ) said corticosteriods did not help in preventing disease progression ? Recent research papers have shown,it does help.
 
NSAIDs do not normally.do not affect the kidneys or blood pressure adversely in those who have no problems with their kidneys or blood pressure. In those that do have such problems,all NSAIDs including the Coxibs may be hazardous. They can worsen the blood pressure,fluid retention (edema or heart failure ) and kidney function can be affected
 
Celebrex appears to be different then ibuprofen and disclofenac in this matter,but Vioxx seems to be worse for heart failure,stroke,and high blood pressure (those patients with these underlying problems ) If you have no risk factors for peptic ulcers,heart attacks,or strokes,high blood pressure,fluid retention,or kidney diseas,then problems with NSAIDs or Coxibs will be minimal,or none seriously enough to be concerned about.
 
If you have only risk factors for peptic ulcers then use Coxibs. If you have risk factors for heart attack or strokes then take NSAID (naproxen nay be one of the best ,but depending on dose-higher dose may suggest a stomach protector like Cycotec) and probably Celebrex.
 
If you have high blood pressure or kidney disease or use diuretics,then all NSAIDs and Coxibs (Cox-2 inhibitor ) could make these problems worst.
 
If you are in the caution groups,then try some other treatment strategy if possible. If it is not possible,choose the NSAID or Coxib of least risk for the greater problem that you have.
 
Your physician knows your concerns the best and the directive from him/her is the bottom line.
 
Fosomax (alendronate) and Actonel (risedronate) are in the same class bishosphonates They are used to treat and prevent post-menopausal osteoporosis. They increase the density of the osteoprotic bone thus reducing frequency of fractures to those that are susceptible to it. Fosomax is also used for males with osteoporosis and in person's using corticosteriods like predisone. Predisone may hasten the development of osteoporosis when used at higher doses for long periods.
 
Both are used to treat a uncommon bone disease called Paget's disease. These 2 drugs have not been tested together in a head-to-head study. They appear to have roughly speaking,the same effectiveness when looking at the results of other studies. They are both well tolerated and neither has many or serious side effects of consequence.
 
Individual response may vary,if one is not working,try the other,it may help. Both cost about the same Both are taken once a day on an empty stomach. Fosomax is or will be available in a once-a-week dosage.
 
The rheumatologist and the physician taking care of the patient has to make a decision whether it's really doing the job that it needs to be done. Therefore, rheumatologists will look at the patient's joints and they should actually do a joint count so they find out how many of the joints are tender and how many are swollen, and they will follow x-rays on a periodic basis to be sure that there is no damage that's progressing to make decisions whether or not this is an effective medicine, whether it be a biologic such as Enbrel or a synthetic such as methotrexate.
 
We're all self-managers, and there are two ways of looking at that. If you choose to be a self-manager and you make a deliberate choice and create a mindset that you will take control of the management of your disease, you will likely turn into being a good manager. Most individuals use one to three coping skills, and sometimes denial is that coping skill, but if you deny that you have disease, that is a rather poor thing because you are still a self-manager, you're just a poor self-manager, and you're not making interventions that can help you and your health over time. So, overcoming the grief and the feelings of loss, that "Yes, I have this probably incurable disease," but quickly coming around to the idea that, "Well, jeez, I'm going to do whatever it takes so I can live as full life as I can and that this is more of an inconvenience to me rather than a life-changing illness."
 
Back in the late '90s, '98, '99, we had very few new drugs for much more than a decade. Then we have had the availability of Arava, the availability of Enbrel and Remicade. Now,it's a very exciting time for people who have rheumatoid arthritis because rheumatologists really have a lot to offer.  There will be much more investigation in terms of really how do you add all of these medicines together? The general sense would be that we will continue to use methotrexate, and we will rapidly add biologics of some dose, probably like Enbrel or Remicade or that sort of thing very early on in the disease hoping to change the pace of progression, and  that physicians will find that there are people who will benefit from having maybe multiple blockers of immune function or scientists may define better than we can now what are the different groups of people within rheumatoid arthritis and maybe can be more specific in tailoring an individual treatment to an individual person.
 
Why not start on the biologics immediately for most of the patient? One could really make a case for that. One of the things that we as a society have to come to grips with is that the cost of biologics is much more than methotrexate is. While there are individuals that without any question should be started on the biologics first, like people with significant liver disease or someone who has moderately severe kidney disease, in most individuals who do not have those processes, probably an initial trial of a potent disease-modifying pharmaceutical like methotrexate is probably from a financial standpoint the most sensible thing.
 
What is the cost difference? What does it cost to treat somebody with methotrexate? That's actually a complex question because there are a number of factors that would add to that. The drug itself is around 40 dollars a month, although it could be more, and then there is also the cost of monitoring blood tests, which are needed much more commonly than with the biologics. The REAL COST is not just the price of the biologics itself. Bringing up the very important issue that the cost is the medication, the number of physician office visits,(e.g.)with methotrexate, often the patient is in the office for the first six months at least six times where a patient on a biologic such as Enbrel may only be in the office one or two times in six months.
 
The number of blood tests that one needs for the biologics such as Enbrel would be less. The number of blood tests on methotrexate would be six week interval laboratory follow-ups. One thinks about the side effect profile, and one has to add the cost of dealing with-scarring of the liver or scarring of the lungs or a bone marrow problem which would occur much more commonly with methotrexate than the biologics. Again, it is really a global kind of look at what the REAL COST of therapy. Depending on who is paying disability claims, if one can keep a person with rheumatoid arthritis either at home,taking care of their kids so they don't have to hire someone or back at work working and paying taxes. That adds to the positive cost-benefit ratio. These last issues are often overlooked by decison makers,bureaucrats and insurance companies who have to pay for the treatment.
 
 
Gold therapy as a DMARD is discontinued.