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Description:
This is an inflammatory arthritis involving upper and lower extremity joints.

Presentation:
– Pain
– Stiffness
– Swelling in multiple joints including hands, wrists, elbow, shoulders, hips, knees, ankles, and feet
– Night pain
– Morning as well as rest stiffness
– Fatigue
– Insomnia because of pain

Evaluation:
– History and physical examination
– Tests are then ordered for confirmation of the diagnosis.

Testing:
– Blood tests: Rheumatoid Factor, Anti-CCP, ANA, HLA-B27, Lyme titers, ESR, CRP, Hepatitis C Antibody
– X-rays: Hands, wrists, ankles, feet and other involved joints

Diagnosis: This is based on the following criteria listed below:
– Type and number of joints involved
– Positive Rheumatoid factor or Anti-CCP
– Elevated CRP or ESR
– Duration of joint involvement more or less than six weeks
– The criteria might be fulfilled over time

Treatment:
– Sulfasalazine. I do not use this a whole lot and when I do it is mostly along with Plaquinel and Methotrexate in combination. I use a lot more of Sulfasalazine overseas along with Plaquinel, Methotrexate, and low dose prednisone 5 mg daily for lack of better or cheaper treatment.
– Plaquinel. This can be effective by itself in mild cases and in combination with moderate involvement. I have seen studies claiming the combination therapy of Plaquinel, Methotrexate, and Sulfasalazine work as good as biologic therapy. But in real life patients, I have not seen this to be true. I have seen heavy use of these drug combination along with Prednisone 5 mg daily overseas. Unfortunately, this only works for a number of years and most of these patients end up with severe deformity, terrible osteoporosis, obesity, diabetes, very difficlut ending and I can even say that their life span is shortened by at least 10 if not 20 years.
– Methotrexate. This is the first treatment I use in most patients with moderate to severe disease. It often requires use of biologic in combination to achieve desired effect.
– Arava. This I use if Methotrexate is not effective by itself or I use it in combination with Low dose Methotrexate or Humira.
– Enbrel. This works very well and brings this terrible disease under excellent control especially along with Methotrexate.
– Humira. This is also an excellent choice along with Methotrexate as well. Humira has the advantage of treating Psoriasis and colitis as well as uveitis over the Enbrel.
– Remicade. This works very well with Methotrexate especially in medicare patients who can not afford the self injectables such as Humira. I also use this as a first choice in severe cases when you need rapid control of the rheumatoid arthritis. It is also very useful when Enbrel or Humira are only partially effective.
– Simponi. This is also an excellent choice but most insurances do not want to cover it and they all insist that the patient be on Methotrexate at the same time.
– Cimzia. This can be very effective but being a late comer, it has not gotten the attention it deserves.
– Orencia. This can also be a great choice. I do not see many infections with Orencia but this could be because I do not use it as much as Enbrel and Humira.
– Xeljanz. My initial use of this drug was disappointing as I was using it in those who have failed previous DMARDs listed above. But using it as a first line drug along with Methotrexate has been very promising with rapid and excellent results.
– Rituxan. This is undoubtedly the best treatment for Rheumatoid Arthritis. It takes time to work but once it starts working, it does very well. I have seen the benefits last for as long as 2 1/2 years after one or two treatments. This also help one distinguish the true
– Actemra. This I believe is a very good drug but it is a late comer. It was also mismanaged by the drug company keep emphasizing liver enzyme elevation with this drug early with its release. I yet to see any problem with this drug. It does need a more closer monitoring because of potential for interactions with other drugs. I believe I will be using more of this drug in the future.