Rheumatoid Arthritis

Tags

anti-ccp, arava, cimzia, CRP, ESR, humira, JIA, JRA, Methotrexaate, orencia, Plaquinel, ra, remicade, rheumatoid factor, rituxan, simponi, sulfasalazine, synovitis, Xeljanz

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.

A new test for Scleroderma!

Tags

chemokine, CXCL4, interferon, plasmacytoid dendritic cells

Systemic sclerosis (scleroderma) can soon be evaluated as to the severity of the disease by measuring chemokine CXCL4 secreted by plasmacytoid dendritic cells.

A recent study showed that the mean CXCL4 levels were much higher in patients with Systemic sclerosis (over 25000 pg/ml) than those with Lupus, Ankylosing spondylitis, or Liver fibrosis (all under 2000 pg/ml).

This is significant because CXCL4 level correlates with severity of disease in systemic sclerosis including Skin thickening and Respiratory: Non-labored respirations. Lungs with clear lung fields and no rubs noted. Involvement. This means that those with high levels of chemokine CXCL4 may have to be treated more aggressively.

There is also potential for CXCL4 to be developed as a therapeutic target as well.

Lyme disease

Tags

acaricides, c6, CDC, ELISA, erythema migrans, false positive, idsa, IgG, IgM, Lyme, PCR, tick, western blot

Points to consider when you are dealing with Lyme disease:

1. Prevention is very important including using insecticide (acaricides) in the endemic areas, using protective clothing, tick repellent, checking for ticks and taking a shower within two hours of being in the tick habitat.

2. It would take two weeks for Lyme IgM to become positive after development of erythema migrans and two to six weeks for IgG to become positive. With early treatment these test may never turn positive. Also these antibodies may remain positive for a long time despite successful treatment of Lyme disease and resolution of all of the presenting symptoms.

3. False positive Lyme testing can occur in 5% of the normal population with more false positivity seen with IgM than IgG. Western Blot should help as to rule out these as well as other false positive results caused by cross reacting antibodies.

4. PCR can help but it has both false positive and false negative results. PCR can not tell if there is active infection as it measures only the DNA of either live or dead spirochetes.

5. Urine antigen testing for Lyme and PCR of urine are useless.

6. The C6 testing that measures IgG to VlsE (Variable major protein-like sequence-expressed) sixth invariant region can be helpful along with traditional testing by increasing both sensitivity and specificity of these tests with IgG antibodies developing very early (within one week) in the disease process. This test is FDA approved but not endorsed by CDC. C6 testing also can detect both American and European species while the ELISA and Western Blot are optimized for the American species mostly.

7. Reinfection can also occur. This can be diagnosed with presence of new rash of erythema migrans. Repeating Lyme titers are not always helpful as previous titers from earlier infections may remain for a long time.

8. Recommendations for treatment of Lyme disease are outlined here by the Infectious Disease Society of America: Treatment Recommendations and Antibiotic Therapy.

September 2013

Sulfasalazine

Tags

anti-ccp, arava, cimzia, enbrel, humira, methotrexate, remicade, rheumatoid arthritis, rheumatoid factor, sulfasalazine, synovitis, Xeljanz

Points to remember about Sulfasalazine are:

– This is seventy year old medication.
– It was developed as a combination of an anti-inflammatory and a sulfa antibiotic to treat Rheumatoid Arthritis.
– It is the first disease modifying drug (DMARD) that was actually developed to treat Rheumatoid Arthritis.
– Enteric coated form of Sulfasalazine would minimize stomach side-effects.
– It can be used by itself or along with other DMARDs such as Methotrexate, Plaquinel.
– Periodic blood testing is needed to look for possible toxicity specifically affecting liver and Neutrophils.
– Although never approved by FDA, it is used to treat variety of inflammatory conditions including:
– Rheumatoid Arthritis
– Psoriatic Arthritis
– Spondyloarthropathy
– Ankylosing Spondylitis
– Juvenile Rheumatoid Arthritis
– Ulcerative Colitis
– It can help both bowel and joint symptoms in patients with inflammatory bowel disease who also have associated arthritis.
– It may take up to three months to see an effect.
– At times the improvement is so slow that Sulfasalazine has to be stopped to see if the patient actually becomes worse off of it. Becoming worse off of this treatment would be indication of a response and treatment with Sulfasalazine can thus be resumed.

XELJANZ: The New Rheumatoid Arthritis Drug

Tags

cytokine, interleukin, jak, janus kinase, joints, ra, rheumatoid arthritis, synovitis, tyrosine kinase

XELJANZ ® (tofacitinib) is the new rheumatoid arthritis drug on the market and it is made by Pfizer.

Important points about Xeljanz to remember are:

– It is a biologic therapy therefore infections can occur.
– Therapy should be stopped in case of infection.
– Patients should be screened for TB prior to start of therapy and monitored periodically afterwards.
– It should be used with caution in those with history of diverticulitis.
– No information is available for use in patients with chronic hepatitis B or hepatitis C.
– Monitoring by blood testing is needed for possible effects on blood counts specifically hemoglobin, lymphocytes, neutrophils, liver enzymes, Creatinine, and lipids.
– Xeljanz dose should be reduced to 5 mg daily in patients with moderate liver or kidney involvement and not used in severe liver disease.
– The dose should also be reduced to 5 mg daily in patients on potent inhibitors of Cytochrome P450 3A4 (CYP3A4) (e.g., ketoconazole) and CYP2C19 (e.g., fluconazole).
– Use of live vaccine in patients should be avoided as has not been studied and there were reports of reactivation of herpes zoster in the clinical trials.
– No information is available in terms of multiple sclerosis
– It was recently rejected by european equivalent of FDA as they felt the risks were more than the benefits.

TMJ or Temporomandibular Joint Pain

Tags

Arthritis, disc, displacement, jaw, JCA, JRA, osteoarthritis, psoriatic, rheumatoid arthritis

Key points to remember here are:

1. The first step here is to make sure there is no dental issues causing the TMJ such as the mandible not lining up with maxilla. It is not unusual for this to develop after dental work.

2. MRI often provide the details needed to make proper diagnosis as to what is causing the pain in TMJ.

3. The causes here vary from trauma with damage to the joint structures to various forms of arthritis including:

– Disc displacement
– Meniscal tear
– Juvenile Idiopathic Arthritis (Juvenile rheumatoid arthritis)
– Rheumatoid arthritis
– Psoriatic arthritis
– Traumatic arthropathy
– Gout

4. Treatment obviously depends on the cause. Early treatment of the underlying disease is the key to avoid damage to TMJ.

5. Aggressive and early treatment of Rheumatoid, Psoriatic, and JIA with new biologics treatments such as Enbrel and Humira has resulted in significant decline of TMJ problems in these patients.

6. Oral Surgeons often deal with TMJ when medical therapy is exhausted.

C-reactive Protein

Tags

Arthritis, ESR, infection, inflammation, Rheumatic

Points to remember here are:

1. High CPR concentration should raise the suspicion for possible infection.

2. CRP, unlike ESR, can change rapidly as condition evolves.

3. Although CPR is very sensitive, it is not very specific. Therefore physical examination of patient is very important.

4. Common uses of CRP are: Infections, Polymyalgia Rheumatica, Rheumatoid Arthritis, Temporal Arteritis, malignancy, vasculitis,

5. Combination of ESR and CRP as well as history and physical examination will enhance the sensitivity and specificity of these tests.

6. Ultimately patients should be treated based on history and physical examination. These tests are not always reliable.

7. Obtaining both ESR and CRP from the beginning and following them serially will help you decide on which one to use for monitoring the disease activity.

Baclofen

Tags

cerebral palsy, multiple sclerosis, Muscle relaxant, spasm

Seven points to remember about Baclofen.

1. It is used primarily as a muscle relaxant for patients with severe spasm as a result of Multiple Sclerosis, Cerebral Palsy, Dystonia, and Trigeminal Neuralgia.

2. It should not be stopped suddenly as it can cause serious spasms, seizures, hallucination, muscle damage and even death.

3. It can cause significant drowsiness.

4. It does not help patients with stroke.

5. It does not help patients with rheumatic problems.

6. It may help with reflux disease of stomach (GERD).

7. It is being evaluated for treatment of alcohol and drug addiction.

M. Rezaian, MD

MRI examination

Tags

ct scan, imaging, MRI, radiology, X-ray

Seven points to consider about MRI testing:

1. Sixty four percent of patients with no history of back pain had abnormal MRI exam. This simply means just because you see a herniated disc on an MRI, this does not necessarily mean the herniated disc is the cause of the back pain.

2. History and physical exam is the key to decide on the cause of the back pain. Therefore MRI should be interpreted in the context of history and physical exam.

3. A neurological exam by a neurologist not a neurosurgeon would be worthwhile when looking at severe back pain with possibility of surgery.

4. A radiologist who is fellowship trained in MRI would be most qualified to read your MRI exam. Always ask who will be reading your MRI.

5. MRI of hands and feet should be read by a fellowship trained radiologist in MRI as these are difficult to read and requires much experience.

6. X-ray examination should be done before MRI exam as X-rays may reveal enough information that MRI may no longer be necessary.

7. MRI exams are expensive therefore only specialists should be allowed to order these tests.

M. Rezaian, MD

Flexeril

Tags

baclofen, cyclobezaprine, Muscle relaxant, robaxin, skelaxin, soma

7 important points to remember about Flexeril.

1. Start at 1/4 of a pill as it can make you tiered or put you to sleep for a long time at full dose.

2. Take it at supper time so that you will not be tiered when you wake up the next day as Flexeril has a long half life.

3. The dose can be adjusted depending on the tolerance that can develop over time.

4. It is not addictive and goes not cause weight gain.

5. It can be taken to help with sleep in patients with chronic pain. The benefits in these cases are seen over 6 to 12 months. So be patient can give it time.

6. Be careful mixing this with other drugs such as sleeping medications, other muscle relaxants, and pain medications.

7. It can be taken for a long time especially in cases of patients with chronic pain. It does not need monitoring by blood testing.