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Tag Archives: synovitis

Rheumatoid Arthritis

26 Friday Jun 2015

Posted by uptodatemedical in ACR Criteria, Acute Phase Reactants, arthritis, Autoimmune diseases, Biologic Therapy, Bone and joints, Musculoskelethal, Rheumatic diseases, Rheumatoid Arthritis, Serologic Testing

≈ 2 Comments

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.

Sulfasalazine

16 Thursday May 2013

Posted by uptodatemedical in arthritis, Autoimmune diseases, Bone and joints, Medication, medicine, Musculoskelethal, Rheumatic diseases

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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

15 Wednesday May 2013

Posted by uptodatemedical in arthritis, Autoimmune diseases, medicine, Rheumatic diseases

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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.

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