1) Could you comment on the study cited in the May 17 issue of the Journal of the American Medical Association that TNF-blocking drugs raise the risk of developing cancer and serious infections?
The recent meta-analysis in JAMA does indeed show the increased risks you allude to, but one must also consider the beneficial effects of anti-TNF therapy, and the lack of therapeutic alternatives in patients with active/severe rheumatoid arthritis who fail with older therapies. The risk of malignancy is higher in patients using high dose infliximab—but these are dosages which many rheumatologists do not use. While there was a higher risk of infection in patients on anti-TNF therapy, this was apparently not dose-dependent.
But it should be remembered that this analysis was based on a collection of studies already done--it is always best to answer a question or prove a hypothesis by performing original placebo-controlled studies.
2) Do you recommend that RA patients eat specific foods to control symptoms?
Dietary manipulation does allow a patient to assume some sense of control over the management of his illness. There is scientific rationale for using n-3 fatty acids to treat rheumatoid arthritis. But there is not adequate evidence for the usefulness of antioxidant supplements, fasting, elemental or elimination diets (Seminars in Arthritis and Rheumatism; 35:77-94, 2005).
3) How do you advise female patients with RA on childbearing: Is it safe to get pregnant? Are there any symptoms a women with RA should be aware of during pregnancy?
The main contraindication to a woman attempting pregnancy would be the concomitant use of drug treatment that may place the fetus at risk. Obviously, if a woman's disease is significantly active, it might be best to defer conception until things are better controlled, as I do not feel comfortable using anything but low-dose prednisone to treat a woman with an inflammatory illness such as RA while she is trying to become pregnant or is pregnant.
In the March 2006 issue of Arthritis and Rheumatism, a study found a slightly increased risk of hypertensive disorders in pregnant women with a diagnosis of rheumatoid arthritis.
Early data from the OTIS Rheumatoid Arthritis in Pregnancy study wowed higher rates of preterm births in women with RA compared to those without.
Finally, there are respective auto antibodies which can cause fetal heart block and placental vessel infarction leading to miscarriage, and I feel that women of child-bearing age should be tested for these so that they may be counseled appropriately.
4) Is there a particular medication or treatment regime that you have found to be particularly successful for your patients?
Every RA patient is unique; there are those who do well with minimal medical intervention, and there are those who require multiple and aggressive medical treatment. But I do believe that RA should be aggressively treated, the goal being to return that patient to the "well" state prior to the onset of disease.
Published On: June 05, 2006