ANSWER TO QUESTION REGARDING "OVERLAPPING ARTHRITIS"
From a reader: "I have an overlapping arthritis, based on my last x-rays, I have deterioration in all of the fingers on my left hand, as well as my knuckles and wrists on both hands. I also have deterioration in 3 fingers on my right hand. ...
I would like to know if you could advise me of any arthritis drugs that could maybe slow down the deterioration?
Answer: Deterioration could mean several things - including joint deformities or joint erosions.
An even more important question deals with whether you have active joint disease that would respond to even more aggressive therapy. Perhaps the damage is done, so to speak. If that is the case, no drug is going to reverse the deformities that have developed as a result of the unchecked inflammation of progressive rheumatoid arthritis.
You mention swelling, but you have no morning stiffness. Usually, patients with active inflammation will have significant morning stiffness - or sometimes all-day stiffness. Is your sedimentation rate or C-reactive protein elevated (which could indicate ongoing joint inflammation)?
Methotrexate is a strong disease modifying drug. It is referred to as a disease modifying drug because it has the potential to allow a patient to actually go into remission. Assuming you are having no adverse effects associated with it, the dose you are on is reasonable. The combination with Plaquenil probably does not add all that much.
However, if the methotrexate and Plaquenil do not offer complete control of your arthritis, then most rheumatologists in the United States would add a so-called biologic agent to your regimen. Generally, the first choice would be a tumor necrosis factor (TNF) inhibiting drug. The anti-TNF drugs now on the market in the United States include Enbrel, Remicade, and Humira. Orencia is also indicated for those rheumatoid arthritis patients who are not helped by methotrexate, but it works differently than the anti-TNF drugs.
In patients with moderate to severe disease, methotrexate often is used in combination with other disease-modifying drugs. In patients with active and severe disease, initial therapy often consists of a combination of medications. The combination of methotrexate, Plaquenil and sulfasalazine has been one of the more popular regimens, but as I discussed in the previous paragraph, nowadays the combination of methotrexate with a biologic agent has become the treatment of choice if methotrexate or a combination of methotrexate with another disease modifying drug is not offering ideal relief to the patient.
If the deterioration you refer to in your question involves tendon damage or crippling joint destruction, then orthopedic surgery has the potential to improve function, mobility, pain control, and quality of life for the rheumatoid arthritis patient.
Examples of surgery include tendon repair and transfer, carpal tunnel release, total joint replacement, and cervical spine stabilization surgery.
The major goals of whatever therapy you and your doctor finally decide upon will generally include pain relief, reduction of swelling and fatigue, an improvement in joint function, a halt to joint damage, and the prevention of disability and early death.
Of course, certain of these goals may become more prominent during particular stages of the patient's disease and life. For example, there are some patients who have advanced joint damage, and yet experience minimal swelling, fatigue and morning stiffness. Such patients may benefit from an emphasis on pain control, physical therapy and orthopedic surgery.
No two rheumatology patients are alike. And the disease process in an individual patient will very often have stages, just as life has its stages. It is important that you work with your doctor to assure that your concerns are addressed.
Better still, work with your doctor to assure that your concerns are anticipated and a plan of action if put into effect quickly.
Published On: May 19, 2008