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Since being diagnosed with RA in 2009, it’s been an interesting process trying to find the right treatment combination. To date, seven biologics and four disease-modifying (DMARDs) medicines in various combinations and dosages have been tried. The DMARDS used in the past include the following:

Sulfasalazine – This was the first DMARD tried after diagnosis. An allergic reaction resulted in severe hives and cessation of this drug.
Methotrexate – Oral pills were used. Unrelenting and unbearable gastrointestinal issues precipitated an end to this trial.
Leflunomide (Arava) – This DMARD did not have much impact on RA symptoms.
Azathioprine (Imuran) – This DMARD did not have much impact on RA symptoms.
Methotrexate – Self-injections were used for the second trial of MTX. Injections were stopped about a year later due to evidence that they were contributing to migraines.

Rituxan (Rituximab) is the latest biologic and I’ve been on it for 1½ years. The typical suggested treatment plan is two infusions every six months but I’ve been on a schedule of two doses every four months. The last infusions were in October and November but it seems that its impact is not just not optimum. Joint pain, swelling, and fatigue are all on the increase and neck surgery six months ago coupled with an elbow surgery in the near future lend evidence that Rituxan alone is not keeping the disease in check. After a discussion with my rheumatologist this week, it was decided that adding another DMARD might help control the disease processes. There aren’t many choices left and my rheumatologist suggested trying Mycophenolate, or CellCept, in combination with the Rituxan infusions.

CellCept was originally developed to help organ transplant patients from rejecting their new organs. It works by suppressing the immune system. Now it’s commonly used to treat lupus but is also used for other autoimmune diseases including rheumatoid arthritis. As with many DMARDs, common side effects involve the gastrointestinal system. Blood counts can be impacted so regular blood tests are conducted. [1] There aren’t many published studies on CellCept although it’s been proposed as an alternate DMARD for those with refractory disease not responding to other treatments. [2]

A new treatment experiment begins. Hopefully it will bring some much needed relief.

[1] http://www.rheumatology.org/Practice/Clinical/Patients/Medications/Mycophenolate_Mofetil_(CellCept)_and_Mycophenolate_Sodium_(Myfortic)/

[2] http://www.smw.ch/docs/pdfcontent/smw-12441.pdf

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I’m blushing to even be included in the list of such great and widely read health blogs. There are many excellent RA blogs on the list including those listed below. Vote for your fave!

From This Point. Forward (Mariah my writing buddy at rheumatoidarthritis.net)

Carla’s Corner (my writing buddy over at rheumatoidarthritis.net)

RA Warrior

Pollyanna Penguin’s RA Blog

Arthritic Chick

RheumaBlog

Pain Demands to be Felt

 

 

 

photoThanksgiving Thursday, Black Friday, Cyber Monday…and now Giving Tuesday. In this season of over eating and commercialism, it’s good to take a step back and think about how we can give. This second annual event is designed for people to give back to the community. When it comes to rheumatoid arthritis, there are many non-profit organizations to choose from. For me, it comes down to the following four factors:

  1. A focus on the patient.
  2. A focus on autoimmune-based arthritis (including rheumatoid and related diseases).
  3. A focus on research designed to improve patient care and develop cures/treatments.
  4. Fiscal and organizational accountability. Charity Navigator is an independent organization that rates the fiscal management, transparency, and accountability of non-profit organizations.

I find that the organizations below meet these criteria.

The Arthritis National Research Foundation (ANRF) is focused on providing grant funding directly to scientific researchers. You can even get nifty blue Cure Arthritis wristbands like the one I’m wearing! http://www.curearthritis.org/bracelet/.

The American Autoimmune Related Diseases Association. This organization focuses exclusively on autoimmune diseases which includes RA.

Please consider joining the fight against rheumatoid arthritis by giving to these and other excellent non-profit organizations.

Given the overwhelming glut of information, patients need to be armed with knowledge in order to be good patients and consumers. This is where evidence-based medicine comes into play. Evidence-based medicine is used as the foundation for the current training and practice of medical doctors, physical therapists, pharmacists, and nurses. It is the norm in the Western world. According to Sackett, et al (1996),

Evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systemic research.”

There are multiple sources of evidence ranging from opinions of authorities to the ultimate source of evidence – the randomized control trial (RCT). The RCT is the “gold standard” of medical research. In a RCT, patients are randomly assigned to either receive a treatment or placeboGovernment regulations require the extensive use of these designs for the approval of medical treatments. For drug approval, years of development and testing are required from testing on animals through three phases of clinical trials on humans…

read the entire article at http://rheumatoidarthritis.net/living/using-evidence-based-medicine-make-decisions-treating-ra/

six month cervicalToday was a six-month follow-up on anterior cervical discectomy and fusion surgery where two herniated discs were removed, vertebrae C5-C7 were fused, and bone spurs removed. Before seeing the surgeon, a CT scan was conducted. The scan showed significant bone growth between the vertebrae (circled in the image). The screws are visible in the scan. The surgeon was very pleased at the amount of bone growth, decreasing muscle pain, increasing muscle strength, and decreasing numbness and tingling in my fingers. Nerve regeneration may take 1-2 years and hopefully things will continue to get better over time. If Payton Manning can lead the Denver Broncos to the Super Bowl after a similar surgery for one disc, then there’s hope for me!

Vertebrae C1-C2 were also checked on the CT scan since rheumatoid arthritis commonly impacts those joints that are near the skull. On a MRI radiology report last spring, it was noted that there was mild degeneration in that region. The surgeon showed those joints on the CT scan and indicated that there was some inflammation and bone-spurring present but it didn’t appear to be problematic at this time. I was told to pay attention to any deep pain in that region.

This was a very good report to receive. In hindsight, getting this surgery was a good decision giving the deteriorating situation at the time.

My right elbow has been giving me troubles for over a year now and my rheumatologist referred me to an orthopedic surgeon who specializes in hands and elbows. An MRI revealed a 50% tear in a tendon. Other parts of the elbow exhibit pain. In fact, the left elbow also displays the same symptoms but to a lesser extent probably due to the fact that I am right handed. The orthopedic doctor knows about my struggles with RA and my history with soft tissue damage. In fact, he works in the same clinic with the surgeon who conducted three surgeries on my ankles.

A bevy of conservative treatments were prescribed starting with rest and immobilization with splints designed to prevent movement of the tendon. After that failed to help, a cortisone injection was done. The doctor also used the needle to aggravate the tissue in the joint in order to stimulate a healing process by increasing blood flow to the region. Needless to say, excruciating pain was experienced for the next 24 hours but after that, the steroid provided some relief…for about 1 month after which time the pain returned. Occupational therapy was then prescribed. Occupational therapists (OT) tend to focus on the arm from the elbow down to the hand and they engage in treatments similar to physical therapists. Treatments included heat and transcutaneous electrical nerve stimulation (TENS), gentle stretching exercises, and continued use of immobilization with splints. The goal was to move into more rigorous strength building exercises. But this goal was never met as the pain only became worse. After several months of OT, the therapist made the decision that things were getting worse and indicated that I need to return to the surgeon to determine next steps. At about this time, severe neck problems were popping up and the orthopedic surgeon and I both agreed that priority needed to be given to the neck. The past six months were devoted to recovering from neck surgery.

The elbow continued to cause problems and it came to the point where use was difficult and pain was constant so I returned to the orthopedic surgeon. He said that surgery to repair the torn tendon and its attachment point to the bone would be the next option. But before doing that, he wanted to try one more, last ditch strategy – a platelet-rich plasma injection or PRP. He admitted that the research was sketchy and that it was not an FDA or insurance approved treatment. I would be required to pay for it out of pocket and the cost will be about $300. His argument is that in spite of the lack of experimental research on its effectiveness, there is clinic evidence, it is relatively inexpensive, and it is not as invasive as surgery. He did give me a choice between PRP and surgery but his comments were, “If it were me, I would do this first before having surgery.”

In PRP, a patient’s blood is drawn, platelets are separated from other blood components, and the concentrated solution is injected into a joint that has tissue damage in an effort to jump-start a healing process.[1] The theory is that growth factors contained in the platelets are able to help damaged tissue heal. It has been applied to tendon areas like the Achilles and elbow where there is a lack of blood low and healing is difficult. This approach is quite popular with professional athletes but clinical trails show mixed results (Harmon & Rao, 2013).[2]

In medical practice, there is a range of possible qualities of treatments. Balshem et al (2010) categorizes the ranges from very low quality to high quality evidence.[3] The approval of drugs would rate as high quality evidence. At the lowest end of the evidence quality continuum would be treatments that have little or conflicting evidence. Platelet-rich plasma would rank at the lowest end. This is why the FDA and insurance companies won’t approve it. There is even less research about PRP and rheumatoid arthritis. A search of research studies specific to RA revealed one study conducted on pigs[4] and another conducted in 1989 on knees of RA patients.[5] Never provided sufficient evidence documenting the effectiveness of PRP for rheumatoid arthritis.

Given the lack of evidence, I remain quite skeptical about PRP but am willing to give it a shot (pun intended) in order to avoid surgery.

[1] http://orthoinfo.aaos.org/topic.cfm?topic=A00648

[2] http://www.ncbi.nlm.nih.gov/pubmed/24319241

[3] http://www.jclinepi.com/article/S0895-4356(10)00332-X/abstract

[4] http://onlinelibrary.wiley.com/doi/10.1002/art.30547/full

[5] http://link.springer.com/article/10.1007/BF00270285#page-1

The American College of Rheumatology (ACR) diagnostic criteria incorporate four main areas – joint involvement, RA related blood tests, general inflammation blood tests, and duration of symptoms.1According the ACR,

Joint involvement refers to any swollen or tender joint on examination, which may be confirmed by imaging evidence of synovitis.”2

Physical examination is the starting point for identifying joint involvement. But confirmation by actually looking inside the joint with imaging techniques remains a critical part of confirmation.The synovium is a sac-like lining around certain joints. It provides nutrients and lubrication for joint soft tissues. During the disease processes involved with RA, the synovium swells and thickens, becoming permeated with inflammatory cells and chemicals. Ultimately, cartilage and bone tissue erodes leading to the classic joint damage associated with RA.3 The synovial fluid can be taken from a joint and analyzed for chemicals and cells associated with RA.4 This can be done via needle biopsy or surgery. During an ankle surgery I had several years ago, the orthopedic surgeon sent a sample of tissue to a laboratory for analysis – the results came back positive for RA related synovitis. Medical imaging procedures can be used in as a noninvasive technique for examining a joint.

Read the rest of the article at http://rheumatoidarthritis.net/living/medical-imaging-diagnosing-ra/

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