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Posts Tagged ‘ESR’

Going to the dentist is something that many people avoid. In fact, it is estimated that up to 40 million Americans avoid seeing a dentist each year.1 Reasons may include fear of pain, negative past experiences, and embarrassment. That last reason is probably the one that drove me to stay away for almost eight years! During that time, I was diagnosed with rheumatoid arthritis. Given my newfound attention to all things having to do with my body, I finally ventured into my family’s dentist that is literally only two blocks away from my house. Upon examination, the dentist indicated that I had periodontal disease – meaning inflammation around a tooth.2 Risk factors for periodontal disease include having other illness, lack of saliva, and certain medications.

Read the rest at http://rheumatoidarthritis.net/living/dont-avoid-dentist-ra/

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There are several blood tests that rheumatologists currently use to diagnose and monitor rheumatoid arthritis disease activity. Rheumatoid factor (RF) is an antibody identified with RA and other autoimmune diseases. A newer test specific to RA called anti-cyclic citrullinated peptide, or anti-CCP, has been found to have more predictive value than rheumatoid factor tests.1 Since RA involves inflammation, general tests of systemic inflammation including erythrocyte sedimentation rate (ESR) and c-reactive protein may be used. These tests are not specific to RA and are used for a variety of diseases and conditions. But these tests are not completely accurate and they may fail to identify disease activity.

Read more at …http://rheumatoidarthritis.net/living/better-diagnostic-and-individualized-tests-for-ra-needed/

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Although not publicly well known, scientists and doctors have known for sometime that rheumatoid arthritis is linked to an increased risk for cardiovascular disease (CVD) including heart attack and stroke. The first person I knew with RA some 20 years ago succumbed to heart problems at the age of 62. When I was informed of his death by his family, they immediately attributed his heart problems to the RA.

My doctors have been tracking some of the variables typically connected with CVD including blood pressure, lipids, and insulin. This came about when a sharp increase in these markers were noted while I was taking Actemra infusions (a listed side effect of Actemra). Even though I’m not on Actemra anymore, we continue to track these variables as the increase may be attributed to active RA.

According to a study at the Mayo Clinic, traditional forms of documenting CVD risk don’t necessarily apply to RA patients, particularly those who are seropositive for rheumatoid factor (RF). Traditional predictors of CVD are helpful with RA patients but not sufficient as in general populations. Systemic inflammation inherent in rheumatoid arthritis may play a role in the increased CVD risk (see this review). Some researchers have called for the development of specific CVD predictors for RA patients as a special population with unique characteristics.

My rheumatologist recently mentioned something called “metabolic syndrome” and it’s relationship to RA. Metabolic syndrome involves a set of interconnected risk factors which are related to cardiovascular disease and diabetes (see this excellent overview from the U.S. National Institutes of Health). All of these complex biochemical processes are connected and involve metabolism of food for energy, sugar processing, insulin, insulin resistance, fat/lipids including cholesterols and triglycerides, liver health, food types, excess weight, exercise, and systemic inflammatory responses. Whenever one of the interconnected systems gets out of normal parameters, a cascade of problems may occur which may impact cardiovascular health. In a study published in 2013, it was found that 18-49% of RA patients also had metabolic syndrome which was significantly higher than general populations. These researchers also found that RA patients with higher inflammatory blood markers and those who used corticosteroids were more likely to show signs of metabolic syndrome. Anti-inflammatory treatments for RA including DMARDS and many of the biologicals like anti-TNFs may impact the biochemical pathways involved in metabolism (see this recent study).

Cardiovascular risk is one extra-articular manifestation of RA that can have serious and fatal consequences. All RA patients and their doctors should be aware of the risk factors, closely monitor CVD related factors, and treat as needed. Ultimately, control of RA and it’s underlying systemic inflammation should help lower CVD risk.

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laptop and stethoscopeMy first systemic autoimmune symptom was in 2004 – I was not formally referred to a rheumatologist. Three years later I had ankle surgeries in both ankles which later was attributed to RA. Again, I was not referred to a rheumatologist. In late 2008 I started having additional symptoms that drove me to my primary care physician. He put all the symptom pieces together and immediately sent me to a rheumatologist resulting in a formal diagnosis five years after the first symptoms appeared. After diagnosis, I progressed rather quickly through a series of treatments (that journey continues today but that’s a story for another post). Now I am nowhere near clinical remission and have a severe level of disease activity that caused permanent joint damage and is dramatically impacting my life. I only wish I knew more about RA back in 2004. The good news is that there are some quality resources available that are designed to encourage early diagnosis and aggressive treatment.

One such resource is an online presentation from Dr. Martin Jan Bergman, a rheumatologist from Drexel University. He recently gave an excellent, relatively short, and non-technical presentation in October 2012 titled Rheumatoid Arthritis: Diagnosis, Treatment and Monitoring. The presentation was sponsored by Quest Diagnostics. His presentation is a superb resource for primary care physicians, RA patients, and care givers to better understand the disease and treatment processes.

One key point made by Dr. Bergman is that RA is more serious than most people think and there is a lack of public awareness of this severity. He points out that RA leads to disability, reduced work capacity, and lower quality of life. He strongly asserts that RA is a lethal disease and he shows how the survival rates of patients with high RA disease activity is similar to coronary artery disease and Hodgkin’s lymphoma. RA also brings about an increased risk of heart attacks, strokes, infection, and lymphoma.

Dr. Bergman is emphatic about early and aggressive diagnosis and treatment of RA. His says that his most common referrers are orthopedic surgeons but argues that this is often too late and primary care providers need to be more aware of RA symptoms. He stated that “there’s no such thing as arthritis- it’s a field of study.” He compares the loose use of the term arthritis to getting a diagnosis of a “belly problem” for a heart attack. With over 100 kinds of arthritis, keying in on the exact nature of the symptoms and diagnostic keys is critical to helping the patient. He discusses common diagnostic tests but warns that lab tests are normal in 35% of patients with RA. Common inflammatory tests like ESR and CRP are also normal 40% of time and should never be used to exclude a diagnosis.

Once diagnosed with RA, Dr. Bergman states that it should be treated aggressively. Waiting only results in permanent loss of function and poorer responses to treatment over time. He describes how the ACR/EULAR classification criteria should be used and he states that monitoring the disease using detailed criteria rather than just asking patients how they’re feeling provides a quicker response to treatments. His goal is to get patients as close to “normal” as possible.

Awareness of these issues discussed by Dr. Bergman is critically important for patients’ well-being. I only hope that more physicians will diagnose early, treat aggressively, and monitor carefully. Patients and care givers will find Dr. Bergman’s presentation enlightening.

Creative Commons Photo Credit: http://www.flickr.com/photos/67272961@N03/6123892769/

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Measurement of Erythrocyte Sedimentation Rate ...

The answer to this question eluded me over the years with the wide variety of RA medicines I’ve taken. It came up this week when my wife asked it again after seeing me go through a particularly long and nasty flare. I reminded her that there is no cure, only treatments for RA. But it did raise my curiosity.

In an attempt to answer this question, I went back to the Orencia package insert[i] – those 20 page, 5 point font documents that every pharmaceutical company puts inside their medicines – to try to find some answers. Bristol Myers Squibb likes to include a copy of these inserts every time they send me something in the mail. Most people probably don’t read these lengthy, highly technical documents that include information on dosage, indications, administration, warnings, side effects, and efficacy. There are likely some regulatory guidelines from the government dictating their contents since at the bottom of the document it says, “The Instructions for Use has been approved by the U.S. Food and Drug Administration”.  I dug through the insert until finding the section on clinical response – in other words, how well does it work?

Most clinical researchers use a variety of tools to gauge RA drug efficacy. The Health Assessment Questionnaire – Disability Index (HAQ-DI) which is a short version of the full HAQ is one such measure.[ii] Here’s a link to an online version of the HAQ. Many rheumatologists have their patients complete a HAQ and I remember doing this at my very first visit. Another commonly used tool to assess is the Disease Activity Score 28 or DAS28. It uses a count of the number of tender and swollen joints plus either a sedimentation rate (ESR) or c-reactive protein (CRP) blood test of inflammation. There is also an online version of DAS28 and an app for the iPhone. According to one site, “A DAS28 score higher than 5.1 is indicative of high disease activity, whereas a DAS28 below 3.2 indicates low disease activity. A patient is considered to be in remission if they have a DAS28 lower than 2.6.”[iii]

According to the online DAS28, I currently have high disease activity. One of the clinical studies on Orencia reported in the insert, “…a greater proportion of patients treated with ORENCIA plus methotrexate achieved a low level of disease activity as measured by a DAS28-CRP less than 2.6 at 12 months compared to those treated with methotrexate plus placebo.” The proportions reported were 41% of patients on Orencia/Methotrexate reached a DAS28 of less than 2.6 compared to 23% of placebo patients. That means that a larger proportion of patients, 59%, did not reach remission.

I’ve been on Orencia plus Arava for 11 months now and am not currently in that minority who reached remission. In fact, just the opposite has happened. It’s hard to tell at this point if this combination of disease modifying drugs is not working for me or it’s just a nasty flare induced by too much work in the past few months. But this will be a conversation my rheumy and I will have at our next visit in early December. I am very hesitant to try yet another treatment regimen as I’ve already been through a truck load. But my rheumy encouraged me there’s still hope and other treatments to try and her goal is remission.


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