Ask the Expert

This information is not intended as a substitute for the professional advice of your physician, nor to be a complete description of every aspect of a condition, nor a complete list of possible side effects of any medication. Decisions concerning your treatment should be based on your own health care provider's evaluation of your personal health history and current condition. Consult your physician before following any of the suggestions on this Web site. All articles on this Web site represent the personal opinions of the individual authors and should not be construed as official policy of Hospital for Special Surgery.

Question and Answer List

Answers by Stephen A. Paget, MD
Physician-in-Chief, Hospital for Special Surgery
Joseph P. Routh Professor of Medicine, Weill Medical College of Cornell University

1. I am doing well on Remicade and Celebrex. Do you have to take methotrexate if you are on Remicade?
   
   Answer: The FDA indication for Remicade indicates that patients should also be on methotrexate. This is because methotrexate appears to decrease the immunological response of the body to the mouse component of the Remicade. Remicade is called a chimera protein which means that it is made up of three-quarters human protein and one quarter mouse. This reaction can manifest itself as a decreased responsiveness to the Remicade and/or an allergic reaction to the infusion in the form of fever or shortness of breath. However, some patients seem to do fine off of methotrexate. It must be noted that a recent trial that studied the efficacy of Enbrel (another anti-TNF medication) plus methotrexate led to fewer joint erosions and improved clinical outcome than that seen with Enbrel alone.
   
   
2. I was diagnosed with RA three years ago and, after being on a several different medications, I am only taking Celebrex twice a day and getting Enbrel injections. My doctor wants me to take Minocin, which is not specifically a drug to fight RA. Is this a common treatment in RA?
   
   Answer: Minocin is an antibiotic in the tetracycline family. It was studied in RA because RA is thought to be triggered by some type of infection. In two studies, Minocin was better than placebo in the control of the clinical signs of RA inflammation. However, it has never been shown to be disease-modifying, which means that it has not been shown to decrease the development of joint erosions. Interesting enough, its effectiveness in RA is thought to be due to its ability to inhibit certain body enzymes that lead to inflammation and not due to its anti-bacterial action. Enbrel, on the other hand, has this capacity but Celebrex does not. The use of Minocin in your situation must mean that your doctor does not feel that Enbrel and Celebrex are not completely controlling your inflammation.
   
   
3. If the rheumatoid factor is very high in a person diagnosed with rheumatoid arthritis, does this determine the severity of the disease?
   
   Answer: Rheumatoid factor is an antibody protein that can be detected in the blood of some people with RA. Another type of antibody is directed against cyclic citrullinated peptide, also called CCP. The presence of both of these in the blood of a person with RA is associated with more severe RA, but not invariably so. It is a biomarker and, as such, may guide treatment choices and predict outcome. However, each person with RA differs from every other one and decisions are made in partnership between the doctor and the patient, employing facts specific to that person. With our amazing new medications, the predictability of such biomarkers will likely mean less.
   
   
4. I am a 57 year old male with rheumatoid arthritis since 1986. Presently I am on Enbrel. I've had my two wrists fused plus my right knee replaced. All my teeth are paining and my jaw joints are very bad as well. I have been to the dentist and he says my teeth look fine. My jaws joints are very bad as well. Would the arthritis cause my teeth to ache?
   
   Answer: No, given your normal teeth, this pain is likely due to arthritis in the joints of the jaw. The temporomandibular joints (TMJ) are just in front of the ear and they are the same type of joints as in the wrists. Often, a maxillofacial dentist deals more with the TMJ and can help you. Local steroid injections can be a great help in controlling such inflammation. Also, realignment of the teeth with night inserts can decrease the stress on the jaw joints.
   
   
5. I have RA and I am on Warfarin for another problem. Is it true that if on Warfarin one cannot take any arthritis medications? If so, what should I do to deal with my RA?
   
   Answer: The main issue with having RA and needing warfarin is that certain medications that are used for RA may lead to further thinning of the blood and potentially bleeding problems. Drugs that canbe taken without any problem while you are on warfarin include: prednisone, Celebrex, Vioxx, Bextra, minocycline, methotrexate, leflunomide, sulfasalazine. antimalarial drugs such as hydroxychloroquine, etanercept, infliximab, anakinra, These drugs do not thin the blood on their own and thus will not be problematic with warfarin. Drugs that you should avoid include aspirin and traditional NSAIDs such as naproxen, ibuprofen, piroxicam. These drugs do have effects upon platelets that can because further blood thinning on top of that already caused by warfarin. Thus, you have many very good options.
   
   
6. I have been on an antibiotic (augmentin) for the past 12 days due to an infection and noticed that my RA symptoms have lessened. Is there a connection between antibiotics and RA treatment?
   
   Answer: Many patients have noticed the same improvement in their RA while they are on antibiotics for another reason. As you are probably aware, for many years it has been thought that RA is likely triggered by an infection - most likely a virus. Thus, many different types of antibiotics have been studied and some have shown to be effective in controlling the inflammation of RA, particularly a tetracycline drug called minocycline. However, its effect is thought to be due to its ability to block the action of certain enzymes that cause joint inflammation. In your situation, your improvement may reflect the natural waxing and waning of RA, or a local infection may have been exacerbating your inflammation and the Augmentin helped this. This does not mean that you should go on such an antibiotic for life because of the problems associated with changes to your bacterial flora and future ineffectiveness of such antibiotics.
   
   
7. I am 58 years old and got rheumatoid arthritis suddenly after a hysterectomy. Medicines are not able to control the arthritis. Both hands and wrists are so badly deviated, with bone degradation, that I have it's been suggested to have hand surgery. My rheumatologist does not want me to have the surgery. I find that rheumatologists never agree to surgical correction of the hands. Is there any special reason?
   
   Answer: Hand surgery can be amazingly helpful. However, a good hand surgeon will often not recommend surgery because they feel that your function will be worse after surgery, even if the hand looks better cosmetically. If a hand surgeon does not recommend hand surgery, listen to them.
   
   
8. Is it possible to combat RA disease with regular exercise and diet as opposed to taking steroids to decrease joint inflammation?
   
   Answer: Regular exercise and diet are indeed very important parts of the treatment of RA. Steroids such as prednisone can also be very helpful in controlling inflammation but should never be used as the sole drug, and we try to use it in short courses and not chronically. However, in this day and age, with our amazing new medications for RA, exercise, diet, and steroids alone are not appropriate. Just imagine using leeches for the treatment of infections once antibiotics were found to be effective. The same can be said to be true today regarding RA. Since untreated RA (and the sole use of exercise, diet, and steroids would be considered untreated RA) will go on, inexorably, to cause joint damage and we can now avoid that with new medications, it behooves you to strongly consider adding new, innovative medications to the treatment plan that you mention.
   
   
9. I am a 43 year old woman who was diagnosed with RA in 1998 and with Lupus in 2003. I have severe hair loss even though I have been off of methotrexate for the last year. Is this common? Is there anything that can be done for the hair loss?
   
   Answer: Hair loss is a common problem in patients with lupus and may be the first sign of a lupus flare. Hair loss can also be due to or exacerbated by medications such as steroids, methotrexate (in only 5%), cyclophosphamide, and rarely with hydroxychloroquine (Plaquenil). In lupus, treatment of the lupus inflammation commonly treats the hair loss. If medications are the culprit, stopping them can stop the problem. Also, seeing a dermatologist who specializes in hair loss can be very helpful because they can treat you with medications, either orally, topically, or via local injections into the scalp.
   
   
10. I was diagnosed with severe RA in 1978 and am currently being treated with Remicade and methotrexate. Are the nodules that grow on the muscles and tendons of the legs common? Will they go away? This seems to be the reason I lack flexibility and limited range of motion in my knees after replacement surgery 18 yrs ago.
    
    Answer: Nodules occur in approximately 10-20% of patients with RA and seem to be less and less common these days due to the modern aggressive treatment approaches to RA. Of interest is the fact that methotrexate often causes nodules to increase in number, and they often appear on the fingers and can be painful and limit function. Anti-TNF medications such as Remicade often cause nodules to decrease in size and number, but this is not always the case.
    
    
11. I have been on Enbrel, and only Enbrel, for over a year and have responded extremely well. I also like to drink white wine and do so on average 5 times aweek, 1-3 glasses or up to two bottles per week. I exercise regularly and am 42 years old, very fit at 140 lbs and 5'11". I take pilates, latin dance and scuba dive. Will drinking wine while on Enbrel have any long term effects on my health? My rheumatologist monitors my liver through blood tests four times a year and there are no problems.
    
    Answer: No, drink away and enjoy your life. Obviously, you need to monitor the amount of wine that you drink because too much can be harmful. While we commonly will recommend avoiding alcohol while patients are on methotrexate because it can lead to scarring of the liver, no such admonition exists with Enbrel.
    
    
12. I have been on Enbrel with no improvement and I am now on Kineret with good blood work results, but not much change otherwise. Now my doctor wants me to try Remicade, which I heard is very similar to Enbrel. Is it worth trying even if Enbrel did nothing?
    
    Answer: Even though you have not had an optimal improvement with one biologic agent, that does not mean that you will not improve after using another. This is true with the movement from Enbrel to Remicade, Remicade to Enbrel, Humira to Enbrel, etc. These drugs are different enough in their chemical structure that the absence of response to one does not augur a negative response to another.
    
    
13. I am 74 and was diagnosed with RA 10 years ago. I am experiencing numbness at night in both arms and numbness that is almost permanent in both feet and ankles. Is this expected? Is it treatable?
    
    Answer: It sounds as though you have a neuropathy, which means that the nerves of your arms and legs are irritated either by the RA itself and/or through pinching of nerves in the neck or back. You need to see a neurologist to define the actual cause, which can range from RA itself, to a pinched nerve, pernicious anemia due to vitamin B-12 deficiency, a medication, or some combination of several of these factors. Once that has been defined, specific treatment can be instituted. Also, there are excellent medications that can control neuropathic pains such as Neurontin. Your neurologist will be able to prescribe it or other medications.
    
    
14. What is the prognosis if you have rheumatoid arthritis causing mild pulmonary hypertension, and how common is it?
    
    Answer: Pulmonary Hypertension is not very common in RA. However, once it has been defined as to its extent and severity by either an ECHOcardiogram or right heart catheterization, it needs to be carefully assessed and treated. Luckily, there are excellent medications that can be used for this, including anti-hypertension medications such as calcium channel blockers, Bosentan, an endothelin blocker, and the anticoagulant warfarin. One of more may be right for you, or your doctor may not think that you need any of these. A cardiology or pulmonary specialist should be seen to define the extent of your problem and whether or not medications are needed.
    
    
15. I have severe RA. I take Enbrel, methotrexate, and folic acid for my condition. I also have had recurring shingles since I was 5 years old. I am now 46. I had a sudden onset of RA when I was 42. Since I have been on methotrexate, I have had frequent outbreaks of shingles. In the last six months I have had 23 outbreaks. My doctor said there is nothing we can do about it. Is there something I can do?
    
    Answer: If, indeed, you are having recurrent episodes of shingles (Herpes Zoster) rather than Herpes simplex, you can consider using an oral anti-viral agent regularly to prevent the flares. Your immunosuppression with Enbrel and methotrexate is the culprit in these recurrences, but you may not want to stop those medications if they are working well. I would recommend seeing an infectious disease specialist.
    
    
16. My husband has been diagnosed with RA and was prescribed Arava, which we cannot afford. He has been seeing a Chinese acupuncture doctor and had three treatments so far. After the first treatment he had lost the pain in his right knee and the pain in his right arm was reduced. He has lost almost all the pain in his fingers and the morning stiffness is gone. We are very hopeful with these treatments so far. Have you heard of acupuncture being an effective treatment for RA?
    
    Answer: Acupuncture can be effective in controlling all types of pain, including that caused by RA. However, some type of disease-modifying medication should also be employed. Unfortunately, some medications used for the treatment of RA are expensive, but there are often less expensive alternatives. You should discuss this with your rheumatologist. Also, drug companies often have certain plans that will allow you to get their medications for free. Your rheumatologist often knows about these.
    
    
17. I have had RA for one year now. I have been on 20 milligrams of methotrexate and 200 milligrams of Plaquenil. I still have some stiffness in the morning and notice weather changes. I am still on five milligrams of prednisone. How do you know when you are in remission? How much stiffness will I notice once I am in remission, and will my energy return to normal? Please talk about remission and current guidelines to progression of therapy. How long do you recommend proscribing a treatment if remission has not occurred?
    
    Answer: Remission actually means "no signs of active inflammation," including the absence of joint pains, morning stiffness, limitations in range of motion, and fatigue. Often, people with RA do not attain this full definition but are much improved from their status prior to taking their medications. A more difficult definition is to have no joint problems off of all medications. This is even rarer. Rheumatologists will commonly add medications to the drug regimen in order to attain, as much as possible, a full remission. The use of anti-TNF medications such a etanercept, infliximab, adalimumab, and the IL-1 blocker anakinra can add greatly to a regimen such as yours and can go a long way to helping your achieve the sought-after remission.
    
    
18. I've been on Plaquenil for about seven years. Two and a half years ago I started having bad ringing in my ears and have been noticing hearing loss. I became so concerned that I started doing some research and discovered that this definitely could be a side effect. My doctor has left the area and due to the shortage of rheumatologists nearby, I haven't been able to ask anyone about this. If it is the Plaquenil, will the hearing damage be permanent? And if I switch to some other medication will the ringing in my ears stop?
    
    Answer: Plaquenil, rarely, can cause such hearing problems. It is important to stop it and see an ear, nose, and throat (ENT) doctor to assess the type and extent of ear problem. Luckily, there are many wonderful new medications for your RA, and you need not worry if you have to stop Plaquenil.
    
    
19. My husband is 31 years old. He has just recovered from his third episode of gout in three to four years. Is gout related to rheumatoid arthritis?
    
    Answer: Interestingly enough, the co-existence of gout and RA is very uncommon, but not unheard of. The diagnosis of gout should be made by seeing the characteristic crystals in the synovial fluid from an involved joint.
    
    
20. I am 35 and have recently been diagnosed with RA. I have the symptomatic joint pain and swelling, and my maternal grandmother had RA with several nodes. However, all my lab work has been negative, including a very low anti-CCP. How likely it is that I have RA, given my lab work? What amount and type of exercise is helpful for RA?
    
    Answer: If you have a persistent inflammation in the small joints of your hands and feet on both sides of your body, it is likely, given your family history, that you do have RA. If there is any question, you should be seen by a rheumatologist. Exercise is very important and should be guided by a physical therapist and graded upward depending on your particular joint problems and response to the initial therapy program.