Treatment Options | Arthritis Information

 

hi everyone,

i need some advice and sage words from you, if at all possible!

i have been diagnosed with RA,  it's early and mild.  I have seen 3 Rhematologists and they all agree that I have RA but without the MRI I probably would not have been diagnosed.

To give you a quick summary:
- i have joint pain, but NO stiffness in morning or visible swelling
- My RF is 37
- Sed rate is near normal, CCP is negative, C-Reactive Protein was a bit elevated in November but has come down now
- my symptoms are very sore joints, migratory joint pain and fatigue

The radiologist who wrote the report from the MRI wrote: "multiple small enhancing erosions within the capitate bilaterally with mild synovitis of the carpus and MCP joints.  Findings are consistent with and concerning for mild inflammatory arthropathy".  Also, mild to moderate tendonopathy of both carpus extensor ulnaris tendons in both hands/wrists.

My white blood cell counts are low (2.4) and one RD says I'm not a candidate for methotrexate because of it.  She suggests I go on Enbrel immediately.  I asked her about minocycline and she thought that with my joint damage it was not advisable.

Next RD says I could try many things and suggested:
a) enbrel
b) minocycline
c) triple therapy (meth, plaquenil and sulfasalazine)
d) methotrexate (and watch my WBC frequently)
e) sulfasalazine

The next RD thought "If you start with the milder drugs and they do not work, you can proceed to the stronger ones rapidly; the damage described is early.  However,  that damage has happened fairly rapidly, and may not be reversible.  There is accumulating data suggesting that very early aggressive treatment has a better outcome, and may be worth the little bit of extra risk associated with the treatment."

So.... the opinions are a bit different and I'm trying to figure out next steps.

I am toying with the idea of trying the antibiotics first, for 3 months, and if that does not work, going on Enbrel.  I'm not too jazzed up about the idea of trying Methotrexate and I refuse to go on Prednisone.

I am 38 year old white female with 2 children under the age of 3, so I need to get my life and energy back.  Any sage advice appreciated.

I am currently taking Vitamin D, Diflofenac, Turmeric, Fish Oil & Evening Primrose Oil.
I forgot to mention... right now I'm trying to decide between Enbrel now, or antibiotics first and Enbrel later....  or maybe the "triple therapy" option.... I have heard that triple therapy can work very well.  I have only been on MTX a little while, and am having to wait to add other drugs.  Ugh.  So far MTX alone isn't doing anything. 

hi cdndream welcome to you.. all of my joints were ruined in the first 4yrs
even though i was on mtx and prednisone..  tough desision on these meds.
i was never given a choice just got given the meds.. i hope you find the
right meds for you

Boney
I'm no expert, but you could consider NSAIDs as a first line of defense. Naproxen or Nabumetone would deal well with the inflammation and discomfort and they are inexpensive. If they don't work or you can't tolerate them, switch to something more potent like Enbrel. Chances are you will switch regimens over the course of your illness anyway. I have tried Mobic and am currently on Diclofenac, both are NSAIDs.  Neither help at all. NSAIDS are not a suitable treatment for someone with early joint damage. I don't know if you are aware but it is possible to use minocycline with Enbrel. While I think AP is a GREAT long term therapy it can take a while to kick in (some people have reported several years). What you want to do is get the RA under control rapidly and then get a maintainance program going. Many people use Enbrel in conjunction with AP, then later stop the Enbrel.

My vote?

Do the Minocin, and look at your diet. The sooner you get onto the diet the better.
Like Pip say's you need to experience the 'herx' - feeling crappy before you feel better. This has been many peoples experience with this disease. With you sed rate at 0, i believe it means you don't have inflammation, being that the test is what they go by on me for inflammation. My sed rate isn't at 0, it's just not as high as it was. I will find my latest bloodwork and let you know what it is. Hello. Welcome to the board, sorry you had to find us though.

I am a 40 year old female with a six year old daughter who I am a single parent to. I have been diagnosed for three years and they are yet to find a medication to stabilise my symptoms. As a result, I have tried every medication except one, so I have had a bit of experience.

My advice would be this...triple therapy plus add a probiotic.

It's a good, solid combination that has worked well for many people and a good place to start.

In my opinion, MTX is a no more dangerous or scary than anything else and Enbrel won't necessarily do a better job because it's a biologic.

Also, I'm afraid that there is 'no getting your life back'. I have been looking for three years and wanting that can cause you a lot of disappointment. What you have to do is create a new life from what you have now. I have done much crying and screaming in the last three years...wanting my life back but I can't have it. Better to look at what you can have now. I know what it's like to feel desperate to get your energy back to cope with young children, it's awful but work with what you have, find new ways of doing things. This means there will be lots of change and loss for you and your family. It isn't easy.

I hope that whatever therapy you choose goes well for you.

I am also on Mobic.  My RD (and what I have read) says that NSAIDs CAN drastically reduce pain & inflammation.  It has for me, pain when I am resting is gone, as is most of the inflammation.  However it does NOT stop the disease process-damage to cartlidge and bone will continue even if pain is gone.

I agree with Cordella. Triple therapy is starting to be standard treatment. Now a days, they recommend aggressive treatment to start as a lot of damage happens the first two years. Think about how important your hands are, even if just your pinkies are damaged that can limit how you hold a cup. You are talking about your hands. Your hands. MTX has been around for at least 20 years and works for more people more often than any other medication. That is why it is the first line drug. Try taping two fingers on both hands together that might show you what it can be like. Remember, once you have damage it isn't easily repaired so it is much better to not have damage.

MTX takes 2 to 3 months to start working, antibiotics can take a year to start working and Enbrel starts almost immediately. Time is not on your side, it is on the arthritis side. You can all normal bloodwork and still have a lot of rapid damage.

This doctor said it best>>>The next RD thought "If you start with the milder drugs and they do not work, you can proceed to the stronger ones rapidly; the damage described is early. However, that damage has happened fairly rapidly, and may not be reversible. There is accumulating data suggesting that very early aggressive treatment has a better outcome, and may be worth the little bit of extra risk associated with the treatment." <<

I'm surprised that any RD would suggest mtx with your white blood cell count so low.  I suppose though it would depend on how much you'd be taking and then really watching your WBC count.  I know that the few times I've had to stop my mtx for a few weeks was when my WBC count got down to 2.4  I'd have to go off until it worked it's way back up to 3.0 I believe.

I was surprised about RD #2 suggesting mtx with my WBC being so low too.  He really doesn't think that the mtx would make them drop further - RD #1 did though, she ruled MTX out entirely.  I told each of them what the other has said (they know each other) and they stand by their opinions.

I have heard and read that a lot of people feel like crap when they are on MTX and with two little rugrats to take care of, I would prefer to feel better rather than worse.  Power of positive thinking???  :-)

I am sooo confused...  triple therapy, enbrel, mtx, plaquenil, sulfasalazine... these were all just cryptic words to me a few short weeks ago. 

I want to figure out what to do first.... like others have said I can always try another if the first doesn't work out.  I really want to nip this in the bud and feel better.  I feel like such a "newbie" writing this.

BTW, my sed rate was 12, now it's down to 1....  But since different labs did the 2 tests  I've been told that they cannot be compared directly.  ANA was negative.  C-reactive was 8.   Vitamin D was low at 26 (supposed to be 30-100).
Before you add in D - make sure they run all 4 D tests to make sure you're not D sensitive.  I suspect a lot of us are - but I haven't completed my research so even tho I'm low too - I'm not doing anything about this until I do. From the way I understand ra, (someone correct me if I am wrong) that the first few years are the most vital because that is when most damage is done and the ra is most aggressive. I have been on enbrel for five months and am doing quite well. I tried all the others, alot I was allergic to and some didn't work. I noticed improvements on enbrel the day after my first injection. My morning stiffness was gone and I now have some energy and my pain has gotten better too. RA is such a personable disease and everyone is different. But IMO I would treat is fast and with aggression! Remember Pip doesn't have RA and has no real medical education she just pretends. MTX doesn't really effect WBC's like is Azulfasdine does.

The first couple doses of MTX you might feel nausous. Take it in the evening, with carbs. Many many people take it with kids, a job and a very active life.

The insurance co wiill probably make you take MTX before letting you have Enbrel, Enbrel is expensive. The insurance co knows how well MTX works.

You are talking about your hands. What if you can't make dinner for the little ones? The medical advances are happening rapidly. So far there is no cure, but there might be soon. Protect your hands.This might be helpful. I thought it was very positive and it certainly seems to be a good fit with your situation.

Take care,

Lynn

Early Treatment With Remicade and Methotrexate For Rheumatoid Arthritis Has Led To 1/5 Of Patients In Drug-Free Remission:

Early treatment with a combination of methotrexate and infliximab may be effective as remission induction therapy and alter the course of early rheumatoid arthritis (RA), according to data presented at EULAR 2007, the Annual European Congress of Rheumatology in Barcelona, Spain.

At four year follow up, over half (51%) of the patients who started treatment with a combination of methotrexate and infliximab in the BeSt ('Behandel-Strategieën' or 'treatment strategies') trial had been able to discontinue treatment with infliximab and maintained a good response (Disease Activity Score (DAS) ≤2.4). 41 patients were still taking methotrexate monotherapy at trial end. Almost one in five (17%) of patients had reached clinical remission (DAS <1.6), with minimal joint damage progression, and were no longer receiving any anti-rheumatic drugs,

Study leader Dr Cornelia F. Allaart commented: "Our findings indicate that clinical remission from RA is achievable provided effective treatment - such as the infliximab methotrexate combination we used in the fourth arm of this study - is administered early in the course of the disease."


http://www.medicalnewstoday.com/articles/74289.php
[QUOTE=cdndream]

I have heard and read that a lot of people feel like crap when they are on MTX and with two little rugrats to take care of, I would prefer to feel better rather than worse.  Power of positive thinking???  :-)



[/QUOTE] Lynn and Anna -

Because RA can do a ton of damage early on, as apparently is happening with you, I personally wouldn't fool around with it.  I wouldn't wait a year for minocin to work, possibly causing further damage to my joints.  Especially at your age with your young children.  If mtx does make you nauseous you can always switch to injectable, that seems to take care of it for many.  But what if 5 years from now you're looking at a knee relacement because you weren't aggressive enough now?  I'm not saying don't try minocin, I just don't think you should try it alone.  In my opinion their is just too much at stake.

Also, don't discount MTX. It works very well in undifferentiated RA....

Rheumatoid Arthritis May Be Prevented with Early Treatment

Results of a study presented at the Annual European Congress of Rheumatology by Henrike Van Dongen, MD, Leiden University Medical Center, Netherlands, and her colleagues on June 21, 2006, suggests that people diagnosed with undifferentiated rheumatoid arthritis could have their disease outlook changed significantly if the proper treatment is given at the right time.

The PROMPT-study (Probable rheumatoid arthritis: Methotrexate versus Placebo Treatment-study), a double-blind, placebo controlled, randomized, multicenter trial in 110 participants with undifferentiated (having an undetermined diagnosis) rheumatoid arthritis (RA), was conducted to determine whether participants would benefit from treatment with methotrexate.

The study concluded that the methotrexate group had fewer patients develop RA during the observed time and more participants reached remission than in the group receiving placebo. “This data is excellent news as it shows that methotrexate appears to delay or even prevent progression to rheumatoid arthritis amongst patients," said another member of the study Tom Huizinga, MD, Leiden University Medical Center, Netherlands.

Methotrexate is a disease modifying anti-rheumatic drug (DMARD) and is well established in the treatment of cancer and autoimmune diseases such as RA. In rheumatoid arthritis, methotrexate seems to work, in part, by altering aspects of immune function which may play a role in causing the disease.

“One of the most interesting findings from the study was that the patients who benefited the most were the ones showing a positive anti-CCP test, which would in general terms show that a patient has a very high likelihood to develop full-blown RA. However, this study indicates that the progression to a full-blown disease amongst these patients could be influenced,” noted Dr. Dongen.

"This is an important study," said John H. Klippel, MD, President and CEO, Arthritis Foundation, "which suggests that there may be a window very early in the development of rheumatoid arthritis in which treatment significantly alters the course of the disease. Identifying patients in this phase of the disease and instituting treatment is an important public health goal."

Linda- Pip, I'm so surprized you don't agree with me!  LOL Ah, Linda, you do my heart good.  LOL  Remind me to show you my errant toe when I'm back there so you can 'vouch' for me.  That will be fun, no?  Taking my shoes and socks off in a restauant. [QUOTE=Bird Girrl] Remember Pip doesn't have RA and has no real medical education she just pretends. MTX doesn't really effect WBC's like is Azulfasdine does.

The insurance co wiill probably make you take MTX before letting you have Enbrel, Enbrel is expensive. The insurance co knows how well MTX works.

.[/QUOTE]

Anna, are you some kind of a long distance doctor that knows more than Pip's and CdNDream's doctor? Pip has RA and CDNdream is Canadian, so CDNdream doesn't have to deal with insurance companies, you moron.

Grow up.Thought I saw a post here that she has paladron arthritis, not RA. I did not see her denounce that.

Here is a post about early aggressive treatment. It even mentions mincen (as a MILD DMARD).

http://arthritis.about.com/od/rheumatoidarthritis/f/earlytreatment.htm
Anna/BrrdGrll/BeeBee/TrollNameOfTheWeek, I know you know Pip has RA, that she has herself told you, and that you've pulled this "Pip doesn't have RA" on other boards. If you're going to try to play innocent and manipulate people, could you at least be clever about it so we can have a crumb of respect for you?

People come here for input and information. Just because you have a chip on your shoulder for whatever reason doesn't excuse your constant throwing in of misinformation. We all have major health issues and your behaviour is damaging.

You need to find another hobby besides looking, or making up, ways to discredit people who's health management choices you don't agree with.
cdn - if you haven't given up on this thread yet LOL, here is some info about minocycline from the Arthritis Foundation site that might be helpful:


  Hey - I just want to be a representative for the early aggressive treatment.  I was diagnosed in Jan.  As you can see below, bad numbers.  The combination of plaquinel and MTX put me in , dare I say, remission in 2 months.