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Transcripts-4/23/00
Arthritis Q and A with Dr. Barry Waters
InsightHostKJ> Hi Dr Waters!
DrWaters> Hi
InsightHostKJ> how are you?
DrWaters> Fine and ready to begin.
InsightHostKJ> Great! Type a ? if you have a question for Dr Waters
InsightHostKJ> I'll start....Have you used remicade in your practice yet? If so...whats been the result?
DrWaters> Yes and the results have been excellent.
InsightHostKJ> Great! Any side effects
DrWaters> I only have a few patients on it and they have had none.
InsightHostKJ> Results comparable to Enbrel?
DrWaters> RA is so different from patient to patient I can't judge from personal experience. In clinical trial, results seem to be the same.
DrWaters> Enbrel and Remicade block the action of TNF-alpha. This is an major cause of joint inflammation. Enbrel is a small molecule, so we don't make an immune response against it. Remicade is a large molecule, so we do. Therefore, Remicade is given with MTX or Arava. Enbrel can be used with or alone.
InsightHostKJ> If one didnt respond to enbrel, do you think remicade is worth a try?
DrWaters> Yes, but along with MTX or Arava. Enbrel is given by onself twice weekly. Remicade is by IV infusion at 8 or less often, 4 week intervals (after a more intensive startup protocol).
InsightHostKJ> Are your patients experiencing hair loss with arava? we've had a number of people commenting on it lately
DrWaters> Hair thinning is common with Arava. Most often it is not bad enough to stop the drug.
higgy> I have an Arava question, after taking it one month i began tasting it and smelling it like i was taking the loading dose again. Also had a weird feeling in my stomach or intestines, Felt pretty sick
DrWaters> Your Arava side-effect is not uncommon. One can stop it for a few weeks and then try 10mg daily or 20 mg every 2nd or 3rd day and see if that's better tolerated.
higgy> I quit taking it a week ago and am now starting to feel better,
InsightHostKJ> does it work at that decreased dose?
higgy> I notice no difference in my ra which is pretty good right now
DrWaters> Often it does, especially in combination with other DMARD's.
swimmer> The nurse has a very hard time finding my vein for blood samples, and IV's are also hard to get in....these bad veins,,,is that due to RA or the meds?
DrWaters> Bad veins are common in older people or people with low muscle mass. Weight lifting can help. There is also a lot of luck and genetics involved.
swimmer> how old?
DrWaters> Anything older then me is old and I'm 44.
InsightHostKJ> LOL Dr Waters
swimmer> hey...I am young
InsightHostKJ> Have you used the Prosorba column?
DrWaters> No
InsightHostKJ> No one interested or you just havent?
DrWaters> No one interested
DrWaters> Have any of you tried Prosorba?
InsightHostKJ> Me....got me off of methotrexate
DrWaters> How often do you have to do it. Prosorba I mean.
InsightHostKJ> I did the 12 week series...finished about 7 weeks ago....
DrWaters> Why did you have to get off MTX?
InsightHostKJ> Didn't have to....was on mtx, plaquenil, pred, alzulfadine...failed enbrel...nothing was working...felt it was worth a try
DrWaters> I think that's a perfect time to try Prosorba.
DrWaters> What do you people think about doxycycline and RA?
InsightHostKJ> I dont know anyone on it Dr Waters. what do you think of it?
DrWaters> I think it is one of the most effective RA med's except for MTX, Arava and Enbrel/Remicade.
InsightHostKJ> really? why isn't it used more?
DrWaters> I often use it in combination with one or more of the above, and maybe that's why no one has needed Prosorba. Who knows.
InsightHostKJ> Hmmm.....I'll have to discuss that with my RD
DrWaters> It's not used more because of the "Tomato Effect"
InsightHostKJ> explain please
DrWaters> Until the early late 1800's it was universally accepted that tomatoes are poisonous. (boy, is my spelling bad) It was a mass hallucination, so to speak.
DrWaters> The same is with doxycycline. Since it is accepted that microbes don't cause RA, everyone assumes it can't work.
InsightHostKJ> makes sense
DrWaters> Well, doxycycline works in RA by blocking metaloprotineases, not as an antibiotic, and it is very safe and effective.
higgy> I assume minicin or minocyclene would have the same effect?
DrWaters> Research suggests that those treated for 6 months with doxy early on in RA have much milder disease 3 years later even though they've been off doxy for years. I put mist people on it, therefore, for at least the first 6 months. Usually with MTX, too. Of course, doxy can't be used in children or in those who can get pregnant.
DrWaters> Monocin works as well but has more side effects. I use Minocin less often.
IndyRon> My dad was just Dx'ed with Spinal Stenosis, He is 82, his RD basically disamissed him and said that nothing could be done. I don't accept that answer..Maybe no surgery at that age but what about alternatives. any suggestions?
DrWaters> Epidural blocks and narcotic pain killers. Narcotics are best treatment for many.
IndyRon> how about traction or pt at that age....
DrWaters> Spinal stenosis is a miserable thing to have. Traction and PT, IMHO, help very, very little.
InsightHostKJ> Betty go ahead
Betty> Please explain metalprotineases
DrWaters> It is an enzyme that is an important troublemaker in the immune response. Blocking it decreases inflammation and cartilage degradation. The ACR is even doing a study on doxycycline to prevent knee osteoarthritis.
higgy> Whats your opinion of food allergys and should people try to see if they react to certain foods. I for example have a flare for about 24 hours when i eat wheat
DrWaters> In general, food trials in RA are rarely helpful, though there are exceptions. You need to be checked for gluten enteropathy.
DrWaters> What do you people think about this Chiari malformation and fibromyalgia thing?
InsightHostKJ> Chiari malformation?
DrWaters> On March 10 on the ABC TV show 20/20 they reported that fibromyalgia can be "cured" by surgery to make more space for the brainstem and cerbellum in the bottom of the skull where it meets the neck. The Chiari malformation is a congential smallness of this space that leads to squishing of the brain stem.
InsightHostKJ> OK....I did hear about that... sounds kind of far fetched that everyone with Fibro has a congential defect
DrWaters> These two neurosugeons, Dr.Michael Rosner in Alabama and Dr. Dan Heffez in Chicago believe that most FMS is caused by this and can be cured by this operation.
InsightHostKJ> isn't it very risky?
DrWaters> Supposedly not, though they do have to cut open the bottom of your skull and touch your brain.
InsightHostKJ> ewwww
IndyRon> no thank you
InsightHostKJ> What do you think about it?
DrWaters> What is this is really true and us rheumatologists have all been idiots.
InsightHostKJ> LOL
DrWaters> Another Tomato effect thing.
Guest49> How do they determine who was actually born with the defect and all those whose FMS is caused by a multiple of other problems?
Melanie> Just wanted to say, would need a lot of case histories before I would go with any kind of brain surgery. Makes me think of lobotomies of earlier years.
DrWaters> Everyone is supposed to have a MRI of the foramen magnum, the bottom of the skull.
InsightHostKJ> I agree melanie
Guest49> Comment - My brain is the only thing I got left that is intact -- nobody is touching it.
DrWaters> I agree with Melanie, too.
InsightHostKJ> LOL 49!
OldRetiredMan> heard that, 49
InsightHostKJ> Are they actually doing this in a large number of people?
DrWaters> HMO's have made my brain into mush. Sorry.
IndyRon> LMAO
InsightHostKJ> LOL Dr Waters..I can imagine!
DrWaters> A fairly large number.
InsightHostKJ> and they've all been successful?
DrWaters> They claim an 88%% success rate.
InsightHostKJ> wow
Guest49> Well......... I will pass on it, thank you.
DrWaters> Go to 20/20 transcript site for more details. It's all there.
OldRetiredMan> Do you think that their high success rate is because they "pick and choose" who they help?
InsightHostKJ> I will do that
DrWaters> They make it sound like almost eveyone with FMS has Chiari, so almost everyone can be helped.
InsightHostKJ> now that all of us are holding our heads wincing!
DrWaters> What do you people think about Glucosamine, MSM, SAMe, etc.
InsightHostKJ> Glucosamine I think works well for many with OA...MSM is a NSAID....and SAMe....I don't know. Hows that for an unprofessional opinion?
DrWaters> I tried glucosamine and it didn't help me, but then I don't have arthritis.
higgy> take msm and g/c for oa
Melanie> No cures, but helps some. Glucosamine eased symptoms.
higgy> i was on crutches 3 months ago and im walking now
DrWaters> I tried it for herniated disc in neck and it didn't help.
InsightHostKJ> glucosamine helped my dogs OA
Guest49> From peoples' comments, I feel that glucosamine seems to aid the large joints primarily, and also before one is in the severe stages of OA.
InsightHostKJ> I've heard several people say they think it helps in tendonitis/bursitis
DrWaters> I recommend it to most of my patients, but now I'm worried because they say it can cause diabetes. You can't win.
Guest49> I tried it for a year (a few yrs back). Did nothing for me but lighten the wallet.
Betty> I think arthritics are willing to take some risks for relief.
DrWaters> In my patients, I'd say around 1/3 think it helps enough to stay on. That's not bad.
InsightHostKJ> I agree Betty
DrWaters> You let them filter your blood. You're wild.
InsightHostKJ> LOL! It worked! and i'll do it again!
DrWaters> Do you know I see around ten bad RA patients a day! Tomorrow will be Prosorba day.
InsightHostKJ> I think it is worth a try Dr Waters....you'll have to keep me posted if you do try it on anyone
swimmer> is there any such thing as a good RA patient. LOL
Melanie> LOL
IndyRon> LOL, swimmer
OldRetiredMan> lol, swimmer. agree.
InsightHostKJ> LOL Swimmer
Melanie> You may have already discussed this but I was wondering about the efficacy of Celebrex and Vioxx and what you have observed so far with your patients?
gwyn> my GP won't put me on any addictive pain pills as he don't want me addicted but i don't worry about that i just want the apin gone or reduced
DrWaters> Let's talk about Voxx and Celebres first, and then narcotics.
DrWaters> Vioxx ands Celebrex work as well as older NSAID's, no better, no worse. They seem to be much safer, better tolerated and more convenient. It is probably the most correct thing to try Vioxx or Celebrex as first choice of NSAID's.
InsightHostKJ> I can't take traditional NSAIDs...GI Bleed...tried Vioxx and swelled up like a blimp...think celebrex will do the same?
IndyRon> I broke out in hives on both of them
DrWaters> They are expensive, NSAID's help only the minority of Arthritis patients a lot, so they do not need to be used for everyone.
Melanie> They work in same way? Some use Celebrex and others Vioxx and get different results.
DrWaters> They are similar, dose for dose. You'd probably swell form Celebrex, too. Hives are not common, though I get itchy from both of them myself.
Melanie> Thanks, Dr. Waters
DrWaters> Let's talk about narcotics. It is a complex issue. It is now consensus that it is not incorrect to put patients with OBJECTIVE joint damage and pain on strong narcotics. The addiction thing is not supposed to be a reason not to use them.
Melanie> objective?
DrWaters> Patients with vert comp fx's, severe OA, crippling RA, are all "allowed" to use them, so to speak. Objective means other people can see that something is abnormal. Subjective means only the patient can see it.
InsightHostKJ> what about those with subjective pain?
DrWaters> It is medically incorrect to refuse to prescribe pain killers to those with severe pain and severe joint damage.
IndyRon> So in a case like mine where there is no "malformation" but significant.pain, no narcotics?
gwyn> "my hip is swollen to twice the size of the other one i can't walk with out crutches and i can't even use them at the mo thanks to tenis elbow and they refuse to put me on anything stronger tha co-porxamol and then they wonder why i get so crappy with them!
DrWaters> We can't use narcotics in those with subjective-only pain because of social considerations, not medical ones. It is a harsh world.
InsightHostKJ> It sure is! Hard to be a gimp now a days!
DrWaters> Objective could be xrays, warmth, swelling, etc.
Melanie> Just wondered? I go to my PCP for pain relief, as RA doesn't "see" what hurts so can't or won't give me relief. But are there non-narcotics that are anything equally effective - such as Ultram? What do you think?
DrWaters> One last question because I have patient charts to do. I bring them, home to do after my kids go to sleep. Mel has last question.
DrWaters> Ultram works for some, but it has less oomph then strong narcotics in severe pain.
InsightHostKJ> So you use narcotics regularly for you more severe patients?
Melanie> Thanks, Dr. Waters. Ultram is effective for me right now but others have stated it is not for them.
DrWaters> You mean you have RA and no joint warmth, swelling, deformities or errosions on xrays?
InsightHostKJ> OK..yeah..for the subjective pain
Melanie> I have some of those, but no deformities yet. RA is very cautious. Beginning with new RA in two weeks.
DrWaters> I use narcotics, especially in the very elderly (80 and up), with severe OA, spine problems, vert. FX, etc. It is the current accepted standard of care.
InsightHostKJ> What about us youngies with RA, mild deformities and erosions
DrWaters> In younger people it is case by case. Clearly, if there is severe, otherwise uncontrolled pain and something that others can see or measure that would explain that degree of pain, then using narcotics is medically correct in any age group.
DrWaters> Does your pain keep you from doing things you want to do? Have other treatments failed to relieve the pain? Does the pain wake you from sllep? These are indications for narcotic pain killers.
InsightHostKJ> We all qualify then! LOL
TRANSAM> yup
gwyn> yup
DrWaters> Thanks for having me. I need to get a good rest so I can crack some fibromyalgics skull tomorrow. Invite me back soon.
InsightHostKJ> LOL LOL! You're welcome back anytime! Thank you Dr Waters....As he goes into the office with an ax in his hand tomorrow
IndyRon> Nite Dr Waters, thank you
higgy> Thanks Doc
Betty> Thank you doctor
swimmer> Thanks Dr. Waters
Melanie> Thanks again and good night
Guest49> Thank you Dr. Waters.
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