Home Community Chat Transcripts-8/21/00

DMARDs with Dr. Barry Waters M.D.

InsightHostKJ> Tonights guest is Rheumatologist Dr Barry Waters and our topic is DMARDs, please type a ? if you have a question and wait to be called on

InsightHostKJ> Please keep questions focused on DMARDs if possible!

Melanie> Mtx - If you have flares as a result of mtx, what are your alternatives?

DrWaters> Usually add medicines to MTX. Prednisone. Plaquenil and Azulfadine. Enbrel or Remicade. Etc.

Melanie> Can't take plaquenil or Sulfasalazine. Will probably look at others. thanks.

InsightHostKJ> If someone failed Enbrel do you consider remciade an option?

DrWaters> Yes. Remicade dose is more flexible. Start at 3mg/kg every 8 weeks and can go up to 5 or 6 mg/kg every 4, so might work when Enbrel dosen't.

Melanie> Just wondered what is the difference in how Enbrel and Remicade work?

DrWaters> Enbrel you're sort of stuck if 25mg 2x per week dosen't work.

DrWaters> The work the same in that they both block TNF-alpha. Remicade is a large molecule and Enbrel is a small molecule and they block it in slightly different ways.

DrWaters> Remicade is antigenic and must be used with another immunosppressant. Enbrel can be used alone.

swimmer> been on enbrel since June, felt great soon after, now not feeling so good. How do I know if Enbrel is still working?

DrWaters> Basically you go by your symptoms. Sometimes it seems to stop working.

swimmer> so soon?

DrWaters> Unlikely.

Donna> I have been on plaq for over 10 years and lately it doesn't seem to be working as well

DrWaters> If even slightest chance of active inflam. I'd add another DMARD.

Betty> Is there any data on how long Enbrel will work?

DrWaters> It's believed to work forever in most patients, though purely conjecture, obvioulsy.

Giggles> Is Pred the most effective treatment for SLE still or is there something with less side effects ?

DrWaters> Pred is worst treatment for SLE. SLE should be treated with DMARD's like RA

Giggles> oh ok thanks, I am on a host of others as well, but Dr said the pred was for treatment of the Lupus

oops> I have a very stupid question. What EXACTLY are DMARD's?

InsightHostKJ> No stupid questions oops! they are all important!!!

DrWaters> No one knows. It is a secret code.

InsightHostKJ> LMAO

oops> no, really?

InsightHostKJ> Disease Modifying Anti Rheumatic Drugs

DrWaters> DMARD's are medicines that seem to actually put RA or other AI disease into remission and not just cover up the symptoms, but in reality it's not so clear-cut.

InsightHostKJ> If you have a history of Gi bleeds can azulfadine iritate the GI tract?

DrWaters> No.

panda> I was on MTX for 4 months it didnt seem to help much but about 10 days after i stopped i got a lot worse and have stayed that way

DrWaters> MTX almost always helps to a degree. I usually add other med's without stopping MTX. Now you know why.

InsightHostKJ> In your opinion what is the "best" DMARD?

DrWaters> All things considered, MTX. In future if cheaper and in more convenient form, probably Enbrel.

Guest100> Can you become immune to metho? MEaning it isn't as effective over time?

DrWaters> Not common to become immune to MTX. Most patients worsen when it's stopped even if they thought it wasn't helping. Probably arthritis was getting worse, not MTX working less.

panda> do DMARDs help all of the innflammatory arthritis's

DrWaters> DMARD's work less in Ankylosing Spondylitis and Reiter's. Work a little less in Psoriatic. Work best in RA.

jimmy> I've been on remicade for 2 treatments and it is working great.My RA is reducing the preizone and MTX.Will I ever be able to get completely off MTX

DrWaters> On Remicade you have to also be on MTX, Arava or Immuran. It's the rule.

Melanie> I've wondered about that. The RA worsening as opposed to the DMARD having less effectiveness. Is that common?

DrWaters> Yes. Medicines are honest and reliable. It's people that are the problems.

InsightHostKJ> LOL....but at least we are good at something!

Melanie> (keep the doctors challenged) lol

DrWaters> It's what makes us interesting.

Guest100> MTX originaly put my PA in remission. I just has my second child and I can't get the arthritis into remission. If fact the psoriasis part has really flared up. I am frustrated.

DrWaters> Can go up to 9 pills of MTX and if that dosen't work I usually add Endrel for psoriatic.

Giggles> we have to keep increasing my doses of MTX, but it has also caused luekopenia, why increase when it seems to be causing more problems, I am also on Arava, Slaz, Plaq, pred etc

DrWaters> What's slaz?

Giggles> slazapyron,

Giggles> sulphasalasine

DrWaters> Giggles is a foreigner.

Giggles> I dont know what you guys call it

Giggles> yep, I admit it, I from mars

InsightHostKJ> that i beleive Giggles! LOL

panda> what about in undifferentiated spondyloarthropathy and DMARDS?

Angelblue> Dr. Waters, I have just benn diagnosed with RA and i am new to all the treatments. My question is if i continue to get kidney infections with the MTX and Pred will my Dr. likely keep me on these drugs or change it when the trial period is over?

DrWaters> OK, no more ? for a minute so I can catch up.

InsightHostKJ> hee hee we finally got him!

DrWaters> If problems from MTX or other DMARD we back off and try other combo's.

DrWaters> 2 - MTX and pred don't cause kidney infections.

Giggles> but the MTX seems to be controlling it

Giggles> but only in the larger doses

DrWaters> 3 - spondylarthropathy type arthritis responds more poorly to MTX then other arthritis types. Strongly recommend Enbrel for that. It's incredible for the HLA -B -27 stuff.

DrWaters> If you're having problems from MTX have your doctor add Leucovorin 5 mg the day after you take the MTX and stop your folic acid.

Angelblue> My Dr. stated something to me about a count of 1-10 being one type of range and mine being 821. I don't know what he was talking about, because i became quite depressed when i heard the verdict. Do you know what he might have been telling me?

DrWaters> Not your IQ?

DrWaters> Probably your RF BUT ASK HIM!

jimmy> Are Arava and Immuran also hard on the liver?

DrWaters> jimmy - yes.

swimmer> any exciting new DMARDS for us to try soon?

DrWaters> Lot's of new interleukin inhibitors on the horizon. You will all have to find something else to complain about.

InsightHostKJ> wouldnt that be great!

barbtoo> Have you seen good results with Mobic for pts with Ra and Lupus?

DrWaters> My wife says it's much better then Vioxx for her tennis elbow. I took it for sore muscles from too much weight lifting and it gave me terrible tinnitus. Doubt if any bettewr then ibuprofen.

oops> I have had swelling since 12. Diagnosed at 12. I am told I have Ankylosing Spondilitis. I am also told I have RA. Why is my swelling continual? And what is my diagnosis, then?Arthro started swelling in knees and limiting hips. Now swelling everywhere.Doc says it originated in spine. 

DrWaters> People with ank spond can have RA-like arthritis, too. Hard to treat. Strongly recommend Enbrel. If that dosen't work then add sulfasalazine and/or MTX.

barbtoo> sigh.......can't seem to get a DMARD that is helpful

DrWaters> If no DMARD's help might not be RA. Try combinations first like MTX + Arava or MTX + Enbrel. Also always try doxycycline in resistant RA. SOmetimes it works when others don't. Can use Imurran, Cyclosporin, Prosorba, etc. in resistant RA, too. Never give up.

panda> is enbrel as useful in B 27 negative?

DrWaters> If ankylosing spondylitis like illness, yes.

wilma> what side effects on imurran? is cancer one of them?

DrWaters> Very unlikely that Imurran causes cancer.

wilma> can it after being on cytoxan?

DrWaters> Cytoxan can definitely cause cancer. Often stop cytoxan as soon as possible and change to Imurran to decrease cancer risk. I've had very good luck doing that with my lupus nephritis and Wegener's patients.

Guest172> When might the first of the interleukin inhibitors hit the market?

DrWaters> Enbrel and Remicade are interleukin inhibitors as TNF is an interleukin. Inhibitor of interleukin 7 and 10 expected in next 5 years.

I<i>nsightHostKJ> And those may work better than enbrel and remicade?

DrWaters> Or maybe it's 5 and 8. Anyhow, they'll be used in combinations.

DrWaters> Not better, additional, as far as I know.

DrWaters> They're also working on inhibitors of the enzymes that degrade cartilaage

InsightHostKJ> cool!

DrWaters> Lot's of cool stuff. Though I'm sure it'll all be unaffordable.

InsightHostKJ> arent they all...sad but true

DrWaters> They need to nationalize the pharmaceutical industry.

InsightHostKJ> they need to do something...

DrWaters> They need to either simplify or lighten-up on spelling.

InsightHostKJ> LMAO Dr Waters....tell me about it!

panda> what about arava? that is just new to australia

DrWaters> Arava is effective but a lot of people have side effects like itchy, dry skin, hair loss and diarrhea. Also stays in your system for YEARS which is a little creepy. But works well and serious side effects are like MTX, relatively uncommon.

Angelblue> Dr. Waters if my RA gets under control will I be able to continue doing the hard physical work i do for a living without it hurting me more or should i get ready for a career change. I work on highway construction!

DrWaters> If RA under control there's no need to give up hard physical work. At least you won't be getting heart attacks soon like the rest of us.

jimmy> How long will MTX stay in your system

DrWaters> We say no getting pregnant for 3 months but out of system in a few weeks.

jimmy> Pregnantcy not a problem here lol

DrWaters> No impregnating either.

InsightHostKJ> Dr Waters I think you missed jimmy's other question....what is the lowest dose MTX you can use with remicade?

DrWaters> 3 pills in a normal person, 2 in a tiny old one.

Guest172> Mtx with Remicade. Must it be taken weekly or can one take it just around infusion time?

DrWaters> Weekly.

Guest172> If one cannot take MTX, what else would do the same in relation to the Remicade?

DrWaters> Arava or Imurran.

Melanie> Backtracking a bit: Is Mobic a DMARD? I thought it was a NSAID or like one.

DrWaters> Mobic is an NSAID. Supposed to be similar to Voltaren.

Guest172> Can the lowest doses of Arava (10 mg) and Imuran (?) do the trick?

DrWaters> I would try that. Arava 10mg or Imurran 50mg.

DrWaters> Let's take a minute to reiterate the Dr Waters simple approach to RA.

InsightHostKJ> go for it!

Guest172> Simple approach?

DrWaters> At the beginning start Doxycycline and Methotrexate. After 6 months can try stopping Doxy. If things don't go well add Enbrel or Remicade. If things still don't go well add other meds like Plaquenil or Azulfadine. Most patients do best on 5 mg or so of pred daily too. Avoid NSAID's. And that's it!

InsightHostKJ> Sounds like a good approach to me!

Melanie> Wow! That needs to be sent to all rheumys. LOL

Shug> I do well on remicade and mtx and 6 mgs of pred..why does my doc want me off pred so bad?

Shug> I rode bike 6 miles two weekends in a row...yeah whooooooo

DrWaters> Pred OK if take Fosamax or Actonel, too, keep weight down, etc. Just no more then 7.5 mg. 6 mg is OK.

Guest172> Except if one cannot take the corticosteroids, what in place of them?

DrWaters> If can't take pred then I might give in and try an NSAID. But not a good situation. You really need to change diseases then.

Melanie> ROFL

InsightHostKJ> ROFL

InsightHostKJ> Thanks Dr Waters!

Guest172> I would love to change diseases but no one is paying attention to my desires.

InsightHostKJ> Night Dr Waters! Thanks again!

Angelblue> Thanks again!

Katie> thank you Dr.Waters

Nicole> Thanks Dr. Waters

If you didn't get to ask Dr. Waters a question you can always send it to him via experts@arthritisinsight.com