Home Community Chat Transcripts-8/28/00

Juvenile Arthritis with Dr. Thomas Lehman

I<i>nsightHostKJ> Our guest tonight is Dr Lehman-Guest 3 in disguise

InsightHostKJ> And we'll be discussing juvenile arthritis. Please hold all general conversation

InsightHostKJ> Dr Lehman, would you tell us a little about yourself?

Guest3 Sure

Guest3 I'm a pediatric rheumatologist teaching at the Hospital for Special Surgery in New York City

Guest3 I've been doing this for 20+ years, the last 13 in NY

InsightHostKJ> You've seen a lot of kids then!

Guest3 Lots, of kids. It's what I do.

InsightHostKJ> Any advice for parents before we start?

Guest3 I think the most important thing for parents to understand is that there is no perfect advice

InsightHostKJ> makes sense to me

Guest3 Every child is different, Every family is different. In addition it is important to remember that arthritis is a family affair. Only one child may have the arthritis, but every family member is affected by it. If anyone is left out of the 'loop' everyone suffers.

InsightHostKJ> Ready to start with questions?

Guest3 Any time

InsightHostKJ> I'll ask the first question. If you have a question type "?" and wait until you are called on. Dr. Lehman, I have RA, my daughter was diagnosed JRA three years ago. After six months all her synptoms disapeared. How likely is it that they will never return?

Guest3 It is always difficult to predict the future. Dr's crystal balls are only a little better than everyone else's

InsightHostKJ> Can JRA go away and never come back?

Guest3 A lot depends on the type of arthritis and the laboratory values

Guest3 Typical pauciarticular JRA in a young child often goes away and stays gone. Most of the other types aren't so clear

InsightHostKJ> it was pauci..but can you clearify what that means? pauci, poly , etc

Guest3 In the old nomenclature, JRA was divided by the number of joints involved during the first six months of disease. 4 or less is pauci, more than 4 poly, if fever and rash systemic JRA

Guest3 Now as we understand JRA better, we know there is more to it. For example pauci shouldn't involve fingers or toes

Guest3 Pauci often goes away. Poly rarely does - but some 'poly' is really reactive arthritis which does go away. Systemic onset JRA is very variable. Some goes away and some stays and is awful.

InsightHostKJ> Thank you! Ok SHU go ahead

SHU> ? My daughter has been in remission for 3 years. Her eyes flared recently-her ankle hurts-sed rate 4. Could she be flaring?She was pauci, ANA + with bilateral knee swelling and multiple joint pains during her original flare.

Guest3 It's difficult in a situation like this to be sure. Eye disease and arthritis don't always flare together. The sed rate is often helpful, but sometimes it is misleading. Is the ankle pain in the morning with stiffness?

SHU> It seems to brought on by activity.

Guest3 That would suggest it is her arthritis. Pain with walking alot, may be mechanical damage not active disease

Guest3 Sorry it is stiffness that suggests active disease

SHU> Thanks

peanut> my daughter has a positive RA factor is was just diagnosed in january she is 12 she has polyarticular does the factor mean that it will always be and always bad? It is also hard when she treats her brother mean i think that its because he is not sick (both children are adopted) also is JRA of this type hereditary? also people talk of flares...my daughter always has some type of stiffness or pain so what really is a flare?

Guest3 In general RF positive disease in children is the early onset of 'adult type' disease. It is riskier, but it doesn't have to be bad. As far as behavior goes. You have to treat children with arthritis just as if they didn't have it. If you let the discipline slack you and they will regret it forever

peanut> she resently had to have her hands injected ...she could not bend them will this do away with her hand & wrist problem?

Guest3 Injections tend to make things better. Sometimes the benefit lasts forever, but other times it wears off. Can't predict

peanut> what do you suggest for medicine to stop deformatie in a 12yrold?

Guest3 This is a tough question. The doctors don't all agree on the answer, so I can only give you mine

Guest3 I'm from the 'old days' when we gave a lot of gold shots. They are the only thing that I've seen do a really good job on RF+ disease in kids

Guest3 However, most Drs now give methotrexate. Enbrel is the new big drug and it see ms to work wonders, but we don't know how long the affect is going to last

SHU> My daughters aunt-paternal had Lupus-I know she was ANA positve. Ire there any proof of Rheumatoid diseases being hereditary

Guest3 All of the rheumatic diseases occur with a greater than expected frequency in close relatives. It is roughly 1/50 as opposed to 1/1000 or more in the general population. To that degree it is hereditary, but there is no single gene to look at

TEXAS> 12 yr old daughter has bad poly jra with severe mouth ulcers.....???????cause and best treatment?

Guest3 Mouth ulcers are not normally from the JRA. They can come from methotrexate and other drugs. What is she taking

TEXAS> mtx

Guest3 Is she taking folic acid. That often cuts down on mouth ulcers and other complications from MTX

TEXAS> sorry, don't have details.......was going to try to help her mom

Sharon> My 6yr old daughter was just diagnosed by her ped last week, we haven't been to the rheumatologist yet. There's no rheumatologist in our area that is board certified as pediatric, but there are rheumatologists that see children. I may be able to go out of town to see a ped specialist - is it something I can/should fight with my insurance about? We're in the Phoenix area.

Guest3 This kind of question is difficult becuase of course I am biased. I think a specialist can often provide a lot of information and answers that the adult rheumatologist can't

Guest3 I would fight with my insurance to get me to someone pediatric for at least periodic monitoring. Los Angeles or Las Vegas both have pediatric rheumatologists. There are also some people in Tucson, but I'm not sure if they are 'board certified.'

Sharon> Yes, Tucson was where we were going to go. Thank you.

oops> You mentioned reactive arthritis, could you please elaborate on the description for that form of this disease?

Guest3 Reactive arthritis is also known as 'infection associated arthritis' often it follows a viral infection. It can look very bad at first, but it goes away over 3 - 6 months in most cases. If you're still sick after a year, it wasn't reactive no matter what the doctor thought.

InsightHostKJ> Do you feel there is a relationship between vaccinations and RA or JRA?

Guest3 This is a very difficult question. Arthritis often starts in young children. Young children are getting shots all the time. Therefore the arthritis often starts soon after a shot.

Guest3 Most doctors think it is a coincidence. However, some shots are known to cause arthritis, so it's not that simple. There is a committee working on this problem. They've been working for several years and still haven't delivered a report.

InsightHostKJ> My concern is that I feel the Hep B was major trigger for my onset...I am afraid it may trigger another episode in mydughter if she gets it

Guest3 I wouldn't give my child a shot of something she got just before her arthritis started. However, if you got the shot and got worse it may not mean anything for your daughter. These are questions we can't answer. I generally try to work with my patients and give them options and 'best' opinions

InsightHostKJ> Thank you Dr Lehman...Sassy go ahead

sassy> Can you explian any connection between ra and kidney problems-Chronic infections and always blood in urine

Guest3 Kidney problems in arthritis patients can be due to the arthritis or the medications. The medications are a more common cause. The NSAIDs interfere with renal blood flow and cause all sorts of problems in a small number of people.

Guest3 That said. There are people who get kidney disease which comes from RA or JRA. Very few however.

Guest3 There is no direct association with chronic infections unless the arthritis is so bad you can't maintain proper hygene.

oops> My diagnosis was at the age of 12. Now I am 23. I had a rash at the age of 10 years old. It matches the description of the "RA rash". I also experianced a fever around the same time that showed up out of the blue. Parents never sought physician's help until I showed signs of swelling in knees. I have been told I have Ankylosing Spondilitis. I am not sure what my diagnosis should be. Arthritis has caused swelling in every major joint now. My sed rate remains high

oops> What do you think I have?

Guest3 That's difficult to answer without actually examining your records and being your doctor. It is possible the rash was a coincidence. OR that it was a viral infection which triggered AS. Another option is that it is systemic onset JRA that was missed

oops> I see, thankyou, I know you can only do so much through the computer, thank you

peanut> would a flu shot be a bad idea for my 12yr old to get this year? she never had one before but i'm afraid she will get sick this winter. also she has a hard time eating she takes motrin now... we see the rheumatologist this friday in hopes of getting a different medicine. we had to wait until the insurance approved the visit. again what constitutes a flare?er

Guest3 FLu shots are controversial because of the possible role of vaccinations in stirring up the immune system and causing more arthritis. Some doctors want all their patients to have the flu shots. Others tell there patients to avoid them.

Guest3 A flare is a period of your disease being worse. No more or less

peanut> what do you suggest to your patients?

Guest3 I'm on the no flu shot band wagon. However I know if you put 20 doctors in a room it would divide 10 and 10. No one knows who is right

oops> I have heard that Ankylosing Spondilitis IS a form of RA, I have also heard that RA and AS are two different diseases, can you please help clear this up for me?

Guest3 The world is made up of people who group things and people who split them up. I think RA and AS are two very different diseases. The outcomes are different and the best medicines are different. Even so many of the problems and many of the medicines are the same. When we understand everything (if ever) I think we'll see that there are several different genes involved some of which overlap.

barbtoo> our 8 year old granddaughter was diagnosed with Ra at age 6. As I have Ra and SLE, I wondered if this Ra is "genetic"? I really feel guilty sometimes about her having it too.

Guest3 This is a very common qeustion. None of this is directly genetic, but all of it occurs more often in relatives of someone who has it. The best answer is that the predisposition is genetic. However, it's not enough. Something else has to happen to get the disease. It's like giving someone a lottery ticket. They might win, but most lose. This is just in reverse

SHU> My daughter always has microscopic blood in her urine. Her DR says it has to do with the Calcium ration, and is common in JRA kids. It still exits while in remission.Do you agree that this condition is correctly diagnosed and should be followed by a specialist?

Guest3 There are clearly children with JRA who have episodic hematuria (blood in the urine). This has been well described since the 60s. No one has ever found a complete explanation. I would do the routine testing and then stop if eveything comes out okay.

woodenboy> i have ra and my hemoglobin is 92 is that low and is this common in persons with ra, even when the ra seems to be under control somewhat with medication

Guest3 I'm not sure what scale you are using. Normal hemoglobins are in the 10 - 15 gms/dl range. IF you are using a Canadian scale and 92 translates to 9.2 in my terms then yes it is low. This is common in RA. However if the RA is under control then other explanations need to be investigated.

InsightHostKJ> woodenboy are you in Canada?

woodenboy> yes i am from canada why

InsightHostKJ> That explains the numbers you used...go ahead with your other question woodenboy

woodenboy> i just wanted to say that i saw a blood doctor and he did other tests and concluded that it was anemia of chronic disease. my esr is high does that mean the ra is active

Guest3 A high ESR can mean many things. Just being anemic will make the ESR go up. Can't really fully answer your question.

owie> You have been treating JRA for years, what are the the greatestest advances you have seen

Guest3 There are a number of important advances in the last 25 years. First there are many more pediatric rheumatologists. Second the peds rheums are more aggressive. It used to be don't do anything that might cause harm. Now we know we have to put the fire out. As a result I rarely have patients in wheel chairs or chronic rehabilitation hospitals anymore. Total hip replacement, methotrexate, Enbrel. All have been great.

InsightHostKJ> Thats it...no more questions...times up

Guest3 One quick plug. I have a lot of answers to usual questions at http://www.goldscout.com 

InsightHostKJ> Great site!!!!

Guest3 Thanks for being such a good audience. Good health to everyone.

InsightHostKJ> Thank you so much Dr Lehman for being here!

owie> thanks doc

InsightHostRon> Thank you for an excellent Session Dr Lehman...Very informative, please come back

Guest3 My pleasure. I'm off to bed. It's 10:30 on the east coast

InsightHostKJ> Sleep well!

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