Ask the Expert: Rheumatoid Arthritis

David Curtis, M.D.

Rheumatoid arthritis (RA) is a chronic autoimmune disease. It is characterized by joint pain, swelling, stiffness, and an eventual loss of function.

While more than 1.3 million Americans suffer from RA, no two people will have the same symptoms or the same experience. Because of this, getting the answers you need can sometimes be difficult. Fortunately, Dr. David Curtis, M.D., a licensed rheumatologist based in San Francisco is here to help.

Read his answers to seven questions asked by real RA patients.

Q: I’m 51 years old and have both OA and RA. Will Enbrel help control my OA or is it just for RA symptoms?

Coexistence of osteoarthritis and rheumatoid arthritis is common since we all will develop OA to some degree in some, if not most, of our joints at some point in our lives.

Enbrel (etanercept) is approved for use in RA and other inflammatory, autoimmune illnesses in which it is recognized that the TNF-alpha cytokine plays an important role in driving the inflammation (pain, swelling, and redness) as well as the destructive aspects on bone and cartilage. Although OA has some elements of "inflammation" as part of its pathology, the cytokine TNF-alpha does not seem to be important in this process and therefore TNF blockade by Enbrel does not and would not be expected to improve the signs or symptoms of OA.

At this time, we do not have "disease modifying drugs" or biologics for osteoarthritis. Research in OA therapies is very active and we can all be optimistic that in the future we will have potent therapies for OA, as we do for RA.

Q: I have severe OA and was diagnosed with gout. Does diet play a role in OA?

Diet and nutrition play a key role in all aspects of our health and fitness. What may seem complicated to you are the apparent competing recommendations for these different conditions. All medical problems can benefit from a "prudent" diet.

Although what is prudent can and does vary with the medical diagnosis, and the recommendations by physicians and nutritionists can change over time, it is safe to say that a prudent diet is one that helps you maintain or achieve an ideal body weight, relies on unprocessed foods, is rich in fruits, vegetables, and whole grains, and restricts large amounts of animal fats. Adequate protein, minerals, and vitamins (including calcium and vitamin D for healthy bones) should be part of every diet.

While completely avoiding purines is not necessary or recommended, patients taking medication for gout can restrict purine intake. It is recommended to eliminate foods that are high in purines and reduce intake of foods with moderate purine content. In short, it's best for patients to consume a diet comprised of low-purine foods. Complete elimination of purines, however, is not recommended.

Q: I’ve been receiving Actemra infusions for 3 months, but haven’t been feeling any relief. My doctor wants to order a Vectra DA test to see if this medication is working. What is this test and how reliable is it?

Rheumatologists use clinical examination, medical history, symptoms, and regular laboratory testing to assess disease activity. A relatively new test called Vectra DA measures a collection of additional blood factors. These blood factors help assess the immune system's response to disease activity.

People with active rheumatoid arthritis (RA) that aren't on Actemra (tocilizumab Injection) will typically have elevated levels of interleukin 6 (IL-6). This inflammatory marker is a key component in the Vectra DA test.

Actemra blocks the receptor for IL-6 to treat the inflammation of RA. The level of IL-6 in the blood rises when the receptor for IL-6 is blocked. This is because it's no longer bound to its receptor. Elevated IL-6 levels don't represent disease activity in Actemra users. They. It just shows that a person has been treated with Actemra.

Rheumatologists have not widely accepted Vectra DA as an effective way to assess disease activity. Vectra DA testing isn't helpful in assessing your response to Actemra therapy. Your rheumatologist will have to rely on traditional methods to assess your response to Actemra.

Q: What are the dangers of going completely off all medications?

Seropositive (meaning the rheumatoid factor is positive) rheumatoid arthritis is almost always a chronic and progressive disease that can lead to disability and joint destruction if left untreated. Nevertheless, there is great interest (on the part of patients and treating physicians) in when and how to reduce and even stop medications.

There is a general consensus that early rheumatoid arthritis treatment produces the best patient outcomes with reduced work disability, patient satisfaction and prevention of joint destruction. There is less of a consensus on how and when to reduce or stop medication in patients doing well on current therapy. Flares of disease are common when medications are reduced or stopped, particularly if single medication regimens are being used and the patient has been doing well. Many treating rheumatologists and patients are comfortable reducing and eliminating DMARDS (such as methotrexate) when the patient has been doing well for a very long time and is also on a biologic (for example, a TNF inhibitor).

Clinical experience suggests that patients often do very well as long as they stay on some therapy but frequently have significant flares if they stop all medication. Many seronegative patients do well stopping all medications, at least for a period of time, suggesting that this category of patients may have a different disease than the seropositive rheumatoid arthritis patients. It is prudent to reduce or stop rheumatoid medications only with the agreement and oversight of your treating rheumatologist.

Q: I have OA in my big toe and RA in my shoulders and knees. Is there any way to reverse the damage that’s already done? And what can I do to manage muscle fatigue?

Osteoarthritis (OA) in the large toe joint is extremely common and affects almost everyone to some extent by the age of 60.

Rheumatoid arthritis (RA) can affect this joint as well. Inflammation of the lining of a joint is referred to as synovitis. Both forms of arthritis can result in synovitis.

Therefore, many people with RA who have some underlying OA in this joint find substantial relief from symptoms with effective RA therapy, such as medications.

By stopping or reducing the synovitis, damage to the cartilage and the bone is also reduced. Chronic inflammation can result in permanent changes to the shape of the bones. These bone and cartilage changes are similar to the changes caused by OA. In both cases, changes aren't significantly "reversible" with treatments that exist today.

The symptoms of OA can wax and wane, become worse over time, and become aggravated by trauma. Physical therapy, topical and oral medication, and corticosteroids can help ease symptoms significantly. However, taking calcium supplements won't influence the OA process.

Fatigue can be associated with various medications and medical conditions, including RA. Your doctor can help interpret your symptoms and help you plan the most effective treatment.

Q: At what point is it acceptable to go to the ER for pain? What symptoms should I be reporting?

Going to a hospital emergency room can be an expensive, time-consuming, and emotionally traumatic experience. Nevertheless, ERs are necessary for people who are severely ill or have life-threatening illnesses.

RA rarely has life-threatening symptoms. Even when these symptoms are present, they're very rare. Serious RA symptoms such aspericarditis, pleurisy, or scleritis are rarely "acute." That means they don't come on quickly (over a matter of hours) and severely. Instead, these manifestations of RA typically are mild and come on gradually. This allows you time to contact your primary doctor or rheumatologist for advice or an office visit.

Most emergencies in people with RA are associated with comorbid conditions such as coronary artery disease or diabetes. Side effects of the RA medications you're taking — such as an allergic reaction — can warrant a trip to the ER. This is especially true if the reaction is severe. Signs include high fever, severe rash, throat swelling, or trouble breathing.

Another potential emergency is an infectious complication of disease-modifying and biologic medications. Pneumonia, kidney infection, abdominal infection, and central nervous system infection are examples of acute illnesses that are cause for an ER evaluation.

A high fever may be a sign of infection and a reason to call your doctor. Going directly to an ER is wise if any other symptoms, such as weakness, trouble breathing, and chest pain are present with the high fever. It's usually a good idea to calling your doctor for advice before going to an ER, but when in doubt, it's best go to the ER for a rapid evaluation.

Q: My rheumatologist said hormones don’t affect symptoms, but every month my flare-ups coincide with my menstrual cycle. What’s your view on this?

Female hormones can affect autoimmune-related illnesses, including RA. The medical community still doesn't completely understand this interaction. But we do know that symptoms often increase before menstruation. RA remission during pregnancy and flare-ups after pregnancy are also mostly universal observations.

Older studies have shown a decrease in RA incidence in women who took birth control pills. However, current research hasn't found convincing evidence that hormone replacement therapy can prevent RA. Some studies have suggested that it may be hard to differentiate between normal pre-menstrual symptoms and an RA flare-up. But associating a flare with your menstrual cycle is probably more than a coincidence. Some people find that it helps to increase their short-acting medications, such as nonsteroidal anti-inflammatory medication, in anticipation of the flare-up.

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