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Neo
26th April 2011, 08:51 PM
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Just diagnosed with rheumatoid arthritis (RA)? Asking the right questions (and understanding the answers) will help you get the best treatment. Read on for our office visit “cheat sheet”...

New medications are changing the way doctors are treating rheumatoid arthritis, making the chronic, incurable disease easier to control.

"You don't have to look forward to a future with disability," says Bevra Hahn, M.D., chief of rheumatology at the University of California-Los Angeles Medical Center. "Highly targeted therapies developed in the past 12 years help prevent damage in the joints."

To get the best possible care, it’s important to be an informed patient. Here are 14 key questions to ask during your office visit:

1. I think I have symptoms of RA. What diagnostic tests will the doctor order, and what do the results mean?
There's no single test for RA. If you have symptoms – warmth, swelling and pain in the joints – your doctor will order blood work that tests for one or more of the following:

* Rheumatoid factor (RF). Only 30% of patients test positive for this antibody at the start of arthritis, but eventually it’s found in 80% of patients.

* Cyclic citrullinated peptid (CCP). Patients who test positive for this antibody and RF are more likely to develop a more severe form of rheumatoid arthritis.


Your doctor will also do a blood test for anemia and an elevated “sed rate” (erythrocyte sedimentation rate), which can confirm the amount of inflammation in the joints.

X-rays, MRIs and ultrasounds won’t show any changes in the first 3-6 months of the disease. They can be used later, however, to track changes in the joints.

A physical exam is also part of the screening process, looking for, among other symptoms, a joint swelling and inflammation, their location and bumps and nodules.

2. I’ve been diagnosed with rheumatoid arthritis. What’s my next step?
“The most important thing is to start treatment,” Hahn says.

If you start a treatment program as soon as you’re diagnosed, you’re less likely to need surgery – for example, joint replacement – in the future, says Leslie Crofford, M.D., chief of rheumatology and director of the Center for the Advancement of Women’s Health at the University of Kentucky in Lexington.

3. What's the treatment?
The latest RA medications are disease-modifying antirheumatic drugs (DMARDs), such as methotrexate, and biologics, which are administered by injection.

DMARDs slow or stop joint destruction over time. Biologics – newer medications that are derived from living substances – act directly on the immune system, inhibiting proteins that contribute to inflammation.

“Most of the time, we start a patient with RA right away on a medication like methotrexate,” Crofford says.

4. What are my options if methotrexate doesn’t work?
Methotrexate takes 3-6 weeks to begin working. If you’ve been taking it longer and your symptoms haven’t improved, your doctor may add another oral medication, such as prednisone, a steroid to reduce inflammation. The latter’s side effects include weight gain, irritability, jitteriness and fluid buildup.

Or your physician may prescribe a biologic.

“We usually don’t start with biologics because they’re very expensive and have to be given by injection,” Crofford says.

5. What results can I expect?
No matter what your treatment, the goal is to get the symptoms under control within six months after diagnosis, she says – before the disease can progress and risk damage to the joints.

This means you have less than 30 minutes of morning stiffness, no tender and swollen joints, and no markers or signs of inflammation in the blood (see below).

6. What are methotrexate’s side effects? Who shouldn’t use it?
Methotrexate, which is taken once a week, can damage the liver. You’ll need regular blood tests to monitor your liver. And it can’t be taken by patients with liver disease.

Because it affects the liver, don’t drink alcohol while on the drug.

One of methotrexate’s most common side effects is short-term nausea, but taking it with meals and a folic acid supplement might relieve that. Another option: Your doctor may adjust your dose.

7. Does RA raise my risk for other health conditions?
RA sufferers face a higher risk of heart disease. Get regular physicals so your doctor can monitor any cardiovascular issues.

Some RA medications – for example, biologics – can increase susceptibility to infection, Hahn says.

Tell your doctor right away if you have a fever or other symptoms, she says.

8. Will I eventually need surgery?
In the past 15 years, fewer people are having joint-replacement surgery (also called “arthroplasty”) – where a damaged joint is replaced with a synthetic one, Crofford says. That’s thanks to new medications, which stop RA’s progress and reduce joint damage.

“My goal with new patients is to control their RA so they never need surgery,” she says.

9. What if I still need surgery?
There have been tremendous advancements in both the surgical techniques and the implants, according to Crofford.

“Both are better than just a few years ago,” she says.

Besides joint replacements, these surgeries sometimes relieve arthritis pain:

* Arthrodesis (also called “fusion”). The joint is removed and bones are fused, sometimes using bone grafts from the pelvis. It increases stability and relieves pain, and is usually done for ankles, wrists, fingers and toes. It’s an effective way to eliminate pain, but can restrict motion. Recovery time varies, depending on where the surgery is performed. It can take up to 12 weeks, for example, before you can bear weight on a fused ankle.

* Tendon reconstruction. Damaged tendons are repaired, either by sewing torn ends together or attaching an intact tendon from another part of the body to them. It can help restore hand function. Recovery is about six weeks. Build-up of scar tissue at the site of surgery can lead to some loss of range of motion.

* Synovectomy. Inflamed synovial tissue (soft tissue within the joints) is removed. This surgery is an option if you don’t respond to medications after 6-12 months. It can restrict range of motion, however, and sometimes joint inflammation can return.


10. Will supplements ease my symptoms?
Increase your intake of omega-3 fatty acids by eating more fish or taking a fish oil supplement, Crofford advises.

The fatty acid effectively reduced pain in RA patients, according to a 2007 meta-analysis by York University in Canada.

“Omega-3 fatty acids reduce inflammation, so I usually recommend RA patients take 2,000-4,000 mg of EPA [eicosapentaenoic acid] and DHA [docosahexaenoic acid] combined,” she says.

11. Will foods or losing weight relieve symptoms?
Some foods may reduce inflammation, Crofford says, but shouldn't replace drug therapy.

“Fruits like pomegranate and blueberries, as well as certain vegetables and spices, like curry powder and garlic, have been shown to have anti-inflammatory properties,” she says. “Just go to the produce aisle and look for fruits and vegetables with lots of different colors.”

And stay as close as possible to a healthy weight. “Every pound you lose unloads the weight on your knees – and possibly hips – by tenfold,” Hahn says.

12. What else can I do to ease symptoms?
“For people with RA, exercise is necessary,” Crofford says.

Studies show that aerobic exercise helps reduce RA pain and swelling, Hahn says.

For example, a 2007 study of 220 adults at the University of Kansas Medical Center found that those who participated in an exercise program had less pain, depression and fatigue.

13. How can I start exercising when it’s so hard to move?
“If your joints hurt and you can’t bear weight on them, start with warm water aerobics,” Crofford suggests.

Also, ask your doctor to refer you to a physical therapist, who can develop a plan to build strength and aerobic fitness.

Above all, choose a physical activity you enjoy and that you can do year-round, Crofford says.

But keep in mind: Just as it’s possible to take too little – or too much – medication, you can over- or under-exercise.

“Pace yourself so you don’t get tired and aggravate your RA,” Crofford says.

14. How do I start exercising?
Walk on flat ground at a rapid pace for as long as you can every day without becoming exhausted, she advises. Then, very slowly, increase your time.

But factor in your other daily activities.



Source: Lifescript