The Q&A page

The Q & A page
	Common Questions and Answers : by drdoc on-line

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Amitryptiline in chronic pain

Question : I have been started on 25mg of amitryptiline at night on top of my normal drug routine.
But I am not depressed, can it help me ?

Answer from drdoc : I find amitryptiline extremely useful for chronic pain from a variety of causes, especially soft tissue rheumatism.
See http://www.arthritis.co.za/fibromyalgia.html . I use LOW DOSE , starting at 10mg , possibly increasing to 25mg taken 1/2 hr before bedtime. It is not used for depression at this low dose, but rather as a pain modulator, and also for its properties in prolonging stage 4 sleep. I always warn my patients, that they are going to feel "odd" for the first 3-4 days, and that the side effects in that time are unpredictable, but I try and encourage them to keep on to get through that early phase. Benefits usually take 3-4 weeks to really notice.

Anti-inflammatory drugs (NSAIDs)

Question : What exactly is the arthritis medicine called an anti-inflammatory / NSAID's ?

Answer from drdoc : NSAIDs are non steroidal anti-inflammatory drugs.
They are a class of drug that interferes with the production of inflammatory chemicals called prostaglandins by the chemical blockade of 2 enzymes, called cyclo-oxygenase 1 and 2.
Blocking cyclo-oxygenase 2 ( COX 2 )results in an anti-inflammatory action at sites of inflammation.
This is a desirable effect of the anti-inflammatory.
Blocking cyclo-oxygenase 1 (COX 1)is an undesirable event, as that enzyme results normally in protection of the stomach and kidney. Blockade of the enzyme therefore is responsible for the well known side effects of the NSAID's - i.e. gastric ulcers and kidney problems.
New NSAIDs have been designed to counter COX 2 and spare COX 1. These are due to be released soon. The companies introducing them - Searle ( celecoxib ) and Merck are in a race now to release the new drugs first. They will be able to give safe anti-inflammatory effect with almost NO side effect on the stomach and kidney.
Remember :
The NSAIDs are purely symptomatic therapeutic agents.
THEY DO NOT CHANGE THE COURSE OF ANY UNDERLYING ARTHRITIS processes.
This requires disease modifying therapy, that a rheumatologist would probably introduce if he/she was concerned about potentially damaging arthritis diseases.
Arthritis IS potentially treatable -and you should NOT see the NSAIDs as treating the cause - but really only the symptoms.
SEE : http://www.arthritis.co.za/nsaids.html

Arthritis general :

Question : My mother has arthritis and she is over 50. I was wondering, since I heard from various people there is, whether or not a cure for this condition has been found yet. I am curious about this because if there is one, then many people have then the opportunity to be relieved!!

Answer : There is always something that can be done for arthritis. However, you have to realize that there are many types of arthritis, and the therapy depends on the type. Arthritis is not a diagnosis in itself. If there isn't a cure for that type, then there is at least a control available. If you can, get her to see a rheumatologist.
There is a large amount of info on my website. However I suggest you see the "myths and facts page"
http://www.arthritis.co.za/myth.htm

Arthritis general :

Question : I have constant pain in a few of my knuckles, as if they are bruised. I cannot squeeze things tightly without pain. I am 61 years old. Could this be arthritis of sorts? What are common symptoms? Thank you.

The answer is yes - it certainly is possible. In most cases at that age, the problem is related to osteoarthritis, which is not an aggressive arthritis, and may be easily treated in the majority of patients with mild analgesics. However sometimes we find more serious inflammatory arthritis conditions. These may warrant a greater aggression of therapy. The key questions to identify that group is... a) Do you have swelling of the joints and b) Do you get symptoms of prolonged stiffness. If a or b are positive, I would seek a specialist consultation.

Arthritis general :

Question : I get a lot of pain in my right wrist and fingers. I am only 19 years old. Is this normal?

Answer : The development of arthritis is not only an "old age problem"
Indeed some of the more serious types are seen in young people.
See : http://www.arthritis.co.za/myth.htm
Things that make us concerned include in particular : Swelling, stiffness, morning stiffness.
If you are concerned - discuss your fears with your doc.

Chronic pain - especially Chronic Back Pain.

Question : I am only 35 and I am in the most excruciating low back pain, with all my tests and scans showing that there is "nothing wrong". I've been to every possible specialist and tried every painkiller and alternative therapy. I've considered suicide. Where do I go from here?

Answer from drdoc : Chronic pain is a vicious cycle, and VERY difficult to treat. In your case you sound like you have soft tissue rheumatism with facet joint syndrome and have got into the pain cycle, which most specialists have been unable to break. You have to go back to the reasons it got worse in the first place. For some reason - you are allowing it to control your life, instead of controlling it. This usually is a subconscious psychological issue. Usually it starts as a work related stress, or less likely a domestic stress.
You need to take a positive type of action.
1. Mobilize your spine - with exercise - especially aquatherapy.
2. Ask your doc about low dose amitryptiline 10-25mg nocte.
3. Ask your doc about inderal 20 mg po BD.
4. Go for some aromatherapy and massage.
5. Commence cardiovascular fitness exercises.
6. Try and reduce the valiums and pain killers aiming to stop them at 10 days to 2 weeks altogether.
7. Stop searching for different practitioners and approach your general practitioner with these concepts.
8. Consider a psychology consultation.
9. Remember - the need for a psychologist DOES NOT IMPLY THAT YOUR PAIN IS NOT REAL.
10. Persist with the exercise....
11. Avoid surgery unless there is a DEFINITE structural abnormality - which doesn't appear to be the case here.
12. DON'T GIVE UP
13. STOP grasping at straws i.e. electrical devices.
14. Don't exchange one dependence ( current drugs) for another (ie marinol / other dependence inducing drugs or other alternative therapies)
15. Remember you are going to have ups and downs - your pain will not just disappear, but will become more irritant.
16. DO NOT ALLOW IT TO CONTROL YOU.
INVERT THE RELATIONSHIP = control IT.
17. DON'T GIVE UP
18. DON'T GIVE UP
19. DON'T GIVE UP
20. DON'T GIVE UP.....

The CRP : C- Reactive protein

Question : What is the CRP ?

Answer from drdoc : The C-reactive protein, CRP is an inflammatory marker that we as Rheumatologists are using more frequently as a measure of inflammation. It is used as a guide to estimate the activity of inflammatory disease, and compliments the clinical assessment. It is a protein made in the liver, and is detectable using a biochemical assay. It is a simple and cheap blood test. However, it is NOT specific and will be elevated with many causes of inflammation - including infection. Interestingly, it is not elevated in active lupus, and is useful in assessing presence of infection there.

Foot problems

Question : I have a bone spur and arthritis in the big toe joint (where bunions occur). It's like walking on a boil. Has anyone had this and found any help for this condition?

Answer from drdoc : There are many causes of arthritis in that joint (The first metatarsal joint - MTP) ..
The commonest would be osteoarthritis, but other causes include gout. The latter would be hot and inflamed, whilst the former would be bony swelling with pain worse with weight bearing activity, much as you describe.
The treatment in the first instance for osteoarthritis of the joint is conservative - with insertion of a metatarsal dome orthotic into the shoe.
Use of soft-sole sport shoes i.e. Nike/Reebok/Saucony is often also helpful.
Analgesia is also usually indicated and may be taken BEFORE you get the pain.
(For example, if you are going to be weight bearing a lot in the day, you might find it useful to take the analgesia before you commence such activity.)
However if all these conservative measures fail, surgery is a possible solution.

Gout versus Psoriatic Arthritis

Question : I have been told that I have gout but , I also have psoriasis. How can I tell if it is truly gout or psoriatic arthritis?

Answer from drdoc : from the pattern of the disease. Gout is usually sudden onset and lasts a few days. Usually it affects few joints usually foot / toe. But obviously the longer it is allowed to go untreated - over time, becomes multiple joints, and may even be persistent. Psoriatic arthritis often comes on slower and lasts longer. To make it more complex - it is not unusual for them to coexist, (as opposed to RA where coexistence is very unusual) To absolutely prove gout if a difficult case - requires aspiration of the fluid in the swollen joint, which may show crystals of uric acid. This stresses again the need for a good history and clinical examination.

Gout with Swellings around the joints

Question : I have been diagnosed with gout. Now I notice increasing, visible changes to some finger joints, with stiffness and there are visible, hard "gatherings" mostly at the sides of the joints. I am being treated with anti-inflammatory drugs. What are the swellings and are they common in gout?

Answer from drdoc : Those hard "gatherings ", sound like tophi - deposition of the gouty uric acid crystals, around the joints. They are definitely compatible with the disease, and are common - especially if the disease is allowed to progress, without proper treatment. They are an absolute indication for "second line therapy", such as allopurinol, or benzbromarone, as they cause bone erosion and damage. The anti-inflammatories do not treat the underlying problem, of the increasing uric acid load in your body.
Details are available on the website at http://www.arthritis.co.za/gout.html

Gout with heart failure on warfarin / coumadin

Question : My Father (58) has had gout for many years. He has severe heart disease and is taking coumadin, amioderone, digoxin, lasix, and accupril . He has been going through one episode after the other of gout that he can't seem to get under control because of his heart medicine. Please is there medicines out there that will not interact with his heart medications?

Answer from drdoc : Probably the best way out is for him to see a rheumatologist. I would suggest that he be controlled initially with low dose cortisone. In his position, the use of an anti-inflammatory is contraindicated. He could potentially use a COXIB such as Celebrex, but this is more difficult to sort him out than the cortisone can. The cortisone should be -prednisone 10mg per day for a week then 7.5 mg per day for a week , then 5 mg per day for a week then 2.5 mg for a week. You will find that the gout attack itself will settle within about the first 5 days. When the gout is completely quiescent, his doc should add allopurinol 300mg per day. The cortisone will overlap for the following 2 -3 weeks. It is critical that the acute gout be GONE before starting the allopurinol. He must take the allopurinol EVERY day for the rest of his life. See www.arthritis.co.za/gout.html

Glucosamine Sulphate

Question : Dear doctor, I have the start of arthritis in both my knees. will it help if i start taking 500mg of glucosamine sulfate each day? Would appreciate your advice.

Answer : Glucosamine is recommended in the book "The Arthritis Cure " by Jason Theodosakis. In fact it's use is not based on strong information. It is currently riding a wave of hype and probably unjustified enthusiasm. Nevertheless, it has some theoretical potential benefits. I have used it in Osteoarthritis, for the last 1 year, and have found only 1 in 4 benefit. This isn't miraculous, but it would do no harm to try it over 3 months and evaluate benefit. I suggest that 500mg is too little for an average adult. You are likely to require a gram. I suggest you see the alternative pages on my website, where further info on the glucosamine is available.

Inflammation ?

Question : How do I know if I have inflammation ?

Answer from drdoc : The answer to that is generally, if you have:
Stiffness. - the more the degree and in particular the presence of...
Morning symptoms of stiffness.
Swelling - NOT BONE thickening - but soft tissue swelling.
Heat in the joints on examination.
Blood tests - ESR and CRP are often helpful as well...and are usually positive.
If in doubt a bone scan (Technetium), is often able to detect inflammation in the bone / joints, that may not be obvious on examination
See my NSAIDs website page for therapy guidelines...

Methotrexate Ulcers ?

Question : I get frequent ulcers when taking methotrexate - Is there anything I can do ?

Reply from drdoc : We use the folic acid as a form of therapy to reduce side effects of the methotrexate. Mouth ulcers are a problem with the methotrexate. They can be caused as a dose related effect, or as a complication of low white cell count. The latter is called leukopenia, and is a serious complication. It requires immediate cessation of the methotrexate, and IT IS IN THIS SITUATION, that we use leucovorin - folinic acid as SALVAGE therapy to try reverse the leukopenia. If the marrow is so suppressed , that there is severe white cell reduction, and poor response to leucovorin, we can use a cytokine called granulocyte/macrophage colony stimulating factor (GM-CSF).
The ordinary mouth ulcers of methotrexate may need dosage adjustment. I have at the American college of rheumatology meeting in Orlando in 1996, learned a novel method to TREAT established mouth ulceration of methotrexate, where the white cell counts have been checked and found to be normal. This I have tried in patients of my own and it WORKS well.
The method is as follows: Dissolve 300mg of allopurinol (also known as zyloprim used in gout)
in 50ml of water and use this as a mouthwash. Rinse the mouth . Do not swallow.
Ask your Rheumatologist about it.
You can get more info on methotrexate at : http://www.arthritis.co.za/methotrexate.htm

Rheumatic fever versus Rheumatoid Arthritis

Question : Is there a relationship between Rheumatic fever and Rheumatoid Arthritis ?

Reply from drdoc : They are different diseases altogether, they are both autoimmune diseases where the body turns against self as a cross reaction to an environmental agent. In the case of rheumatic fever, the agent is streptococcus , in Rheumatoid arthritis - it is not known.

Rheumatoid factor :

Question - I am trying to understand the significance of a positive rheumatoid factor. As I understand it, the results of a positive test, with high titer of 314, can be used as a diagnostic indicator not as indicator of disease activity. Or possibly also a prognostic indicator. So would this mean your positive titer should always remain the same? And if not, how do you interpret subsequent titers?

Reply: Greetings from drdoc on-line
The rheumatoid factor is only one aspect of the diagnosis, as clinical findings are the most important. Indeed, low positive titers may be seen in other situations or diseases.
The rheumatoid factors are ANTIBODIES TO a part (Fc PORTION) of HUMAN Immunoglobulin (IgG) . They are detected by AGGLUTINATION TESTS.
There are 2 main types :
SCAT : the Sheep cell agglutination test - MORE SPECIFIC
LATEX : Where latex particles are used in the detection process - MORE SENSITIVE
Of note is that 1-5% of NORMAL people in the population are positive (NB this increases with AGE ) Only 75-85 % of RA patients are positive. Therefore they are not absolutely necessary for the diagnosis. But a high Rheumatoid factor is a marker of more severe disease.
Positive Rheumatoid Factor is sometimes seen :
1. In several Rheumatic and autoimmune diseases including:
RA
SJOGREN
SLE/SCLERODERMA
POLYMYOSITIS
Celiac disease
Chronic Active hepatitis
INTERSTITIAL PULMONARY FIBROSIS
WALDENSTROM`S macroglobulinaemia

2. As well as several general medical disorders - including :
ENDOCARDITIS
TB
SYPHILIS
LEPROSY
SCHISTOSOMIASIS - BILHARZIA

The levels of the case quoted are significant and "significantly high". They however do fluctuate with time. However a CRP or ESR are a better test for activity of disease. I do not do serial titers of Rheumatoid factor, as they don't really help clinically once shown to be positive.

Seronegative spondyloarthropathy versus seronegative RA

Question :What do these mean

Answer : Seronegative spondyloarthropathy - refers to patients with a negative rheumatoid factor that have certain clinical characteristics of an arthritis peripherally, especially the lower limbs - knees and ankles and feet, but who also can have spinal involvement and Sacroiliitis. Seronegative RA is different as these patients have features clinically of Rheumatoid arthritis but are negative for rheumatoid factor. Sometimes as time goes patients evolve into different groups. For both however you should get disease modifying drugs i.e. sulphasalazine, or minocycline or even methotrexate, that can treat the underlying disease. NSAIDs and COXIBs don't treat the underlying disease

Steroid tapering..

Question : How do I taper my cortisone dose in Rheumatoid arthritis ?

Reply from drdoc : I don't believe that one should lower the dose in an uncompromising regimented fashion in these rheumatic diseases. Each person and their disease is different... I don't get into the situation of mega doses for my patients unless they have systemic organ disease involvement i.e. cardiac/pulmonary/vasculitis etc...
Therefore rule 1 - For joint disease.. I avoid doses >10 mg ....unless clinically required. I seldom start higher than 7.5mg
Once I'm reducing down from 10mg, I reduce by 2.5 mg at a time - but slowly..
Each reduction is done in a stable clinical state , with the joints showing as little swelling as possible.
Nearly All my patients are on DMARDS, which enable me to do this.
This may mean 1-3 months or more between reductions if so required.
i.e. on average
10mg/day for 2 months ..
7.5 mg per day..
5 mg /day..
2.5mg per day...
Sometimes I even use an alternating dose i.e. 7.5 / 5mg or 5 / 2.5mg...
Once I'm at 2.5mg.. II start to go..
2.5mg alt day..
2.5mg every 3rd day..
2.5mg every 4th day....
etc, etc.

If at any stage the patient flares ---I go back to the previous level and retry from that level in a structured but individualized manner.
The important thing is to ensure that whilst this is all happening, the disease itself is being controlled using DMARDS at a deeper level.

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Rheumatologist
Cape Town
South Africa
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