Hi doctor,
I am worried for my 63 years old elder sister who is almost bedridden now due to the following ailments. She has severe pain in the stomach (started two months ago), knee pain for four years and swollen legs for three years. Doctors are of the opinion that she is suffering from severe arthritis and acute gastritis. The medicine, which she is taking for arthritis is causing pain in stomach. How she will get relief from all these ailments? Please advise. A copy of prescriptions and pathological investigation reports are attached herewith. Thank you.
Hello,
Welcome to icliniq.com.
- I think that she has rheumatoid arthritis (not just simple arthritis). It would be very helpful if you say which joints are involved.
- Is she stiff in the morning? How long it takes for the stiffness to go away?
- There are medications for this condition which are gentle on the stomach.
- Going through the medications (attachment removed to protect patient identity); it appears that she is on treatment for osteoporosis and gout at the same time. It would be nice to know if she has an x-ray or DEXA scan for this reason.
- Gout is another form of arthritis. Again, I do not see a latest uric acid report. Does she ever have a joint fluid tested for this reason?
- Did she have attacks where her big joints were involved like knee, big toe and elbow?
- Yes, I agree that medication can cause stomach pain and gastritis.
- The fact that she has anemia makes me think she is losing blood, which is hidden. Like either in her urine or stools. Does her urine tested or stool tested? I would like to see the result and work up for anemia.
- Please share the results as requested and answer these questions so that I can help you in a better way.
Revert back with the details to an internal medicine physician online --> https://www.icliniq.com/ask-a-doctor-online/internal-medicine-physician
Thank you doctor,
I am trying to furnish the information as desired by you. Regarding joint pain, the joints are wrist, hip, knee and ankle. To recover from morning stiffness, she requires more than an hour. X-ray of knee and ankle done long before. Blood sugar fasting 93.07 mg/dL and serum uric acid 8 mg/dL. No joint fluid test was ever done. About one and half years ago, she had trouble in the ankle. It swelled and pus discharged continuously forming holes. Medication continued for five to six months. No recent urine or stool examination done. No physical existence of blood in urine or stool observed. I would request you to advise if any pathological test or any other examination if required.
Hello,
Welcome back to icliniq.com.
- Regarding joint pain, I am leaning more towards her having rheumatoid arthritis (RA).
- Please obtain a blood test ANA (antinuclear antibody panel), RF (rheumatoid factor), latest CBC (complete blood count), LFTs (liver function tests) and U/C/E (urea, creatinine and electrolytes).
- I would also like to have an x-ray of her wrist joint. Is her pain bilateral?
- Although her uric acid is high, she just had one episode of ankle pain and swelling, I think, it was just osteomyelitis (bacterial infection of bone) and not gout.
- Please provide me with a latest x-ray of her ankle joint. I am very much inclined towards discontinuing the Allopurinol.
- Regarding anemia I would highly suggest that she get upper GI and lower GI endoscopy, her anemia (low hemoglobin) could be due to her RA or the gastritis she is having due to all the pain medications.
- Please get a DEXA scan as this is the sac that will help identify if she has osteoporosis.
For further information consult an internal medicine physician online --> https://www.icliniq.com/ask-a-doctor-online/internal-medicine-physician
Thank you doctor,
As desired, the following files are attached herewith: Blood test reports, x-ray of both knees, ankles and wrists, report of upper GI endoscopy and BMD report. All the tests have been done after receiving your direction except endoscopy. Now, she is suffering badly from stomach pain. She is not getting relief from pain, even after taking Hyocimax Injection. Please advise.
Hi,
Welcome back to icliniq.com.
Thank you for following my recommendations, here is my conclusion:
- Discontinue the Allopurinol. Taper it off slowly over two to three weeks. Although her uric acid is 8, it is a little less likely to be gout since her changes on the ankle x-ray are due to old infection of the bone (osteomyelitis) and it was just one episode.
- From the DEXA scan, it is evident that she has osteoporosis. She should not use oral Bisphosphonates like Alendronate. Instead, should get injectable forms like yearly infusion of Zoledronic acid (Zomet or Reclast) or three monthly injections of Ibandronate (Boniva).
- The initial injection may give flu like symptoms and bone pain, which is a common side effect. It does not cause gastritis or stomach pain like oral medications. She should take 2000 IU of vitamin D and 800-1200 mg of calcium with it.
- I saw that the EGD was within normal limits, but was obtained two years ago. Were her symptoms still present during that time?
- Does she have gall bladder surgery done? Please do not take me wrong, but I assumed her pain is in the stomach, which is just below the rib cage in the center. Am I right? If yes, then the Buscopan and Hyoscyamine will not help. They are more for spasms in the large and small intestine.
- Does she have a history of alcoholism? Why is she on Librax (Chlordiazepoxide)? Is this for gastritis only? Does it help? If not, please taper it off gradually over next three weeks. It can cause anemia and constipation among others. Please do not abruptly discontinue it.
- For stomach pain I suggest Amoxicillin 1 g twice daily plus Clarithromycin 500 mg twice daily, Rabeprazole or Omeprazole 40 mg twice daily 45 minutes before meal. All three medications to be taken for 14 days.
- Once the 14 day course is over, then continue the Rabeprazole alone for a total of six months at the same dose. You can use Ranitidine 150 mg daily if she still has the stomach pain.
- Please get an iron profile, anti-CCP (anti-cyclic citrullinated antibody), ESR - erythrocyte sedimentation rate and an ultrasound of the gallbladder (to look for stones).
- Given her anemia she would need repeat upper GI and lower GI endoscopy to rule out cancer.
- For her joint pains, use only Tramadol; you can go up to 100 mg three times a day or Paracetamol 1000 mg twice daily.
For further information consult an internal medicine physician online --> https://www.icliniq.com/ask-a-doctor-online/internal-medicine-physician
Thank you doctor,
Your seriousness overwhelmed me. As advised, Allopurinol will be discontinued. Should she take any medicine for the symptoms as may happen due to injections of Ibandronate (Boniva)? Please name the medicine for vitamin D and calcium. Yes, gall-bladder surgery was done at that time. Yes, as assumed pain in the stomach is in below the rib cage in the center and around the navel. She is not alcoholic and was never in the past. Doctor might have been prescribed Librax (Chlordiazepoxide) for gastritis. It will also be discontinued gradually. Investigations as advised will be done soon. Can I expect that she will be able to lead the rest of her life painlessly or with less pain?
Hello,
Welcome back to icliniq.com.
Thank you for the kind compliment.
- Just Paracetamol two tablets or Trazodone, both will help if she developed flu like symptoms.
- Any calcium supplements like Adcal one pill twice daily (she should have 1000-1200 mg of calcium).
- Regarding vitamin D supplements, she can take either 5000 IU once a week or 1000-2000 IU once daily. I am hoping that she will have a pain free life.
For further information consult an internal medicine physician online --> https://www.icliniq.com/ask-a-doctor-online/internal-medicine-physician
Hi doctor,
Since one month, my sister has been taking medicines as suggested by you. They are Amoxicillin 1 g twice daily and Clarithromycin 500 mg twice daily continued for 14 days. The other medicines she is taking are as follows: Vitamin D (Uprise D3 -2k) once daily, Calcium (Shelcal 500 mg) twice daily, Rabeprazole or Omeprazole 40 mg (Razo-20 two tablets) twice daily 45 minutes before meal and Tramadol 100 mg (Tramazac) three times a day. Along with, she is taking Espin-AT as prescribed by doctor for high blood pressure and Sucral-O syrup. Regarding infusion of Zoledronic acid or Ibandronate injection, please suggest the dosage and precautions if necessary to be taken. The test reports of iron profile, anti-CCP and ESR are attached herewith as advised. To show you the visuals of wrists, knees and ankles, I am submitting herewith some photographs with a hope that these will make your choice of medicines more appropriate. Nowadays, she is feeling nauseous all the time and always her mouth remains sour. How long the medicines need to be continued?
Hello,
Welcome back to icliniq.com.
You did an awesome job of sharing the pictures. My suspicion was correct and she has rheumatoid arthritis.
- I suggest Prednisone 60 mg daily for the first 2 weeks, then reduce to 40 mg for the next 2 weeks, then 10 mg for the next 2 weeks and then leave her in 5 mg daily. Consult a specialist doctor, discuss with him or her and take the medicine with consent.
- Is it possible for you to take her to a rheumatologist?? She will need relatively advance treatment for rheumatoid arthritis.
- For now, let us continue the rest of the medications. She needs them. I am glad that you discontinued that antibiotics.
- Regarding the Zolendronic acid, I will give you the information, but I would wait until she is a little more stable. You can still hold onto the information for future reference.
- Remember, if she has an allergy to any drugs, foods, or other substances, then do not use it. Allergies present as rash, hives, itching, shortness of breath, wheezing, cough and swelling of face, lips, tongue or throat.
- Please hydrate her appropriately before the treatment. Paracetamol after administration will reduce the incidence of acute reaction such as joint pain, fever, flu-like symptoms and muscle pain. The dose recommended is 5 mg once a year; consider discontinuing after 3 to 5 years of use.
- Nausea is the side effect of Tramadol. Use Motilum 10 mg (Domperidone) on as needed basis, up to two times a day. It can make her sleepy so better to be given at bedtime.
For further information consult an internal medicine physician online --> https://www.icliniq.com/ask-a-doctor-online/internal-medicine-physician
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