Patient's Query
Hello doctor,
I am a 36-year-old male with a height of 160 centimeters and a weight of 114.6 pounds. I have been suffering from an autoimmune disease for the last 20 years. Thirteen years ago, I was treated with Methotrexate at a dose ranging from 7.5 milligrams to 12.5 milligrams and recovered completely.
Ten years ago, I developed the same problem again, and the same doctor prescribed Sulfasalazine 500 milligrams for one month. After that, I remained well for the last five years. Recently, the pain has returned.
I started taking Sulfasalazine 500 milligrams again, one tablet daily in the first week, two tablets daily in the second week, and gradually increased to four tablets daily by the fourth week. I recovered only partially. After one month, I stopped the medication and underwent kidney and liver function tests, which were normal. However, the inflammation level in the blood test was reported as 46 percent.
In the first month, I took Sulfasalazine. In the second month, I waited without medication. In the third month, I started Methotrexate 12.5 milligrams once weekly, and now four weeks have been completed. My joint pain has become worse and is almost double compared to the first month.
Should I restart Sulfasalazine for another course, or should I continue Methotrexate and wait for improvement?
Kindly advise.
Hello,
Welcome to iCliniq.
I understand your concern.
Sulfasalazine is a relatively mild disease-modifying antirheumatic drug and may not provide sufficient control in active autoimmune inflammatory disease. Methotrexate is more effective but usually takes around six weeks to start showing clinical improvement.
A short course of oral steroid therapy, such as Methylprednisolone 4 milligrams once daily for ten days, can help control inflammation. The Methotrexate dose can be increased to 15 milligrams once weekly at bedtime, along with Folic Acid 10 milligrams the following day at bedtime.
Sulfasalazine should be discontinued. Hydroxychloroquine 200 milligrams twice daily can be started. Follow up after two weeks.
I hope this helps.
Thank you.
Patient's Query
Hello doctor,
This is a follow-up consultation. I have taken the medications as advised for ten days. I have now completed six weeks of Methotrexate therapy, including five weeks at 12.5 milligrams and one week at 15 milligrams. From tomorrow, I will be entering the seventh week.
I have noticed only minimal relief and still have significant pain and swelling. I am struggling to sit, stand, get out of bed, and walk to the bathroom without assistance. I am currently taking Diclofenac 50 milligrams twice daily. Should I continue Methotrexate, or should I stop and wait for improvement?
Kindly advise.
Hello,
Welcome back to iCliniq.
I understand your concern.
Diclofenac provides only temporary pain relief and does not control disease progression. Methotrexate should be continued, as it is a first-line disease-modifying antirheumatic drug that helps prevent joint damage and deformities.
Ensure that Hydroxychloroquine 200 milligrams is taken twice daily. Instead of Diclofenac, half a tablet of Methylprednisolone 4 milligrams daily can be used, as prolonged Diclofenac use may cause kidney injury.
If pain persists despite this treatment, Leflunomide 10 milligrams once daily can be added temporarily until Methotrexate reaches its full effect, which may take up to three months.
I hope this helps.
Thank you.
Patient's Query
Hello Doctor,
I developed severe pain after stopping Diclofenac. I am continuing the other medications as prescribed. Today, I am entering the eighth week of Methotrexate treatment. When should I start taking Leflunomide 10 milligrams?
Kindly advise.
Hello,
Welcome back to icliniq.com.
I understand your concern.
You add 20 mg of Leflunomide from today only and continue Methotrexate, take Diclofenac or Methylprednisolone 4 mg.
I hope this helps.
Thank you.
Patient's Query
Hello doctor,
I am feeling slightly better now. Swelling has reduced, and around 20 percent of the pain has improved. I am able to go to the bathroom independently. However, I still have severe pain in my left hip and pelvic joint and in both shoulders. I am unable to raise my arms or lift objects such as a water bottle.
I also have pain and swelling in my left elbow, both knees, left ankle, toes, and feet. Currently, I am taking Methotrexate 15 milligrams weekly, Leflunomide 20 milligrams daily, Hydroxychloroquine 200 milligrams twice daily, Diclofenac in the morning, and Methylprednisolone 4 milligrams at night. From today, I have stopped taking Diclofenac.
My C-reactive protein level has reduced from 46 percent to 16.9 percent. Ultrasonography of the abdomen and pelvis is normal. How long should I continue these medications before my next follow-up?
Kindly advise.
Hello,
Welcome back to iCliniq.
I understand your concern.
Stop taking Diclofenac completely. Reduce Methylprednisolone to half a tablet of 4 milligrams once daily. Continue Methotrexate, Leflunomide, and Hydroxychloroquine as prescribed.
I hope this helps.
Thank you.
Patient's Query
Hello Doctor,
I stopped taking Diclofenac more than two weeks ago, but I still have severe pain and swelling. Due to a family issue, all my medications were discarded, and I missed Methotrexate 15 milligrams, Leflunomide 20 milligrams, Methylprednisolone 2 milligrams, and Hydroxychloroquine 200 milligrams. It will take two days to restart the medications.
I have completed almost four months of Methotrexate therapy. Why is Methotrexate not working now when it worked well twelve years ago? I am experiencing severe pain, emotional distress, and depression due to prolonged illness and inability to work.
Should I follow any dietary restrictions? Is it safe to restart all medications? Do I need any additional tests?
Kindly advise.
Hello,
Welcome back to iCliniq.
I understand your concern.
If Methotrexate has been taken for more than 12 weeks, some improvement is usually expected. Persistent symptoms may be due to ongoing inflammation or stress-related pain conditions such as fibromyalgia.
Increase Methylprednisolone to 4 milligrams once daily and continue Methotrexate and Hydroxychloroquine. Diclofenac should be stopped completely. If symptoms remain uncontrolled, Tofacitinib 5 milligrams once daily can be added.
Prolonged bed rest is not advised, as it worsens pain and mental health. Gentle physical activity is important. Inflammatory markers such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) should be repeated.
I hope this helps.
Thank you.
Patient's Query
Hello doctor,
Yes, I do not have pain alone, but my joints are swollen and are paining severely. Totally, I have swelling and pain in 14 of my joints which are as follows:
I cannot sit in a chair for more than 15 minutes. I cannot walk a single step without a walking stick. I am waiting for the time when I can at least put on my clothes by myself. I will continue to take the medication as you prescribed and hope I will get well soon.
Kindly advise.
Hello,
Welcome back to icliniq.com.
I understand your concern.
As I said previously, increase the dosage of Methylprednisolone to 4 mg daily and add Tofacitinib 5 mg once a day or alternatively. You can stop taking Hydroxychloroquine and take Leflunomide 20 mg once a day and continue taking Methotrexate and Methylprednisolone 4 mg once a day. This will be a good alternative if there is no response to earlier treatment. Also, do an ESR (erythrocyte sedimentation rate) and CRP (C-reactive protein), as these will help in calculating the disease activity.
I hope this helps you.
Thank you.
Patient's Query
Hello doctor,
I am following all the medications as per your instructions:
Now I feel much better and have great relief as well. However, the pain in my left pelvic hip joint and left elbow joint persists. I have attached the results of ESR, CRP, and CBC as well for your reference. I am waiting for your further instructions.
Kindly advise.
Hello,
Welcome back to icliniq.com.
I understand your concern.
It is good that your symptoms are improving. However, from your reports (attachments removed to protect the patient's identity), it is found that the inflammatory markers are still high; hence, you need to continue the same for one month and repeat the ESR and CRP. Hopefully, by then, your symptoms will be better.
I hope this helps you.
Thank you.
Patient's Query
Hello doctor,
I have great relief now. Thank you so much for your guidance. As per your instructions, I have repeated the same test and have attached the reports for your reference. Now, I have got a job offer in a foreign country and have to join work within two months. Meanwhile, before leaving, I am planning for a second baby. Will there be any side effects, or can I proceed with planning my second baby?
Kindly suggest.
Hello,
Welcome back to icliniq.com.
I understand your concern.
Can you please upload the reports?
I hope this helps you.
Thank you.
Patient's Query
Hello doctor,
I have attached the reports. Should I continue taking the tablets? And also, I am planning for a second baby. Is it advisable?
Kindly suggest.
Hello,
Welcome back to icliniq.com.
I understand your concern.
The reports (attachments removed to protect the patient's identity) are good. The disease is in remission. I suggest you take the following medications:
Kindly follow up after six weeks with KFT (kidney function test) and LFT (liver function test) reports.
I hope this helps.
Thank you.
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Answered byDr. Ashaq Hussain Parrey
Medically reviewed byiCliniq medical review team
Same symptoms don't mean you have the same problem. Consult a doctor now!
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