Q. I have ankle and calf muscle pain. Could it be RA?

Hello,

Welcome to icliniq.com.

After going through the details of your query, there are a few things to be clarified first. You have not mentioned any involvement of the small joints of hands, wrists or feet. The joints you have mentioned only include large joints. If it is really so, then the likelihood of RA (rheumatoid arthritis) becomes lesser.

1. What were the results of the rheumatoid factor antiCCP tests, if performed?
2. Does your pain improve with movement and exercise?

If the answers to these last two questions are yes, then you probably have spondyloarthritis (SpA). Though a positive RF and antiCCP test would be more indicative of RA, they are not absolute. Do you have a recent blood test for CBC, SGPT, ALP, and HLA B27? If yes, please tell me the findings in two to three days. If not, I suggest the following tests:

1. CBC (complete blood count).
2. SGPT (serum glutamic pyruvic transaminase).
3. ALP (alkaline phosphatase).
4. HLA B27 (human leukocyte antigen).
5. RF (rheumatoid factor).
6. AntiCCP (cyclic citrullinated peptide).
7. HIV (human immunodeficiency virus).
8. HBsAg (hepatitis B surface antigen).
9. HCV (hepatitis C virus).

I have seen your X-rays (attachments removed to protect the patient's identity). The clinical (by history), and radiological diagnosis is SpA. Though, I would prefer that you resend the pelvic X-ray again with a tube light in the background.As far as the treatment is concerned, at this stage, I suggest the following:

1. Instead of Pirox 20 (Piroxicam), take Naproxen 500 mg twice a day.
2. Also, take Sompraz (Esomeprazole) 40 mg once a day before breakfast.
3. No need of Gabapentin.
4. Continue Imutrex (Methotrexate) 20, its dose will be adjusted after the reports.
5. Continue Folvite (Folic acid) 5 mg, but only twice a week.
6. Continue Osteofos (Alendronic acid) 70 once a week.Continue Bio D3 (Calcitriol) and Uprise D3 (Vitamin D).
7. Add tablet Saaz (Sulfasalazine) 500 mg once a day. Please ensure that you never had an allergic episode with a sulfa drug before starting it. Its dose will be escalated gradually.
8. If you still have severe pain, then add tablet Ultracet (Tramadol) twice or thrice a day.
9. I would also like to add a steroid, but I am not suggesting it due to glaucoma.
10. For cholesterol, I suggest Atorva (Atorvastatin) 10 mg daily.

If we finally establish the diagnosis as SpA, then after three to four months trial of Imutrex and Saaz, if there is still no significant response, then biologics are the next best option. Since you were already on Imutrex, I suggested you add Saaz, and increase its dose by 500 mg every week up to 2000 mg (four tablets) a day. Consult a specialist doctor, discuss with them, and take medications with their consent

Hello,

Welcome back to icliniq.com.

I have seen your reports (attachment removed to protect patient identity).

The CBC and SGPT were done quite a while ago. Ideally, the blood tests for monitoring the side effects of Imutrex should be done every three months. So, I request you to get the following routine tests done as soon as possible:

1. CBC.
2. SGPT.
3. Creatinine.
4. HLA B27. It has to be done only once.
5. Erythrocyte sedimentation rate (Westergren method).
6. Also get an MRI of the sacroiliac joints (with T1, T2 and STIR images).

These two tests are somewhat costly but important in your management. You may get them in one to two weeks as per your convenience.

I suggest a few changes in your treatment:

1. The dose of Saaz has to be increased up to 3 g per day gradually (addition of 500 mg per week so that after six weeks, you would have 1 g tablet three times a day.
2. Add tablet Preega M (Pregabalin and Methylcobalamin) 75 at 9 PM daily.
3. Add tablet Duloxetine 20 mg daily evening, increase the dose to 30 mg daily after a week.

You can have the other medicines as described earlier.

Please do the above tests, and revert with the reports. Next time, please also attach a picture of your swollen ankle and calf muscle. Also, tell me if you have any hardness in the calf region as compared to the other side and if you have an excruciating pain on pressing the calf muscle.

Same symptoms doesn’t mean you have the same problem. Consult a doctor now!

Dr. Srivastava Durgesh

Experience: 18 + Yrs

Rheumatology

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