Hello doctor,
I am a 38 year old male, suffering from RA from the last two years and recently started the treatment with an orthopedic doctor for AVN of the hip. I have been told by my orthopedician at icliniq to consult a rheumatologist for my ankle and calf muscle pain, and for my RA medication and cholesterol levels. The X-ray of the left leg had the problem of soft tissue noted. Please find the X-ray of the ankle and that of the hip and knee attached. I have been on RA medicines such as Imutrex 20 mg weekly, Folvite 5 mg daily, Bio D3 strong daily, Uprise D3 60K monthly once, Pirox 20 mg at night, and Osteofos 70 weekly for hip AVN as suggested by my orthopedic. I was on biologics one year back - Etanercept 50 mg weekly for three months. Please suggest RA medications and a medicine for my ankle soft tissue which causes me pain and difficulty in walking too. I have started Gabapentin 300 mg from today for five days as prescribed by the orthopedic. I am taking Combigan and Dorzox-T eyedrops for glaucoma in the left eye. The X-ray of the hip states that the bilateral femoral heads appear sclerosed with diminished joint spaces and irregular surfaces of femoral head. However, the shape of the bilateral acetabular cavities is maintained. The X-ray of both the knee states that joint spaces are reduced. Osteophytes are noted at the patellar and tibial surface. The patella-femoral space is diminished. The X-ray of the left leg with ankle states no significant abnormality detected. I have pain in the calf muscle and ankle tissue along with tingling (pins and needles) in both the feet. Please suggest proper medication for RA, ankle pain, calf muscle pain and for cholesterol.
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.
- What were the results of the rheumatoid factor antiCCP tests, if performed?
- Do you have early morning pain and stiffness in the lower back?
- 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:
- CBC (complete blood count).
- SGPT (serum glutamic pyruvic transaminase).
- ALP (alkaline phosphatase).
- HLA B27 (human leukocyte antigen).
- RF (rheumatoid factor).
- AntiCCP (cyclic citrullinated peptide).
- HIV (human immunodeficiency virus).
- HBsAg (hepatitis B surface antigen).
- HCV (hepatitis C virus).
- I have seen your X-rays. 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:
- Instead of Pirox 20 (Piroxicam), take Naproxen 500 mg twice a day.
- Also, take Sompraz (Esomeprazole) 40 mg once a day before breakfast.
- No need of Gabapentin.
- Continue Imutrex (Methotrexate) 20, its dose will be adjusted after the reports.
- Continue Folvite (Folic acid) 5 mg, but only twice a week.
- Continue Osteofos (Alendronic acid) 70 once a week.
- Continue Bio D3 (Calcitriol) and Uprise D3 (Vitamin D).
- 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.
- If you still have severe pain, then add tablet Ultracet (Tramadol) twice or thrice a day.
- I would also like to add a steroid, but I am not suggesting it due to glaucoma.
- 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.
- Also, let me know your weight.
- In the longer run, you will need a bilateral hip replacement, but we should delay it as much as possible if you can manage your work without much pain.
Hope I have been of some help. Take care.
For more information consult a rheumatologist online --> https://icliniq.com./ask-a-doctor-online/rheumatologist
Thank you doctor,
I am not facing problems in small joints. The RA test is performed. Please find it attached. I have morning stiffness. There is no stiffness in the lower back. There is no improvement with exercises. CBC, SGPT, and ALP tests are performed. HLA-B27 was not done. HIV test, HBsAg, and HCV are done. My weight is 63 to 65 kg. I have started the medications as per your suggestion. I have also stopped Gabapentin and Pirox 20 as suggested by you. There is tingling (pins and needles) in both the feet. The left leg pain still persists with ankle and calf muscles. I wear an ankle binder as prescribed by my orthopedic. Please suggest if anything needs to be added or changed.
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:
- CBC.
- SGPT.
- Creatinine.
- HLA B27. It has to be done only once.
- Erythrocyte sedimentation rate (Westergren method).
- Also get an MRI of the sacroiliac joints (with T1, T2 and STIR images).Â
- 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:
- 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.
- Add tablet Preega M (Pregabalin and Methylcobalamin) 75 at 9 PM daily.
- 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.
For more information consult a rheumatologist online --> https://icliniq.com./ask-a-doctor-online/rheumatologist
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