Ra Patient Hasn't Found A Medication That Alleviates Joint Pain
DEAR DR. ROACH: I was diagnosed with rheumatoid arthritis (RA), but my rheumatologist hasn't been helpful in finding a medication that I'm not allergic to for alleviating joint pain. (I seem to be allergic to most meds that I've tried.) I'm only 68. I saw the term "biological" medication for RA in one of your recent columns. What is this, and do you have any advice? -- B.R.
ANSWER: RA is an autoimmune disease that may affect other organs besides the joints, including the heart and lungs. While initial treatment for RA may include powerful conventional medicines against the immune and inflammatory system (such as methotrexate or hydroxychloroquine), a "biological" medication is made from live cell systems. These medicines mostly include monoclonal antibodies that bind to active biological molecules (called "cytokines"), but they also include fusion proteins that block cytokines before they can bind to their receptors.
For RA, the major biological medications bind important cytokines such as tumor necrosis factor (TNF), interleukin-6, and interleukin-1. But they may also act on stimulants to antibody-producing cells ("B cells") and T cells, which are the other major part of the immune system that is responsible for cell-based immunity.
Biologicals have the potential for serious side effects, including infections (especially tuberculosis but also pneumonia, skin infections, hepatitis B and sepsis). For this reason, biologicals are only used generally after a person has failed other treatments. Allergic reactions are uncommon with biologicals.
RA requires an expert to treat. I have great respect for RA, having seen terrible outcomes in people who weren't treated early enough. For this reason, I can't say whether a biological is appropriate for you. Your rheumatologist is monitoring your blood tests and clinical findings to balance the damage from RA against the potential side effects of treatment. It's really the disease activity that determines whether a powerful agent is necessary.
DEAR DR. ROACH: I'm a 99-year-old man in good health who suffered a heart attack in 2014 that was caused by an artery blockage. After inserting a stent in my artery, my cardiologist recommended statin drugs. I tried a few, but they were so painful that my insurance company finally authorized me to use a PCSK9 inhibitor.
The inhibitor worked well for a couple of years, but then I started experiencing terrible hip pain when standing or walking. The good news was that there wasn't any pain when I was sitting or lying down. So, the question for me became: Should I keep using the PCSK9 inhibitor despite the hip pain, or should I stop using the inhibitor and risk another heart attack or maybe even a stroke? -- M.F.
ANSWER: Congratulations on doing so well at age 99! Because PCSK9 inhibitors rarely cause muscle or joint pains, I'd first try to be sure that the medicine really is the cause behind your pain. I hope your doctor did X-rays to look for arthritis or even an MRI, since conditions like a torn labrum should be considered.
If there isn't another cause, and the pain stops when you pause the medication, then it'd seem likely that the medicine is causing it. Since there are three PCSK9 inhibitors (evolocumab, alirocumab and inclisiran), I'd try a different one. If they still cause problems, then I'd try something else entirely.
At age 99, your quality of life seems to be the most important issue to me. I'd give you a trial of bempedoic acid, which works similarly to a statin without the muscle aches that some people experience.
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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu.
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