Home Community Chat Transcripts-4/16/2001

Arthritis Tests & Labs with Dr Susan Hoch

InsightHostKJ> Tonight's guest is Dr Susan Hoch and our Topic is Tests & Labs

Guest8 due for my 2nd remicade infusion tomorrow. have just read that you should have a TB test before starting, which my doc did not order. I'm worried as I had a positive TB test years ago. Opinions, please? also this doc has no MTX with the Remicade? Why?

DrSusan> There are some docs using Remicade without MTX now.

Duckie> using Arava instead or alone

DrSusan> Doing all of that. There is only published data with Methotrexate and Remicade but Centocor is conducting studies on Remicade alone as I understand.

Guest8 So should I push the doc on a TB test?

DrSusan> There has been a recent report of tb in patients on Remicade. So, all of us are rethinking our approach to this. But in general, it is probably a good idea to do a tb test before starting any strong immunosuppressant. Most of us have gotten away without doing this.

InsightHostKJ> Dr Susan, what if you have a + TB...can you still use remicade?

DrSusan> I do not believe there is yet a consensus in the Rheum community.

InsightHostKJ> in your opinion?

DrSusan> Most people would get a chest xray if there was a positive TB test and consider a course of isoniazid - INH.

DrSusan> A couple years ago, I had a young woman with lupus who was on Prednisone and she was a nursing student and was exposed to tbc. She came down with miliary tb. We treated her for 9 months with triple therapy, tapered the steroids, the lupus didn't flare so it can be done. She's fine and engaged to be married.

Duckie> Char and I have been discussing increasing Arava's dosage to say 25mg but I found on Arava's site that this could not be done due to more side effects. What is your experience?

DrSusan> I have never personally given anyone more than 20 mg.

DrSusan> My experience is that many people get diarrhea at 20 mg.

Pearl> Is it normal to have a high IGM with RA

DrSusan> Yes, the standard rheumatoid factor test that is measured is anIgM antibody directed against IgG, another kind of antibody.

InsightHostKJ> Do most auto immune diseases raise IgM?

DrSusan> Not necessarily - lupus patients generally have a large increase in their IgG.

InsightHostKJ> What about Graves disease?

DrSusan> I'm not sure. Patients with Graves make an antibody to the thyroid stimulating hormone (TSH) receptor and usually it is the mature antibody which is IgG.

Bandit> excuse me..what is lgG?

DrSusan> IgG stands for a type of antibody - there are 5 classes of antibodies - IgM, IgG,IgA, IgD and IgE. IgM is the kind of antibody you make in the first phase of an immune response. The later antibody you make is more refined and fits the antigen better. That is IgG. IgA is made on mucosal surfaces - i.e. in saliva, in the gut, in the bladder, vagina etc. IgE is what is involved in allergies.

chester> I have had a low albumin since being dx with RA. is this typical, Is there anything I can do to increase it

DrSusan> My guess, Chester, is that you have continuing inflammation - i.e. that your RA is NOT in remission.

chester> very true

D<b>rSusan> Another factor may be poor diet - patients with RA who feel poorly tend not to have a good appetite and may not eat as well as they should. But in general, active inflammation suppresses the body all over resulting in low albumen as well as what we call anemia of chronic disease.

InsightHostRon> Dr Susan, I was asked what Albumen is...Can you explain to the group

DrSusan> Albumen or albumin - pick your spelling is one of the major plasma

DrSusan> proteins.

DrSusan> Many medications circulate bound to albumen.

suzie> My daughter age 12 has stills, they use solumedrol 1 gram doses for 3 consecutive days as a immune suppresent for her about every 3 weeks so far , are there things I should be concerned about or look for ?

DrSusan> Solumedrol is soluble i.e. injectable methylprednisolone so it is a steroid hormone. It has all the risks of steroids including diabetes, hypertension, acne, thin skin, infections, growth retardation, effects on bones such as osteoporosis or aseptic necrosis. She is probably getting it in this form, i.e. pulse therapy every 3 weeks to minimize the side effects she would get if she took it on a daily basis.

suzie> she takes pred on a daily basis

DrSusan> So she is therefore getting a higher dose over a shorter time

InsightHostKJ> Dr Susan,how often should labs be done when on arava?

DrSusan> It is recommended to check liver functions every month for the first 6 months and then lessfrequently. I take that to mean every 3 to 4 months.

InsightHostKJ> Does the same alcohol rule apply as with MTX?

DrSusan> Actually, we don't know. Clearly, one doesn't want to raise liver enzymesbecause of booze and have to stop the Arava.On the other hand, there are to my knowledge no case reports of cirrhosis in patients on Arava. But also remember, Arava is a relatively new drug, cirrhosis takes years,

DrSusan> I personally do not use Arava in patients with hepatitis C because we don't have long term safety data.

DrSusan> KJ, do I get to ask a question?

InsightHostKJ> Of course!

DrSusan> How many of you have had bone density tests - DXAs?

Duckie> me

Carolanne> me

bedipped> I have

Blondie> .I have

InsightHostRon> Got my first one scheduled in May

Renee> I have.

katet35> not me

Tra> not me

InsightHostKJ> Me!! and i passed with flying colors! Only medical test I can pass!

Guest172> Not

Guest152> not me

Bettty> not me

DonnaM> me

Guest8 me too

<DrSusan> Good, I was wondering if the guys with RA were starting to get tested.

InsightHostKJ> how often should we have one?

DrSusan> Anyone on long term steroids, anyone with RA, should get a baseline bone density. Obviously perimenopausal women should consider it as well.

Bandit> why

DrSusan> Other risk factors for osteoporosis besides RA, steroids, post menopausal state, use of cyclosporin, hyperthyroid patients, alcoholics, family history of osteoporosis, liver disease, smoking, long term use of heparin, use of anticonvulsants. Height loss of more than 1 and 1/2 inch.

InsightHostRon> In other words about all of us huh

suzie> children too?

DrSusan> Lots of reasons to get a DXA.

Tra> does it hurt?

DrSusan> Besides, osteoporosis is PREVENTABLE AND TREATABLE.

DrSusan> The table is cold and hard but there is no injection, no risk.

DrSusan> Regarding children, bone density measurements are not standardized for kids yet

DonnaM> Dr Susan, have been on therapy for 5 yrs and I now above the fx line

DrSusan> In addition, the bisphosphonate drgus such asFosamax and Actonel are not approved for use in children.

DrSusan> Good for you DonnaM - see you can increase bone density.

DonnaM> and i am OLD

DrSusan> You don't have to be old to get osteoporosis - a young person with enough steroids can get that way. Conversely there are plenty of people over 80 who don't have osteoporosis.

Bandit> so in the process of treating PA you can get OA?

DrSusan> Back to kids - you should be sure that a child with JRA or lupus is on adequate calcium and vitamin D.

DrSusan> Bandit - OA using stands for osteoARTHRITIS not osteoporosis.

DrSusan> Do you mean OA or osteoporosis?

Bandit> osteoporosis

DrSusan> Sure, if you are on steroids for PA, you may be at risk for osteoporosis. Especially if you have other risk factors.

Harriette> I am going to be having radiation treatments soon, should I have more lab work done?

DrSusan> I'm sure they will want to have a complete blood count to be sure. Why are you getting radiation, if I may ask?

Harriette> I have thraot cancer a long with RA.

DrSusan> That's quite a load.

Harriette> There was no mention of blood work

DrSusan> Since they are radiating your throat, they will likely follow up on your thyroid as well.

DonnaM> DR Susan, do you see alot of thyroid problems along with RA?

DrSusan> You bet, Donna. Patients with RA are at increased risk for autoimmune thyroid conditions such as Hashimoto's and Grave's disease. I check TSH yearly in all my patients with RA and SLE.

InsightHostKJ> I have RA sister has Graves.....does that mean my risk of thryriod problems is higher?

DonnaM> what about with pituitary involvement

DrSusan> Probably slightly higher. Having one autoimmune disease predisposes to a second one.

DrSusan> Hypopituitary problems are more rare than autoimmune thyroid conditions.

suzie> should I add a calcuim supplement to my daughter... she is a good eater

DrSusan> Suzie - how old is she and what does she eat? If she is a teenager, the RDA for calcium is now 1200 mg.

suzie> 12 she eats all veggies drinks lots of milk fruits etc really excellent eater

DrSusan> If she is on steroids, the RDA for calcium is 1500 mg. A 8 ounce glass of milk has 250 mg. Does she drink 6 8-ounce glasses of milk a day.

DrSusan> I doubt it - the only people who drink that much milk are teenage boys (This is the voice of experience speaking here!)

suzie> ok not that much milk..... what is the best kind to buy

DrSusan> Skim milk has the same amount of calcium as !, 2 or 4%% and much less fat.

suzie> thats what i buy... what as far as a supplement???

DrSusan> Yoghourt is a good source of calcium - about 300 mg for a container.

DrSusan> Calcium citrate is probably the best - better than calcium carbonate.

DrSusan> On the other hand, I must say I am partial to the Viactiv calcium - they taste like candy and compliance is pretty good - I take them myself. Just make sure you are getting D to absorb the calcium, either with the calcium or in a good multivitamin.

Blondie> Dr Susan, to your knowledge, is there any higher %% of RA patients with vertigo or Menier's? vs general population?

DrSusan> Interesting question. A difficult to answer because some percentage of the Meniere's patients likely have autoimmune inner ear disease or immune mediated hearing loss.

DrSusan> There is a subgroup of patients with vertigo and hearing loss who have it as an autoimmune disease - they make antibodies to antigens from the cochlea and respond to treatment with prednisone and immunosuppressants including methotrexate. Very interestingly, there was a trial reported at the November ACR of the use of Enbrel in these patients.

DrSusan> The ENTs I know treat them with high dose prednisone and then a rapid wean if the hearing responds. They seem to be able to lower the prednisone faster than I can in my RA patients.

Guest148> Hi - I'm DiWitt - Can the anti-phospholipid antibody test be affected by steroids? Can the test change over time? Does a low titer mean no APA Syndrome?

DrSusan> Hi Di, APA's don't seem to change much with steroids. They can change over time - and for example, if a patient has a clot, a lot of the antibody may be involved in the clot and the test may be low titer or even negative. I think the consensus is once an APA, always worry about an APA.

Guest148> even a low titer?

DrSusan> In addition, as you know there are a variety of tests for antiphospholipid antibodies. The most sensitive test is called the DRVVT, diluted Russell Viper Venon Times.

DrSusan> It can be positive when the lupus anticoagulant test, the activated PTT, and the anti cardiolipin antibody test are both negative. Finally, patients with other problems of clotting, what we call thrombophilia,

Guest148> I have genetic thrombophilia

DrSusan> can have these as additive to an APA, for example, the Factor V Leiden test or elevated homocysteine can contribute to clotting in a patient with an antiphospholipid antibody.

DrSusan> So genetic thrombophilia plus an acquired antiphospholipid antibody may give you more of a problem with clotting than either alone. Sounds like you need to be on coumadin for life.

Guest148> I am .... just after the blood clot last month. What I am noticing is that my pain level is decreasing as my INR increases.

DrSusan> That's neat!

Bandit> When I started on Remicade I was on 37.5 mgs of Mtx, I felt fantastic ALL the time. My Mtx injections were weekly so for 1 month I started getting sick after my injection the 5th inj. I was violently ill, so dr cut it down to 17.5 mgs..now all I do is flare, I hurt in places I didnt know where there even before. So is there any chance I will be able to resume the original dose and feel good again? And why after 2 1/2 years did it all of a sudden make me sick

Bandit> reaction to mtx?

DrSusan> I can't answer a specific question. 37.5 mg is certainly toward the high end of methotrexate usage by rheumatologists for RA.

Bandit> I have PA instead

DrSusan> Has your RD considered inching it back up again - trying 20 mg for a couple of weeks, then 22.5 etc? Were you on folic acid or folinic acid?

Bandit> folic acid...yes

DrSusan> 37.5 mg is still towards the high end for PA.

DrSusan> You may have to work it back up again.

panda> i have PA my sed rate and CRP are never elevated is this normal? most of my pain is caused by enthesis

DrSusan> Yes, even with RA, not ALL patients have elevated sed rates. PA tends to be more characterized by enthesopathy than rA. Some PA patients have spinal involvement as in ankylosing spondylitis and those patients tend to be B27 positive.

panda> thank you it can be hard with pa as there are no conclusive tests

DrSusan> These tests can be helpful in many patients but ultimately the doc has to look at the patient and not the test.

InsightHostKJ> I wish they would teach that in med school! LOL

DrSusan> I try to teach that KJ. LOL

InsightHostKJ> We appreciate it! lol

InsightHostKJ> Any closing words for us dr susan?

DrSusan> Try to learn what tests your doctor is ordering, why he or she is ordering those tests. Then get the results and if you have questions, ask you doc to interpret them. And finally, a plea, if you go to a new doc, pl,ease bring your records and tests to make it easier for them to help you.