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Safety of Biologic Drugs In Rheumatology

Safety of biologic drugs

Biologic drugs have recently revolutionized the treatment of many rheumatologic conditions such as rheumatoid arthritis, lupus, and psoriatic arthritis, to name a few. These powerful agents function by targeting a specific component of the immune system thought to be crucial in causing inflammation.

Specifically, TNF inhibitors (Humira, Enbrel, Remicade, Cimzia and Simponi) block activation of tumor-necrosis factor-α, Orencia inhibits the stimulation of T cells by the B cells, Rituxan inactivates certain B cells, Actemra blocks the activity of interleukin-6, and Xeljanz interferes with the JAK-STAT signaling pathway.

Biologic drugs have helped us achieve remission in many conditions that previously led to disability. For example, whereas rheumatoid arthritis used to lead to joint deformity and disability in a great number of the affected people in the past, nowadays the majority of people with this disease can enjoy a normal and pain-free life. Life threatening conditions, like kidney, lung or heart failure are also now treated successfully with these drugs.

However, safety of biologic drugs has been an issue, and at times, a topic of debate. Keep in mind that all medications, including Aspirin, Tylenol, or even vitamins, can have side effect. It is therefore important that biologic drugs are prescribed and managed by physicians who are well aware of potential side effects and well-equipped to recognize and treat them if necessary.

The majority of the data on the safety of biologic drugs come from people with rheumatoid arthritis. In this article I will summarize the major risks in this group. While it is possible that the risks are similar in other conditions, since the data is limited, little conclusion can be drawn.

 

Infection:

Since biologic drugs target the immune system, it is not surprising that infection is a potential risk.

Bacterial infection:

An increased risk of bacterial infections, like pneumonia and skin infection, has been reported with all biologic drugs.

What this means for you: If you have a serious infection requiring antibiotics, hold your biologic drug until the infection has cleared. This allows your immune system to fight the infection.

 

Tuberculosis:

If you were exposed to tuberculosis in the past, the organism may live in your body for years without causing disease. Once the immune system is lowered, tuberculosis can be reactivated. In severe cases it can affect not just the lungs, but potentially the entire body.

What this means for you: You will need a PPD (TB test) before starting most biologic drugs to make sure you have not been exposed to tuberculosis.

 

Viral infections:

Hepatitis B and C- Biologic drugs are used with caution in people with hepatitis.

JC virus- This is an infection affecting the brain. A very small risk has been observed (4 cases in rheumatoid arthritis patients, or 1 in 20,000 patients treated with Rituxan).

Herpes Simplex

Other infections

What this means for you: Get your vaccines before and while on biologic drugs. This includes Shingles, pneumonia vaccine and flu vaccine.

 

Malignancy:

An early study suggested there may be a very small but increased risk of malignancy (specially lymphoma and nonmelanotic skin cancer) in people treated with TNF-inhibitors Remicade, Enbrel and Humira. However subsequent larger studies and reviews have not confirmed this risk. The data is not sufficient on the risk with Orencia, Actemra, or Xeljanz. Malignancy does not seem to be increased with Rituxan.

What this means for you: If you have a personal or family history of malignancy, alert your rheumatologist. This does not mean that you are not a candidate, but caution may be advised.

 

Demyelination:

Cases of multiple sclerosis, optic neuritis, and Guillain-Barre syndrome have been reported with the use of TNF inhibitors.

What this means for you: If you have one of these conditions you may not be a good candidate for TNF inhibitor biologics.

 

Heart failure:

TNF inhibitors as well as Rituxan may exacerbate moderate to severe heart failure.

What this means for you: If you have moderate to severe heart failure (NYHA class III or IV) you may not be a candidate for some of the biologic drugs.

 

High cholesterol:

Actemra and Xeljanz may cause elevation of the bad cholesterol.

What this means for you: Your rheumatologist will periodically monitor your cholesterol level while on these drugs.

 

Drug-induced lupus:

New onset of lupus-like symptoms have been reported in people using TNF inhibitors. Symptoms usually resolve once the drug is discontinued.

What this means for you: Let your rheumatologist know if you develop new symptoms- including rashes, new joint pain, sores in the mouth, chest pain, etc.- while you are using these medications.

 

The bottom line:

Like any other medication, biologic drugs can be associated with a variety of potential side effects. And like with all other medications, their benefits should be balanced against their risks and individually assessed for every patient. When used correctly and safely, these drugs can save people’s lives.

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Benefits of Therapeutic Massage

Therapeutic massage

If you have ever had a massage, you will agree that massaging sore muscles helps relieve the pain. A good massage just makes you “feel good”.

But massage, especially by a skilled therapist, can provide more than just a temporary relief for sore muscles. It can actually be used as a form of therapy for a variety of chronic conditions.

Therapeutic massage can be used to treat many painful conditions.
Therapeutic massage can be used to treat many painful conditions.

 

Benefits of therapeutic massage

Massage can complement- or at times substitute- potentially harmful medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) or opioid drugs. As a relatively inexpensive and widely available alternative therapy, massage can be an effective way to improve one’s quality of life.

 

Treatment of chronic pain

Massage is an effective modality in improving pain in several chronic conditions, including neck and low back pain, arthritis pain, fibromyalgia and even pain from cancer.

In one study, people with knee osteoarthritis showed a decrease in pain and improvement in functioning after 10 weeks of massage. In another study of patients with rheumatoid arthritis, those treated with light pressure massage therapy had less pain and greater grip strength following massage sessions, which still lasted at one month followup.

People with knee osteoarthritis have also been found to have decreased pain and increased mobility with massage therapy. Massage has also shown benefit in treatment of carpal tunnel syndrome.

Fibromyalgia pain

Fibromyalgia is a chronic syndrome characterized by generalized pain, joint stiffness, fatigue, sleep alterations, anxiety, and depression. Massage therapy as well as myofascial release have been shown in multiple studies to be helpful in some patients with fibromyalgia. Muscle relaxation, improved sleep, decreased anxiety and depression, and a decrease in production of pain chemicals in the body all help reduce pain in people with fibromyalgia.

 

Improved sleep

Poor sleep quality not only causes you to be fatigued, it also exacerbates pain. Massage therapy is shown to be an effective technique for increasing deep sleep and improving sleep quality.

 

Improved mood

There is a reduction in anxiety and depression with massage therapy. One study found the benefits of massage therapy lasted longer than standard medical care in these conditions.

 

Decreased inflammation

A decrease in production of inflammatory chemicals has been observed after massaging an acutely injured muscle. Decreased inflammation will lead to a decrease in tissue injury and pain.

 

Massage Therapy Techniques- Examples

In Swedish massage, the therapist uses kneading, rolling, friction, tapping, and long strokes to warm up the muscles and improve blood flow. Deep tissue massage and trigger point massage treat and reduce myofascial pain, decrease swelling, stiffness, and tension. Sports massage is geared to the needs of athletes.

 

How does massage work?

The beneficial effects of therapeutic massage are thought to be due to a variety of factors:

Relaxing the tissues

Applying appropriate pressure relaxed muscles, tendons and ligaments. This can lead to a reduction in contraction of both superficial and deep tissues.

Improving Circulation

Massage is believed to improve blood and lymph circulation. This is partly due to physical manipulation of soft tissue, and partly due to the chemicals released when the tissues relax. Improved circulation can enhance the delivery of oxygen to muscle cells, allowing them to function more efficiently.

Regulation of natural chemicals

Massage has been associated with an increase in the body’s secretion of serotonin and dopamine, which alleviate stress, and a decrease in production of cortisol, which is a stress hormone.

Slowing of the heart rate and breathing, and a decrease in blood pressure, all of which can reduce stress, are also resulted from therapeutic massage.

 

Where should I get a Therapeutic Massage?

While any massage may help you “feel good”, appropriate and deliberate technique applied by a skilled and experienced therapist can be used to treat specific conditions and areas of interest. Combined with specific instructions from a physician trained in musculoskeletal conditions (such as a rheumatologist), your massage can prove to have long lasting therapeutic effects.

 

*Some insurances may cover therapeutic massage ordered by a physician. Coverage is highly variable.

 

Reference

  1. Supa’at I, Zakaria Z, Maskon O, Aminuddin A, Nordin NA. Effects of Swedish massage therapy on blood pressure, heart rate, and inflammatory markers in hypertensive women. Evid Based Complement Alternat Med. 2013;2013:171852. doi: 10.1155/2013/171852. Epub 2013 Aug 18.
  2. Elliott R, Burkett B. Massage therapy as an effective treatment for carpal tunnel syndrome. J Bodyw Mov Ther. 2013 Jul;17(3):332-8. doi: 10.1016/j.jbmt.2012.12.003. Epub 2012 Dec 23.
  3. Field T, Diego M, Delgado J, Garcia D, Funk CG. Rheumatoid arthritis in upper limbs benefits from moderate pressure massage therapy. Complement Ther Clin Pract. 2013 May;19(2):101-3. doi: 10.1016/j.ctcp.2012.12.001. Epub 2013 Feb 6.
  4. Miernik M, Wieckiewicz M, Paradowska A, Wieckiewicz W. Massage therapy in myofascial TMD pain management. Adv Clin Exp Med. 2012 Sep-Oct;21(5):681-5.
  5. Perlman AI, Ali A, Njike VY, Hom D, Davidi A, Gould-Fogerite S, Milak C, Katz DL. Massage therapy for osteoarthritis of the knee: a randomized dose-finding trial. PLoS One. 2012;7(2):e30248. doi: 10.1371/journal.pone.0030248. Epub 2012 Feb 8.
  6. Crane JD, Ogborn DI, Cupido C, Melov S, Hubbard A, Bourgeois JM, Tarnopolsky MA. Massage therapy attenuates inflammatory signaling after exercise-induced muscle damage. Sci Transl Med. 2012 Feb 1;4(119):119ra13. doi: 10.1126/scitranslmed.3002882.
  7. Field T, Hernandez-Reif M, Diego M, Schanberg S, Kuhn C. Cortisol decreases and serotonin and dopamine increase following massage therapy. Clinics (Sao Paulo). 2010;65(11):1105-10.
  8. Nerbass FB, Feltrim MI, Souza SA, Ykeda DS, Lorenzi-Filho G. Effects of massage therapy on sleep quality after coronary artery bypass graft surgery. Clinics (Sao Paulo). 2010;65(11):1105-10.
  9. Walach H, Güthlin C, König M. Efficacy of massage therapy in chronic pain: a pragmatic randomized trial. J Altern Complement Med. 2003 Dec;9(6):837-46.
  10. Castro-Sánchez AM, Matarán-Peñarrocha GA, Granero-Molina J, Aguilera-Manrique G, Quesada-Rubio JM, Moreno-Lorenzo C. Benefits of massage-myofascial release therapy on pain, anxiety, quality of sleep, depression, and quality of life in patients with fibromyalgia. Evid Based Complement Alternat Med. 2011;2011:561753. doi: 10.1155/2011/561753. Epub 2010 Dec 28.
  11. Kalichman L. Massage therapy for fibromyalgia symptoms. Rheumatol Int. 2010 Jul;30(9):1151-7. doi: 10.1007/s00296-010-1409-2. Epub 2010 Mar 20.
  12. Field T, Diego M, Cullen C, Hernandez-Reif M, Sunshine W, Douglas S. Fibromyalgia pain and substance P decrease and sleep improves after massage therapy. J Clin Rheumatol. 2002 Apr;8(2):72-6.
  13. Sherman KJ, Cherkin DC, Hawkes RJ, Miglioretti DL, Deyo RA. Randomized trial of therapeutic massage for chronic neck pain. Clin J Pain. 2009 Mar-Apr;25(3):233-8. doi: 10.1097/AJP.0b013e31818b7912.
  14. P.M. Barnes, B. Bloom, and R. Nahin. Complementary and Alternative Medicine Use Among Adults and Children: United States, 2007. CDC National Health Statistics Report #12, December 2008.
  15. S.R. Knauer, J.K. Freburger, and T.S. Carey. Chronic Low Back Pain Among Older Adults: A Population-Based Perspective. Journal of Aging and Health 22, no. 8 (December 2010): 1213-34.
  16. M. van Middelkoop, et al. A Systematic Review on the Effectiveness of Physical and Rehabilitation Interventions for Chronic Non-Specific Low Back Pain.  European Spine Journal 20, no. 1 (January 2011): 19-39.
  17. J. Lee and P. Nandi. Early Aggressive Treatment Improves Prognosis in Complex Regional Pain Syndrome. Practitioner 255, no. 1736 (January 2011): 23-6, 3.
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Plantar fasciitis? Blame the shoes!

Plantar fasciitis: The aching feet

What is plantar fasciitis?

Plantar fascia is the thick, fibrous tissue that runs along the arch of the foot, from the heel to the toes. This tissue can become inflamed from overuse and other mechanical injuries. The pain is usually sharp, severe, and worse in the morning. People often describe the pain onset as “the minute I step off the bed”.
Apparently there has been a recent epidemic of plantar fasciitis among Americans. Experts believe the culprit is “flimsy shoes that don’t support the arch”- like flat shoes, flip-flops, and old shoes that have lost their cushioning.

What can you do?

  1. Change your shoes! Consider shoes with better arch support. If you exercise often, change your exercise shoes every 4-6 months.
  2. Insoles- to add extra arch support. You can get these either from a drugstore (like Dr. Scholl’s shoe inserts) or custom-made by your doctor
  3. NSAIDs- non-steroidal anti-inflammatory drugs like advil, ibuprofen, or aleve
  4. Stretching- stand against a wall and stretch out the affected foot every morning
  5. Shock-wave therapy- this is the use of acoustic shock waves in the affected areas to decrease inflammation
  6. Corticosteroid injections by your rheumatologist or podiatrist
  7. Surgery

 

Personally, I would start with more foot-friendly shoes!

http://www.latimes.com/health/la-he-feet-20130309,0,5785167.story

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Take care of your back! –Prevent back pain

Can we prevent back pain?

The other day I watched a friend carry 2 stacked heavy cases of bottled water out of Trader Joe’s. I gasped: “Are you being unkind to your back?”

Back pain is common. In fact, 80% of us experience some kind of back pain during our lifetime. We don’t have control over some causes of back pain- like inflammation or cancer. However, how we live our lives has a lot to do with how often we get mechanical back pain and how permanent the pain will be.

Common causes of mechanical back pain

  • Muscles- muscle spasm, “unbalanced muscles”, weak muscles
  • Spine- misalignment, arthritis, scoliosis, fractures
  • Disks- degeneration, dessication, herniation, bulging
  • Nerves- impingement, spinal stenosis, “sciatica”

All of us can remember instances where we have been unkind to our back- like carrying that backpack on one shoulder, slouching on the couch while watching TV, or lifting really heavy objects like my friend from Trader Joe’s. Some of what we do causes strain or spasms in our muscles. Trauma, repetitive movements, and excessive pressure can cause arthritis (joint wear-and-tear) of the spine joints and disk herniation. Unlike muscle spasm, arthritis in the back is not reversible. Once the anatomy of the bones and disks has changed, this can put pressure on the nerves the course between them. Pressure on the nerves can cause pain, numbness, tingling, and weakness (one example is sciatica).

Take care of your back!

There are several ways you can prevent back pain and damage to the back structures:

        1.  Proper posture

Sit and stand up straight. Avoid slouching, excessive leaning or hunching over things, or sinking into soft sofas. Did you ever see the movie “My Fair Lady“? In it, professor Higgins teaches a cockney flower girl good posture by having her walk while balancing a book on her head. Pretend you have a book on your head at all times! Besides protecting your back muscles, people with good posture appear more confident. I found good posture tips on this website .

2.  Exercise

Stretching and exercising regularly can help prevent back pain. Strengthening the muscles that support your spine take some of the load off your spine and minimize muscle injury. A Pilates instructor told me that people with strong core muscles (including abdominal muscles) do not suffer back pain. I have to admit this to be true- I have not had any back pain since I stated Pilates 3 years ago.

3.  Avoid heavy lifting

Lighten the load as much as possible. Make a few more trips when unloading your groceries from your car and carry less on each trip. Downsize your suitcase- you will never wear all those clothes on your trip!- consider taking a carry-on instead (also a fee-saving strategy!). Leave your laptop at home/work- instead of carrying it back and forth every day- memory sticks are much lighter. If you just have to lift and carry something heavy, do it properly: 1) Bend at the knee, not the waist; 2) Use your legs and knees to lift up, and keep your spine straight; 3) Keep your back straight while carrying a heavy object. Don’t arch back!

4.  Lose weight

Every extra pound on your body is putting pressure on your back. Imagine walking around with a sandbag on your back- or multiple sandbags. You may not be aware of the weight of the extra pounds because you have acquired them over time, but your spine definitely feels it. Now imagine if you carry the sandbag in the front (ie. you have a belly)- the change in the weight distribution can put further strain on your spine. Weight loss is one of the most effective treatments for chronic low back pain.

5.  Stop smoking!

Studies have shown that smoking is a risk factor for developing back pain. It is thought that the damage caused by smoking on the blood vessels supplying the discs and joints may be responsible for the back pain. In addition, smoking has been correlated with osteoporosis, which weakens the bone structure and makes one prone to vertebral fracture.

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Herbal and natural supplements for arthritis

Not infrequently, once I have explained the diagnosis of arthritis, its manifestations and treatment options, a patient will ask me “what herbal or natural supplements can I use to help my condition?  Although not heavily emphasized in Western medicine, there have been several studies on the effects of herbal and natural supplements for arthritis pain. So I decided to make a comprehensive review of what has been proven to work.

 Things to consider

First, let me start by making a couple of points about natural supplements in general:

  • Just because something is “natural” it does not mean it is harmless. Read carefully about potential side effects.
  • Natural remedies are not regulated by the FDA, so their composition may be variable and their claims may be untrue. (see blog on Reumofan)
  • The ingredients in some herbal supplements are the same as those found in FDA-approved drugs
  • The supplements may interfere with your other medications, so please review them with your doctor
  • They may help with mild arthritis, but chances are you may need stronger drugs if your arthritis is severe!
  • Herbal supplements may not be safe in pregnancy or breastfeeding

Herbal and natural supplements for arthritis:

 

Where is comes from

What it claims to do

Dose

Potential side effects

Glucosamine Sulfate

Derived from the shells of shellfish

Reduce osteoarthritis pain and slow progression. Lubricates joints

1500mg/day

-people with shellfish allergy may be allergic

-may interact with blood thinners

-can increase blood sugar

-can increase cholesterol

Chondroitin Sulfate

Usually from bovine trachea or pork by-products

Reduce osteoarthritis pain and slow progression

800-1200 mg/day, usually with Glucosamine

-remote possibility of mad cow disease if contaminated

-may cause blood thinning

-use with caution if sulfa allergy

-diarrhea, constipation

Omega-3 fatty acids

Found in fish oil (salmon and tuna), Canola oil

Decrease joint inflammation and pain

1-4 grams

EPA/DHA

-may have a fishy taste

-can increase risk of bleeding

-may contain high levels of mercury

-can cause gout flare

-gas, diarrhea, bloating

DHEA

(dehydro-epiandrosterone)

A natural hormone produced by the adrenal glands

Reduce disease flare in lupus and perhaps rheumatoid arthritis

10-25 mg/day

-acne, facial hair, menstrual irregularities

-abdominal upset

-may worsen liver function

-contraindicated in prostate cancer and uterine fibroids

S-adenosylmethionine (SAMe)

Naturally occurring chemical in the body.

Sold as a drug in Europe

Reduce pain and stiffness from osteoarthritis, fibromyalgia,  rebuild cartilage, help depression

400mg twice per day

-expensive

-avoid if bipolar disorder

-nausea, vomiting, diarrhea, headache

Borage oil

From Borage plant seed

Anti-inflammatory and anti-thrombotic properties

1300mg/day

-increased risk of bleeding

-liver damage

-bloating, upset stomach

Turmeric

(Curcumin)

From turmeric plant root

Reduce joint pain and inflammation

0.5-2 g/day

(capsule or spice)

-can thin the blood

-stomach upset

-contraindicated in people with gallstones (causes flares)

Ginger

From ginger plant root

Reduce joint pain and inflammation, helps circulation in Raynaud’s, also motion sickness

30-500 g

Any form

-can interfere with Coumadin (warfarin)

-can increase bleeding risk

-contraindicated in people with gallstones

-considered safe by the FDA

Green tea extract

Concentrated from green tea

Anti-oxidant effects, help RA and Sjogren Syndrome

Capsule, liquid extracts

-liver inflammation

-insomnia (it has caffeine)

Arnica

From Arnica flower

Help muscle aches, sprains, bruises, joint pain

Topical cream or ointment

-should not be taken by mouth without medical supervision

-skin irritation, eczema

Avocado soybean unsaponifiables

Made from avocado and soybean oils

Slow breakdown of cartilage

300mg/day

-upset stomach

Cat’s claw

From the bark of an Amazon vine

Anti-inflammatory properties (mild)

250-1000 mg/day

-can lower blood pressure

-nausea, headache, dizziness

Boswellia

From the bark of the Boswellia tree in India

Reduce inflammation and pain in RA and OA

100-250 mg/day

-stomachache, diarrhea

-skin rash

Evening primrose oil

From the evening primrose seed

Contains gamma- lineloid acid (GLA)

Reduce arthritis pain

 

-increased bleeding risk

-may cause seizures

-may interact with medications

-nausea, diarrhea, headache

Black current oil

From black current seeds

 

 

Insufficient data

DMSO

 

Decrease joint pain and inflammation

 

Conflicting data in clinical studies

Thunder god vine

 

Helps symptoms of rheumatoid arthritis

 

Severe side effects including:

-temporary infertility in men, amenorrhea (lack of periods) in women, decreased bone density, suppressed immune system.

-Some parts of the plant are poisonous and can cause death.

 

 

Reference:

http://www.arthritistoday.org/treatments/supplement-guide/supplements/index.php

http://www.rd.com/health/wellness/6-supplements-for-arthritis-sufferers/

http://www.webmd.com/rheumatoid-arthritis/guide/rheumatoid-arthritis-best-worst-supplements-herbs

http://www.rheumatology.org/practice/clinical/patients/diseases_and_conditions/herbal.asp

http://www.mayoclinic.com/health/osteoarthritis/DS00019/DSECTION=alternative-medicine

http://www.mayoclinic.com/health/rheumatoid-arthritis/DS00020/DSECTION=alternative-medicine

 

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8 secrets to finding a great Rheumatologist in Los Angeles

If you have ever looked for a rheumatologist in the Los Angeles area, you would know this is not a simple task. In fact, there are over 50 rheumatologists in the 15 mile radius encompassing Los Angeles. So how does one go about picking the best rheumatologist in Los Angeles?

I put together a list of strategies I would use if I were looking for one:

 1)     Words from the wise- Referrals

Your primary care physician may recommend a good rheumatologist. If you like your primary doctor, chances are you may like the doctors he/she refers you to as well. If you have a friend or family member who sees a rheumatologist, you can also ask them how their experience has been. They can give you the inside scoop on a doctor you will not read on any website!

 

2)     Printed words

Your medical insurance may provide you with a list of their in-network rheumatologists in Los Angeles. You can also find a list of rheumatologists in your immediate are on the American College of Rheumatology website (click here). You can do a web search, but keep in mind not all rheumatologist may have a website or be advertised on the web.

 

3)      The rubber band test

Keeping in mind that the field of rheumatology is constantly changing, I would want a doctor who is aware of and can adapt to the change. New treatments options are rapidly emerging for conditions we had little options for in the past. Rheumatologists that keep up-to-date with the latest developments in the field will be able to offer you more treatment options. Rheumatologists update their knowledge by reading up on the latest journals and attending informational conferences. Some examples of these conferences include the yearly rheumatology meetings by the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR), and the Carl Pearson conference in Los Angeles, to name a few.

 

4)      Age is in the eye of the beholder

With age comes experience, which is indeed valuable when treating rare diseases. However a rheumatologist who just completed training may be fresh with the most up-to-date information. So which to pick? Perhaps a compromise- a rheumatologist with a few of years of experience may offer the best of both worlds.

 

5)      The gift of time

Most of us living in Los Angeles are familiar with the concept of time shortage. However, when it comes to your rheumatologist, abundance is your wish. Rheumatologic conditions are often complex and need a patient pair of ears to get the full picture.  Also, it will be helpful to have your rheumatologist call you back sooner than later when you have a concern, or be able to squeeze you in the same day when you have an emergency. You may not be able to get the attention you want if your rheumatologist is very busy.

 

6)      Back to school

The academic centers are home to some brilliant minds in rheumatology. After all, these are where most of the research in the field is done. The Los Angeles area is rich with such centers- UCLA, USC, Harbor-UCLA, and Olive-View, to name a few. However, getting care in an academic center can be a double-edged sword, as there is often a lot of demand on the time of an academician- from patient care, to research, to administrative duties. Personally, I would opt for a knowledgeable community rheumatologist who has more time to spend with me, and reserve the academician for second opinions.

 

7)      “I know that I know nothing.” –Socrates

No one can pretend to know everything in medicine. I think the best quality of your rheumatologist – or any doctor for that matter- is to admit when he does not know the answer but will try his best to find the answer for you, or will send you to someone who will.

 

8)      Peas in a pod

So you have now seen your rheumatologist a few times and have a feel for his style. The question now becomes- do you get along with your rheumatologist? Do you feel your concerns are listened to? Is he willing to adjust his therapy to your beliefs? Do you trust him? If the answer is no, it may be time to look for another rheumatologist.  If the answer is yes, then congratulations! You have found yourself a great rheumatologist!

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Reumofan – a wolf in sheep’s clothing

Reumofan is…

Reumofan (or Reumofan Plus) has been called the miracle drug by many who have used it. Still, others believe Reumofan to be harmful. After my own patients reported their experience with this drug, I decided to take a closer look at the enigma that is Reumofan.

What prompted this blog

Last week I saw a young woman who was referred for evaluation of swelling in her legs. A quick exam made it obvious that her problem was not rheumatologic. “But why do I have this swelling?”, she asked through tears. Her legs had been swollen for about 4 months, and all labs and imaging studies were normal. In addition, she pointed to an annoying rash that had appeared on her entire face for the same length of time. She had already seen a dermatologist and an allergist, but nothing they gave her was working. She was clearly miserable.

We went through everything she had done and everywhere she had been before these symptoms started. “Any new medications?”, I asked, but her answer was no. When I asked if she was taking anything herbal or over the counter she replied, “well, not now, but 6 months ago I took a supplement from Mexico for plantar fasciitis, but stopped it about 3 months ago”. I was not familiar with Reumofan then, but a quick google search revealed concerns that it may contain dexamethasone, a form of steroids. Suddenly my patient’s symptoms made sense: as expected with long term steroid use, she had gained 30 lbs and developed swelling in her legs, in addition to steroid-acne on her face. In addition, she was at risk of adrenal insufficiency, a life-threatening condition that can occur if steroids are stopped abruptly.

After I saw my second patient with lower extremity swelling and weight gain- this time a middle aged man who had taken Reumofan for low back pain- I started to do a more in depth search on this drug. What I found was petrifying. “Reumofan” or “Reumofan plus” has been marketed as a “100% natural”, Mexican herbalary product to treat arthritis, tendonitis, muscle pain, osteoporosis, bone cancer, and a variety of other conditions. It has been sold not only in Mexico, but online in US and Canada.

Review on Reumofan

Blogs dating back to December of 2011 described a magical effect of this drug- aches and pains rapidly disappeared, people reported a “boost of energy”, and they were able to do things they could not previously. By March of 2012 people taking Reumofan started blogging about weight gain, leg swelling, irritability, sleep disturbance, muscle cramps, and abnormal hair growth, among others.

On June 1, 2012, the FDA, working closely with the Mexican government, issued a warning about Reumafen plus. An FDA laboratory analysis of Reumofan plus found that it contains a few hidden ingredients: diclofenac sodium and methocarbamol. The Mexican Ministry of Health discovered that at least one lot of the product contains the corticosteroid dexamethasone. Consumer adverse reports to the FDA included many of the side effects expected with these ingredients.

The FDA updated its warning on August 21, 2012, noting more reports of fatalities, stroke, severe gastrointestinal bleeding, dizziness, insomnia, high blood sugar, and problems with liver and kidney functions, as well as corticosteroid withdrawal syndrome.

Let’s take a look at what these ingredients actually are:

  • Dexamethasone– a form of steroids, it is a powerful anti-inflammatory medication with rapid efficacy but many side effects when used long term. It is one of the medications that I as a rheumatologist commonly prescribe, but would monitor the patient frequently and carefully and try to wean off as fast as possible. It should never be stopped abruptly as that can lead to adrenal insufficiency. Potential side effects include:
            -weight gain
            -water retention (which can cause swelling in the legs)
            -heart failure
            -skin thinning and easy bruising
            -osteoporosis
            -gastrointestinal ulcers and bleeding
            -cataracts
            -steroid acne
            -steroid psychosis
            -adrenal insufficiency when stopped abruptly (some of the symptoms include fatigue, nausea, low blood pressure, dizziness. It can cause death).
  • Diclofenac sodium (Voltaren)- a prescription non-steroidal anti-inflammatory drug (NSAID), similar to ibuprofen, advil, naproxen, aleve, meloxicam, etc. It may be contraindicated in people with heart disease, kidney disease, or those on blood thinners. It also should not be combined with aspirin or other NSAIDS as it can increase the risk. Potential side effects include:
            -gastrointestinal upset, ulceration, perforation, and bleeding (black box warning)
            -increased risk of cardiovascular events like heart attack, clots, and stroke (black box warning)
            -kidney failure
            -increased risk of bleeding in people on blood thinners
  •  Methocarbamol (Robaxin)- a prescription muscle relaxant, which can cause sedation, dizziness, and impaired mental status. Its use is not recommended in people older than 65.

These ingredients may also interact with other medications and result in serious adverse events.

What is the take-home message?

First, if you have taken or are currently taking Reumofan, make sure to alert your doctor. Do not stop it abruptly as it may cause serious problems. Report any side effects to the FDA (click here).

Second, let’s be more skeptical of supplements that claim to be “all natural”, especially if they come from Mexico.  This is not the first time I have seen a supplement from Mexico contain steroids.

Third, just because a product is natural, or claims to be, it may not be necessarily safe. For example, Ginko biloba can cause serious bleeding and Ginsing can interact with Coumadin (a blood thinner). Keep in mind that tobacco is also a natural product.

Finally, if you see a number of side effects listed on FDA-approved drugs, it’s because these drugs have been extensively tested and side effects are carefully reported. The side effects of many “natural” supplements are unknown. While I am a proponent of herbal supplements that have been around for a long time, like turmeric or glucosamine for arthritis, I advise judicial skepticism when considering a new product with promises too good to be true.

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Why rheumatology?

I’m often asked why I chose rheumatology.

Well the answer is that I didn’t- at first. In fact during most of my internal medicine residency, I thought I was going to be a gastroenterologist.

 

Like any competitive GI hopeful, I worked hard on research, publications, mentoring, and even applied and interviewed for GI fellowships. It was during the application process where I had to write all about why I loved the field of gastroenterology so much that I realized that I really did not.

 

After this earth shattering revelation, I had to exercise some deep soul searching to figure out what I really was passionate for. Everywhere I looked, I saw exceptional heroes. The surgeon cutting out the tumor and saving the day. The cardiologist thumping the heart back to life like a knight in shining armor. The gastroenterologist stopping the bleeding like Spiderman with those sticky fingers.

 

Although mesmerized by the glitter of heroism, I knew I was looking for something different. The artist in me rejected algorithms and longed for creativity- for a kind of medicine that artfully designed a gown to perfectly fit an individual patient. My passion for mystery and puzzles also spoke up. I have always liked being a detective, finding clues where there are few to find, and solving the case. After all, it is an art.

 

It soon became clear to me that rheumatology had all the ingredients I was looking for. Since many of its diseases are so rare, it truly takes a dedicated detective to solve the case. By the same token, there are often no algorithms to lead the treatment- therapy requires artfulness in creating a regimen that works for that patient given their unique circumstances. I sometimes compare rheumatology to trying to solve a 50-piece puzzle, when you have only 10 pieces available to you. It takes some craftiness to get the full picture. And that is why I love this field.

 

And now, the field of rheumatology is evolving. New treatments have emerged for many of our diseases, and they have revolutionized treatment of these diseases. This has made my job even more exciting. Every day, when I figure out a disease that may have gone undetected for months, and artfully craft a treatment that dramatically impacts someone’s quality of life, I truly feel like a hero.

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