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In January 2009, our guest expert was Dr. Dana Jerome, a rheumatologist at Women’s College Hospital.

Dr. Jerome completed her medical training and residency in internal medicine at the University of Western Ontario. She then did rheumatology training at the University of Ottawa followed by a fellowship in systemic lupus at the University of Toronto. Dr. Jerome later completed a Master’s degree in education at the Ontario Institute for Studies in Education at the University of Toronto.

Dr. Jerome runs a general rheumatology clinic at Women’s College Hospital. In this clinic she treats many rheumatic conditions. This includes inflammatory arthritis (such as rheumatoid arthritis), autoimmune conditions (such as systemic lupus) and other conditions ranging from gout to osteoporosis. She also teaches medical students and residents at the University of Toronto.

Here are Dr. Jerome’s answers to your questions on Arthritis:

Q: I have osteoarthritis in my hands and have been taking ibuprofen. I just read an article by a woman who reduced her pain through exercise and weight loss. Her doctor told her to make sure she takes her full dosage of Tylenol every day as well. Should I be taking Tylenol for my arthritis instead of ibuprofen?

A: Patients with osteoarthritis in the knees have been shown to benefit from even small amounts of weight loss. But weight loss is unlikely to have any effect on the pain in your hands. Exercise also has lots of positive health benefits, but mainly for knee and back joints.

Both Tylenol (acetaminophen) and ibuprofen are good ways to treat the pain of osteoarthritis.  Tylenol tends to be a bit safer as it won’t irritate the stomach lining or affect blood pressure or the kidneys.  It is often the first medication recommended by doctors.  If you are unsure of your risks for taking anti-inflammatory drugs like ibuprofen, check with your doctor first.


Q: Does glucosamine help repair cartilage and does it help arthritis sufferers? There seems to be some debate about whether or not to take it with chondroitin: some people are in the pro camp, and some are against it. My family says that their dogs do well using it!

A: There is very little good scientific evidence about the benefits of glucosamine.  Most of the reputable studies show that it has no significant effect building cartilage in osteoarthritis. While chondroitin sulfate may be useful, we await good published evidence about this.

Glucosamine is not harmful unless you have a concern about blood sugars. It may be helpful for pain, even if it doesn’t build cartilage. I recommend that my patients try it at the suggested dose for three months. If they have received no benefit in that time period, there is likely no use in continuing with this therapy.


Q: What tests are used to diagnose arthritis? Are there different tests for diagnosing different types of arthritis?

A: There is no single diagnostic test for any of the different types of arthritis. Arthritis requires a clinical diagnosis based on a combination of a patient’s symptoms, findings on physical examination, and, in some cases, results of blood tests and x-rays. All types of arthritis are a little different from each other and need different combinations of tests and findings to confirm the diagnosis. If you have a question about the type of arthritis you may have, see your family physician. If s/he remains uncertain, you should probably be assessed by a rheumatologist.


Q: What is the connection between falling estrogen levels (as at menopause) and the onset of arthritic symptoms? When I stopped my hormone therapy, I developed arthritic pain and swelling within a matter of days.

A: It is very common to have joint pain at menopause or when discontinuing hormone therapy. It should not be associated with joint swelling. If you have significant swelling in the joints, you should be assessed for a form of inflammatory arthritis which would likely be unrelated to the loss of estrogen.


Q: Is psoriatic arthritis usually accompanied by psoriasis on the skin on or near the affected joints? I have patches of psoriasis on my hands (mainly on the knuckles of my right hand) and some very prominent nodules on those joints. I have a lot of pain in my hands, as well as loss of strength. I'm wondering if this might be psoriatic arthritis. Are there specific measures that I can take to minimize my pain and loss of function? I am 63.

A: Psoriatic arthritis is very common in patients with psoriasis.  Studies suggest this occurs in up to 30 percent of psoriasis patients.  The fingers and nails involved with psoriasis tend to be the ones also affected by arthritis.  By your description, psoriatic arthritis appears to be a concern and I think you should be assessed by a rheumatologist so that you can get a proper diagnosis.

Treatment is varied and will depend on many factors.  There are many treatment options so you should make sure you have a proper assessment so that you can be treated appropriately.


I have rheumatoid arthritis and lower back pain. The pain affects the area from my waist to my tailbone. I was told that rheumatoid arthritis does not affect the lower back. If it is not rheumatoid arthritis, then what is it? What types of inflammatory arthritis affect the lower back and act just like rheumatoid arthritis?

A: You are correct. Rheumatoid arthritis does not affect the lower back. By far the most common causes for lower back pain are degenerative disc disease and osteoarthritis. These can co-exist with rheumatoid arthritis and will not respond to most of the medications we use to treat rheumathoid arthritis. There are a few forms of inflammatory arthritis that can affect the low back (spondylitis) or the sacroiliac joints (sacroiliitis). You should discuss your back pain with your doctor to ensure proper diagnosis and treatment.


Q: What is the best way to prevent the onset of inflammatory arthritis?

A: Unfortunately we do not have any ways to prevent the onset of inflammatory arthritis.  We are still trying to understand the cause of diseases such as rheumatoid arthritis. It is likely that rheumatoid arthritis is caused by a combination of factors such as genetics, and triggers to our immune system and the inflammatory mechanisms in our body. These are things we cannot control.

Osteoarthritis in the knees, on the other hand, can often be prevented by keeping a healthy weight, preventing injury and keeping your leg muscles strong.


Q: I have been diagnosed with rheumatoid arthritis and I am taking methotrexate (MTX), Celebrex, Pariet and folic acid. I was told to avoid the sun as much as possible. Why do I have to avoid the sun? I am a golfer and would like to continue playing as much as I can. Thanks!

A: Methotrexate rarely causes skin problems but photosensitivity (easy sunburn) has been reported. Although photosensitivity is unlikely, it is best to protect yourself from the sun by wearing sunscreen and a hat. Protecting yourself from the sun is good for lots of other reasons.


Q: I am 61 years old. I am taking glucosamine for my arthritis. I seem to have arthritis in most of my body but my feet are my biggest problem. If I walk or am on my feet for any length of time, I can hardly move because of the pain. I have orthotics but they are hard to get into my shoes and they are sticky to walk on. Can you suggest anything to help?

A: Feet are a common place for arthritis. Some foot problems, such as bunions and hammer toes, can be corrected surgically. Many other foot problems cannot be corrected surgically or medically and we are left with trying to control the pain or modify our footwear so that we are a little more comfortable.

Orthotics or even custom shoes can be very useful for foot pain. They have to be good orthotics, and if your orthotics are not working, you should probably get them checked or redone. We generally recommend updating orthotics every 18-24 months.

Sometimes taking pain medications like Tylenol before walking will help.  If you are busy every day, you may need to take something for pain on a regular basis. The joint of the first toe is one that might be helped temporarily by a corticosteroid injection. You should discuss these options with your doctor.


Q: I have osteoarthritis in my cervical spine, knee and shoulder joints, plus rotator cuff injuries. I am taking Arthrotec (75 mg) twice a day for two weeks to see how it helps me. I have been taking it for one week now and it has helped me. In contrast, ibuprofen did very little to ease the discomfort. How does Arthrotec work to provide pain relief? What side effects can I expect?

A: Both Arthrotec and ibuprofen are non-steroidal anti-inflammatory medications (NSAIDs).  The ibuprofen that you buy over-the-counter is not a comparable dose to a prescription NSAID.

All NSAIDs have potential side effects. The most common one is stomach upset or even ulceration.  Although uncommon, it is a concern, especially in older people and/or those who have other medical illnesses.

NSAIDs work with different degrees of success. If you find one that works for you, that is great!

Patients at risk for stomach complications should take NSAIDs in combination with a stomach protector medication. Arthrotec is a combination pill with the NSAID component (diclofenac) mixed with a stomach protector (misoprostol). There are other stomach protectors which may be more effective. All NSAIDs have the potential to increase blood pressure and affect the kidneys. Although these side effects are not common, older patients and/or those with other medical problems, should be monitored by their doctor.


Q: I have had pain in my right thigh for many years. Recently, the pain has moved up to my hip and it hurts to lie on it. Every step is painful. When I am sitting, I have burning pain around the edge of my waistline accompanied by lower back pain. Is this arthritis? Thank you. I have always been a "walker" and a "biker" and these activities are becoming difficult.

A: Arthritis may be a cause of your pain but it sounds like you need a proper assessment to determine if there are other causes. Often it is difficult to figure out where the pain is coming from. Pain from the back, hip, or even the knee can feel similar. Getting a proper diagnosis will help point you in the right direction for the appropriate treatment. 


Q: When I wake up in the morning, the finger joints of my right hand are stiff and it is not easy for me to bend the fingers. Is this arthritis?

A: Arthritis can be a cause of stiffness in the fingers in the morning. But a diagnosis of arthritis cannot be made on symptoms alone. You need a proper assessment to confirm arthritis.


Q: I was diagnosed with rheumatoid arthritis in October of last year. I have not taken any medications except non-steroidal anti-inflammatory drugs (NSAIDs). My husband and I would like to have more children and have heard that we should stay off any other kinds of medication until we are finished having kids. Could the NSAIDs put me at risk or cause irreversible damage? Should I be taking anything even if my RF (rheumatoid factor) levels are not that high? Can having hyperthyroidism affect rheumatoid arthritis and its treatment?

A: If you have a proper diagnosis of rheumatoid arthritis, the sooner you receive disease-modifying therapy, the better your joints will be in the long run.  In most cases, symptoms of rheumatoid arthritis get better in pregnancy. There are some medications that can be used safely during pregnancy and nursing.

If you have a lot of joint activity, it may not be wise to wait several years before initiating therapy as joint damage may occur in the interim. The NSAIDs will not cause irreversible damage to the joints but the lack of a disease-modifying agent can. This is a discussion you should have with your rheumatologist.

The rheumatoid factor level is not an indicator of how severe your joint disease is and should not play a role in making treatment decisions.  Your disease activity can be better assessed by examining the number of tender and swollen joints, and by measuring certain inflammatory markers in your blood.

No, your thyroid disease should not affect rheumatoid arthritis or its treatment.


Q: I have just had major reconstructive surgery to my feet, to correct a deformity in my toes, caused by rheumatoid arthritis. The knuckles in my toes and the metatarsal joints under my feet were removed. Will this procedure prevent any further deformity or damage to my feet in the future?

A: If the metatarsal heads were removed, you cannot sustain more damage to them. But that does not prevent further changes to the feet.

We walk on our feet every day. Over time, bones and tendons shift, especially when there has been previous damage. There are other joints in the feet and ankles that can continue to be affected by rheumatoid arthritis and may affect your feet.

The best thing to do is to make sure that your rheumatoid arthritis is under good control.  That will limit any further joint damage.  Making sure you have good supportive footwear and orthotics will help limit further mechanical changes.


Q: I was diagnosed with ankylosing spondylitis [arthritis that causes inflammation in the joints of the spine] when I was 34 years old. I am now 54 and I still have pain in my spine fairly regularly but am much better now than I was 20 years ago. Does this kind of arthritis ever go into remission or do people ever outgrow the disease? Thank you.

A: There is really no evidence that this disease burns out over time. Some patients feel that their symptoms get better as they age, but this is anecdotal and not based on any evidence. Many patients still have evidence of ongoing inflammation in their older years and could benefit from ongoing treatment, including some of the newer treatments not available 20 years ago.


Q: I would like to know how long a person can stay on methotrexate. I have been using methotrexate for seven years.

A: There is really no limit to the amount of methotrexate that a patient can receive. In the past, patients used to be followed to monitor their cumulative exposure to methotrexate. We no longer believe that is necessary. As long as you have the appropriate bloodwork – testing your liver and blood counts every 1-3 months – and the results are normal, you can likely safely remain on methotrexate.


Q: My 89-year-old mother has had to stop taking medication to treat her arthritis because it is the source of some internal bleeding. Her only pain relief now is Tylenol. The pain is now preventing her from doing things she loves and her mobility has deteriorated. She exercises very little. Is there any medication she could use to restore what she has lost?

A: Your mother should avoid all anti-inflammatory medications due to her bleeding complication. Acetaminophen (Tylenol) is used to control pain but not inflammation, and may not have a similar effect as the anti-inflammatories.

The first thing to do is to make sure she is taking an adequate amount of Tylenol.  Most patients don’t take enough making it ineffective.  Most patients can take 3-4 g/day but she should check with her doctor about the best dose for her situation.

Other than that, there are other stronger pain control medications that contain narcotics such as codeine. These can be used quite safely on a routine basis in patients who have chronic arthritis pain. These medications can have their own set of adverse effects and you should talk to her doctor about balancing the risks and benefits. There are other non-medical treatments which can help, such as physiotherapy, occupational therapy, and aids for walking and other activities. These might help maximize her function.


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