DMARDs non responder are considered for biologicals. However this patient can't afford biologicals. Is there any other way to control her disease activity?
In patients refractory to medications, one should not forget the effectiveness of surgery - early synovectomy or teno-synovectomy. This treatment was very popular in the 70's and its use should be recommended also today for selected patients (especially monoarthritis or oligoarthritic).
https://www.researchgate.net/publication/258837606_Surgical_synovectomy_of_the_knee_joint_in_rheumatoid_arthritis_%28Thesis_Abstract%29?ev=prf_pub
This is an abstract of my doctor thesis on surgical synovectomy (1980). Unfortunately, it is in German.
Data Surgical synovectomy of the knee joint in rheumatoid arthrit...
I would suggest surgery might be a bit radical at this early stage of her dissease and may solve a short term problem but not be of benefit for polyarticular RA over time. How do you define non responders? If you are undertaking regular Disease Assessment Scores and have some clear measurements together with blood results and measures of pain - it would be helpful to know. Have you used combination therapy or even triple therapy? But of course you will need to ensure regular blood monitoring.
But how many joints are swollen and tender? Is the ESR only attributed to her RA - could it be something else? Do you use CRP at all in India?
Dear Dr. Oliver,
Early synovectomy (in resistant to medicaments cases in a period of up to 6 months ) is more effective than late synovectomy when the joint is already severely destroyed. The goal of this treatment modality is to remove the terrain on which the rheumatic process takes place. That is why the results are very encouraging when the operation is done on the knee joints (more inflammed synovial tissue is removed !).
As far as I understood the RA process in this patient lasts about 5-6 months without satisfactory result from the application of multiple drugs. So in my opinion she is suitable for surgical synovectomy (open or arthroscopic). One of the classic works on surgery for RA is the monograph by the Swiss surgeon N. Gschwend named "Die operative Behandlung des chronischen Polyarthritis". I think there are some editions in English.
Madam Susan,last time when she visited me was one week ago.During the visit her MTPs were swollen and tender,wrist joints were swollen and tender,Both shoulder joints and knee joints were swollen and tender.Her CRP is positive and ESR is always on higher side.I also gave her shots of depot steroid but it dint help her much.
When you say DMARDS, what has she received thus far, for example, oral DMARD monotherapy, or a combination, say methotrexte with Plaquenil?
Does she have any underlying infective element e.g. TB etc? have all such possibilities been excluded? Also do you know she has been taking her DMARD's sometimes the fear without the understanding causes a problem.
I agree with above. Both TB and hep C infection need to be ruled out first so that appropriate DMARD therapy can be selected; also the daily dose of steroids should not be excessive,
I agree with above. This patient needs to see a rheumatologist for proper evaluation and treatment,
Hepatitis C and Tuberculosis has been excluded.Patient is receiving Methotrexate,sulfasalazine,hydroxychloroquine and leflunomide was also added.Biologicals is out of question as she wont be able to afford the cost.Rheumatologist consultation has already been taken Sir and Madam.
Thank you for the information. The combination of MTX, SSZ, and HCQ is appropriate. I would be careful however, mixing MTX with leflunomide since the incidence of hepatotoxity then becomes an issue. She would also need effective contraception because both MTX and leflunomide are highly teratogenic. Is she still having swollen and inflamed joints, or just complaining of pain? Many patients with RA have an associated chronic pain syndrome along the lines of fibromyalgia with some associated depression/anxiety, and if this is the case then the treatment would be different as opposed to be chasing pain control with immunosuppressive medications. If the RA is still active, the biological manufacturers can sometimes provide through a patient's assistance program the needed biological treatment for free. However, I don't know if this would be available in your location,
Is the patient on maximum doses of all therapies i.e. methotrexate 20 mg/wk, sulfasalazine 1g tds, hydroxychloroquine 400 mg od and prednisolone 10 mg od? Assuming that she is a reasonable BMI and her blood tests can tolerate this. If she does not respond to this, and cannot afford biologics, other combinations need to be considered such as using IM Gold or tacrolimus.
Well, if she is not responding to adequate doses of triple oral DMARD therapy with MTX, HCQ and SSZ, then other alternatives may be azathioprine and even minocycline. I am not fond of gold shots; I don't think they represent good DMARD therapy. Tacrolimus may be an option, as above. Again, is she having chronic pain or overtly inflamed joints reflecting active RA? Many patients with RA develop associated fibromyalgia with chronic pain all over, and the treatment here is not more immunosuppressive therapy; what are her CRP and other labs?
Hi
I agree with all the comments. However, I would highlight:
1) Confirm with a rheumatologist the diagnosis and there is not an added complication. 2) To consider or attempt to introduce the patient in a clinical trial of a biologic drug
accordin to EULAR and ACR if tw0 or one (methotrexate should included) DMARDs failed to control RA go for second line therapy which is biological tretment which uasually anti TNF
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