Rheumatology. You might think of it as the “Fifty Shades of Gray” of medicine. It’s confusing, and nothing about it is black and white. It’s why I love rheumatology. And it’s also why none of my friends picked it.
Understandably, there are a lot of misconceptions when it comes to rheumatologic conditions, medications, and tests. Today, I’m excited to clear the air.
Not all arthritis is created equal.
“Arthritis” isn’t a very specific word. It simply means that a joint hurts…but it tells us nothing about why a joint hurts. There are many causes of joint pain, and treatment depends on the cause. The most common type is osteoarthritis, which is due to wear and tear of aging. Treatment involves physical therapy, exercise, and weight loss. On the other hand, inflammatory arthritis (like rheumatoid arthritis) occurs when the immune system attacks the joints. Treatment requires special medications that stop the immune system attack (immunosuppressants).
Immunosuppressants don’t equal nonstop infections.
If you have inflammatory arthritis, immunosuppressants are the #1 way to help you feel better and protect the joints from permanent damage. But since they must turn off a piece of the immune system to work, they all come with a slight increased risk of infection.
This may sound scary. But the risk is small, and we’re mainly talking about basic infections like the common cold. I could count on one hand the number of my patients that have been hospitalized for severe infections while taking these medications. And, those patients all had other health problems that increased their infection risk. I am not fielding calls left and right from patients sick on these drugs — even in the era of COVID-19.
Vaccines are the best way to protect yourself from infections while taking immunosuppressants. Talk to your rheumatologist to find out which ones are right for you.
Negative blood tests don’t rule out rheumatoid arthritis (RA).
About 20% of people with RA have negative RA blood tests (RF and anti-CCP). We call this seronegative RA, since “sero” means blood. If the tests are negative, a rheumatologist can still diagnose RA based on symptoms and physical exam alone. Old school, right? But effective.
A positive ANA doesn’t always mean lupus.
Of all tests in rheumatology, ANAs are ordered most often…and helpful least often. That’s because positive ANAs are common. They’re found in up to 20 percent of healthy people. And once you’ve got a positive ANA, it almost always stays positive for life. Repeating ANA tests isn’t necessary since higher titers (levels) don’t mean you’re “more autoimmune.” Symptoms and physical exam findings matter most when it comes to diagnosing autoimmune conditions. As rheumatologists, we take care of human beings — not positive blood tests.
Methotrexate doesn’t cause instant liver failure.
All medications — even Tylenol — have potential side effects. When it comes to methotrexate, abnormal liver tests (AST and ALT) may occur. That’s why your doctor checks labs every two to three months to confirm it’s safe for you to continue taking the drug. If your liver tests are elevated, methotrexate will be paused, decreased, or stopped. Then, liver tests return to normal. No instant liver failure here.
Hydroxychloroquine (Plaquenil) doesn’t cause instant blindness.
Hydroxychloroquine may rarely cause eye side effects, but instant blindness isn’t one of them. Here’s the deal. After 10 years of daily hydroxychloroquine use, 2% of people develop signs that the medicine is affecting the retina (the back part of the eye). That’s why the American College of Rheumatology and American Academy of Ophthalmology recommend an eye exam when you start hydroxychloroquine, and then yearly exams after taking hydroxychloroquine for more than five years. If the exam is abnormal, the drug is stopped to protect the eyes from vision damage. That’s it. Hydroxychloroquine is a safe medication, and when it comes to lupus, it even saves lives. It’s just a matter of keeping an eye on you to confirm it’s safe to continue. (See what I did there?)
Legs and ankles swollen? It’s not always arthritis.
Arthritis of the ankles can cause pain and swelling. However, edema — fluid pooling in the legs and feet — causes swelling too. Veins return blood to the heart. When we’re sitting or standing all day, veins fight an uphill battle to return the blood and don’t always win. Fluid can pool in the legs and feet at the end of the day, causing swelling, tightness, burning, and discomfort.
Propping your feet up on pillows will help, but compression stockings are even better. These are tight knee-high stockings that squeeze fluid back into the veins. You can buy them over the counter or online. Start with a pressure rating of 15 mm Hg, and test out different sizes to see what fits. They should be tight, but not cutting off your circulation.
ESR and CRP aren’t useful when it comes to monitoring arthritis.
ESR (sed rate) and CRP are blood tests. They are nonspecific markers of inflammation in the body that can be elevated for many reasons, including obesity, older age, infection, cancer, and stress. Studies have shown that ESR and CRP don’t reliably determine if arthritis is better or worse, so don’t worry if your labs are always abnormal! The best tools we have for assessing arthritis are free —symptoms and physical exam.
There’s no “best” medication for arthritis.
No two people with rheumatologic disease are alike, so there’s no one-size-fits-all approach to arthritis medication. The “best” medication is the one that works for you! It can take time to find the medicine or combination of medicines that gets your arthritis under control. But, there’s a regimen out there that will help.
Exercise and arthritis go together.
When it comes to arthritis, exercise is your friend. I’m not talking about running a marathon or joining a CrossFit gym. Rather, I’m talking about gently getting the body moving to increase muscle strength and preserve flexibility. When joints hurt, exercise might sound impossible. But sitting still decreases flexibility and strength over time, worsening arthritis in the long run.
Meet yourself where you are. Start small. Do you think you could go for a one-minute walk today? Do you think you could do that every day this week? Awesome. Next week, up it to five minutes. If that’s too much, shoot for two minutes. Before you know it, you’ll be up and moving again — for longer and longer each week.
If walking isn’t a realistic choice for you, don’t sweat it. Physical therapy or walking waist-deep in a pool are options, too. A physical therapist can recommend exercises specific to your current abilities. And walking in water is less painful than walking on land since water takes weight off the joints.
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