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Arthritis (Expert Forum)
RA vs SSLR
Answered by
Kevin Pho, MD - Internal Medicine
Kevin Pho, MD
Boston - MA
This forum is for questions and support regarding arthritis issues such as: Arthritis, Autoimmune Disease, Bursitis, Fibromyalgia, Gout, Juvenile Rheumatoid Arthritis, Lupus, Myositis, Neuralgia, Osteoarthritis, Polymyalgia Rheumatica, Rheumatoid Arthritis, Sciatica, Tendinitis, Vasculitis.
RA vs SSLR
by Sheryl75, Mar 30, 2005 12:00AM
Patient is 48 year old Cambodian female w/ family hx hypertension and autoimmune disorders (multiple drug/food allergies, IgM nephropathy, asthma).
Prior hx:
1) post-traumatic seizure disorder, well controlled on gabapentin1200 mg daily
2) hypothyroidism, euthyroid on 100mcg synthroid daily. Onset was after commencing gabapentin, ? secondary to the drug?
3) hypertension, generally well controlled on irbesartan 300mg daily but exacerbates emotionally stressed
Management of the above has been greatly complicated by allergic reactions to: dilantin, phenobarbital, valproic acid, ACE inhibitors, atenolol, thiazide diuretics.
Excepting valproic acid, all these reactions occurred 2-4 weeks after exposure with rash, urticaria, photophobia, malaise. s. Reaction to valproic acid occurred almost 2 years after initiating therapy and was of Stevens-Johnson type.
1 year ago for gradual onset on neck and shoulder pain radiating down the arms, and numbness in the hand. MRI showed nerve root compression at C5-7. EMG showed median nerve compression. She was treated with physiotherapy and with NSAIDs but latter had to be stopped after allergic reaction. Carpal tunnel release in June 2004 resolved numbness of hand but stiffness and pain at wrist and fingers con tinued & progressed to generalized polyarthralgias, impairing ADLs.
6 months ago, a rheumatologist dx'd RA based on clinical exam & elevated ESR. Placed on ASA and hydrochloroquine with initial e improvement in joint pain but allergic reaction required discontinuation . Switched to methotrexate. Joint pain did not improve and about 3-4 weeks into treatment she had another allergic reaction, this one of Stevens-Johnson type and very severe. Next placed on SSZ;t pain improved allergic reaction (rash/urticaria) required discontinuation.
A second rheumatologist/immunologist conducted more comprehensive exam including hand/wrist xrays, ANA, rheumatoid factor, C-reactive protein etc. All tests negative except for ESR which was elevated. Hand/wrist films showed only mild osteoarthritic changes disproportional to the amount of pain and functional impairment. He dx'd serum sickness rather than RA and rx'd prednisolone 30mg/day tapering down to 10mg.
Now 3 months later, prednisolone is 10 mg daily and joint pain continues to severely limit ADLs. Severity flunctuates but pain never completely absent. She has had 2 mild allergic reactions to drugs during this period. Every effort is made to avoid new drug exposures but unfortunately her other medical problems sometimes result in hospital or doctor visits where, despite being provided with the history, new drugs and/or drugs she is known to be allergic to (e.g. NSAIDs) are given.
Q:
How likely that arthralgia due to past drug reactions? If so, what is long term prognosis? Suggestions on management?
Could it instead be a adverse effect gabapentin or irbesartan? If so, what to do given allergy to most alternatives
Prior hx:
1) post-traumatic seizure disorder, well controlled on gabapentin1200 mg daily
2) hypothyroidism, euthyroid on 100mcg synthroid daily. Onset was after commencing gabapentin, ? secondary to the drug?
3) hypertension, generally well controlled on irbesartan 300mg daily but exacerbates emotionally stressed
Management of the above has been greatly complicated by allergic reactions to: dilantin, phenobarbital, valproic acid, ACE inhibitors, atenolol, thiazide diuretics.
Excepting valproic acid, all these reactions occurred 2-4 weeks after exposure with rash, urticaria, photophobia, malaise. s. Reaction to valproic acid occurred almost 2 years after initiating therapy and was of Stevens-Johnson type.
1 year ago for gradual onset on neck and shoulder pain radiating down the arms, and numbness in the hand. MRI showed nerve root compression at C5-7. EMG showed median nerve compression. She was treated with physiotherapy and with NSAIDs but latter had to be stopped after allergic reaction. Carpal tunnel release in June 2004 resolved numbness of hand but stiffness and pain at wrist and fingers con tinued & progressed to generalized polyarthralgias, impairing ADLs.
6 months ago, a rheumatologist dx'd RA based on clinical exam & elevated ESR. Placed on ASA and hydrochloroquine with initial e improvement in joint pain but allergic reaction required discontinuation . Switched to methotrexate. Joint pain did not improve and about 3-4 weeks into treatment she had another allergic reaction, this one of Stevens-Johnson type and very severe. Next placed on SSZ;t pain improved allergic reaction (rash/urticaria) required discontinuation.
A second rheumatologist/immunologist conducted more comprehensive exam including hand/wrist xrays, ANA, rheumatoid factor, C-reactive protein etc. All tests negative except for ESR which was elevated. Hand/wrist films showed only mild osteoarthritic changes disproportional to the amount of pain and functional impairment. He dx'd serum sickness rather than RA and rx'd prednisolone 30mg/day tapering down to 10mg.
Now 3 months later, prednisolone is 10 mg daily and joint pain continues to severely limit ADLs. Severity flunctuates but pain never completely absent. She has had 2 mild allergic reactions to drugs during this period. Every effort is made to avoid new drug exposures but unfortunately her other medical problems sometimes result in hospital or doctor visits where, despite being provided with the history, new drugs and/or drugs she is known to be allergic to (e.g. NSAIDs) are given.
Q:
How likely that arthralgia due to past drug reactions? If so, what is long term prognosis? Suggestions on management?
Could it instead be a adverse effect gabapentin or irbesartan? If so, what to do given allergy to most alternatives
Doctor's Answer
by Kevin Pho, MD, Apr 01, 2005 12:00AM
, Apr 01, 2005 12:00AM
Serum sickness is a clinical diagnosis, and can be considered given your hypersensitivity to prior medications as well as the negative workup thus far (except for the ESR). There is no specific test for this, except finding and removing the offending medications.
You are being appropriately treated for this, with corticosteroids. Finding the agent will result in curing the arthralgias. Sometimes doctors may add antihistimines to the treatment regimen.
Regarding the seizure medication, your allergies to many other classes makes it difficult to manage - I am not a neurologist, but I would suggest a referral to discuss other options.
There are several other classes of hypertensive medications (you are currently taking an angiotensin receptor blocker). Changing to a different one (i.e. Diovan or Avapro) or to a calcium channel blocker can be considered if the irbesartan is causing problems.
You can discuss these options with your personal physician.
Followup with your personal physician is essential.
This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.
Kevin, M.D.
Medical Weblog:
kevinmd_b
You are being appropriately treated for this, with corticosteroids. Finding the agent will result in curing the arthralgias. Sometimes doctors may add antihistimines to the treatment regimen.
Regarding the seizure medication, your allergies to many other classes makes it difficult to manage - I am not a neurologist, but I would suggest a referral to discuss other options.
There are several other classes of hypertensive medications (you are currently taking an angiotensin receptor blocker). Changing to a different one (i.e. Diovan or Avapro) or to a calcium channel blocker can be considered if the irbesartan is causing problems.
You can discuss these options with your personal physician.
Followup with your personal physician is essential.
This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.
Kevin, M.D.
Medical Weblog:
kevinmd_b
First off, I can identify with so many of the 'signs & symptoms' here, that it's both scarey, & yet a relief to know I'm "not the only one". I have suffered in debiliating CHRONIC pain for 5 years for what was assumed by WAY too many doctors that I had mere TMJ dysfunction, (which is certainly agonizing enough, but I had no idea all the other 'mysterious symptoms' I had could mean anything WITH the jaw/face/neck pain which was chiefly my # 1 Chronic pain complaint - literally, much of the past 5 years I was "flat on my face" in bed or on the couch, unable to work - I mean I didn't even make a good house wife because I couldn't complete ANY task I started! - & hardly able to be a decent wife to my husband or mother to my 5 children. You just have NO idea!)
I had injured my jaw joint in a car accident - flattened condoyle/pocket of arthritis