Valerie in Edmonton asks: My doctor prescribed diclofenac and I have been taking it for 3 weeks. It sometimes gives me indigestion. Is it alright to continue taking it? I have had a past history of stomach problems and recently started pantoprazole once a day.

Diclofenac is an example of an NSAID (anti-inflammatory). Similar medications include naproxen (Aleve), ibuprofen (Advil, Motrin) or celecoxib (Celebrex). There are many potential side effects of NSAIDs, including irritation/inflammation to the stomach lining. Ultimately, this can lead to a stomach ulcer in some individuals. Medications called proton pump inhibitors (PPIs), like pantoprazole, can help reduce the risk of this happening. However, one should consider stopping the NSAID if the stomach discomfort continues despite being on a PPI. Everyone’s individual risk from NSAIDs is different and should be strongly considered when starting a NSAID. A conversation with your doctor to balance the benefits and risks is always a good idea.

Manjinder from Calgary asks: I have rheumatoid arthritis. Is it ok if I keep working? Is it good for me?

Years ago, the answer to this question would be very different. Older data suggest that half of patients with rheumatoid arthritis will be disabled and unable to work after 10 years with the disease. Today, this is unlikely the case, as treatment for rheumatoid arthritis has improved; our goal of treatment is remission, meaning no pain, stiffness, or swelling, and ideally doing everything you want to do in life. This includes the ability to work. For some individuals, it may not be a realistic goal to work while rheumatoid arthritis is still active, and some find it hard to return to work later on. Ultimately, each person needs to be comfortable with their choice, as there are many different factors to consider when it comes to work. However, work itself is not going to make rheumatoid arthritis worse.

Tania from Edson asks: My family and I are planning our next big trip. I know that the areas I can travel are limited because I take a biologic. Can you recommend a good website or other resource for me to research this in more detail? My daughter hopes to visit all the continents!

For most rheumatology patients whose disease is under control, travel should not be a major issue. Many patients are concerned because they may have medications that require syringes and needles, but your rheumatologist can provide you a travel letter which can be presented if requested by authorities. For patients on intravenous medications, arrangements often can be made to ensure minimal interruption to your treatment. The bottom line is to speak with your rheumatologist; if your disease is under good control, you should be able to lead a full and complete life. If that includes travel, so be it!

Sherry from Calgary asks: I was just diagnosed with Rheumatoid Arthritis. I was prescribed methotrexate and hydroxychloroquine. I am currently in a flare so need to continue with diclofenac to control the pain. Is this drug combination safe?

There are animal based studies that suggest a concern about using methotrexate and any anti-inflammatory, including diclofenac, together. However, this combination is used commonly in patients with rheumatoid arthritis without any significant concerns. It is an appropriate way to control symptoms while waiting for the disease modifying agents, such as methotrexate and hydroxychloroquine, to start working. While all these medications have potential side effects, there are no significant increased risks when used together.

Alyssa from Edmonton asks: What type of inflammatory arthritis occurs in multiple joints and yet shows negative on blood tests for the RA factor?

In many cases, inflammatory arthritis is a clinical diagnosis, meaning it can be diagnosed by listening to the patient’s story and performing an appropriate physical examination. Rheumatoid arthritis can be associated with a number of positive blood tests, including a rheumatoid factor or anti-CCP-antibody, but a negative test does not exclude the diagnosis. Other forms of inflammatory arthritis that usually have negative blood tests include psoriatic arthritis, enteropathic arthritis, and reactive arthritis.

Divya from United Arab Emirites asks: I have had two successful pregnancies but have had increasing joint pain, stiffness and swelling after each pregnancy. A CCP antibody test has returned positive. What is going on?

The time after pregnancy is a higher risk period for the development of rheumatoid arthritis (RA). Conversely, rheumatoid arthritis often goes into remission during pregnancy. A positive anti-CCP antibody is usually associated with rheumatoid arthritis as well. It is important to discuss a treatment plan with your physician or rheumatologist to ensure a good outcome, but also safety for you and baby.

Dee from Edmonton asks: Do I need to be in a flare to be tested for RF or anti-CCP antibody?

Rheumatoid Factor (RF), and Anti-cyclic Citrullinated Peptide Antibodies (anti-CCP) are tests which are often performed in the work up of rheumatoid arthritis. A patient does not need to be in flare to have these tests done. However, these tests do not definitively diagnose rheumatoid arthritis. Many patients with rheumatoid arthritis can be negative for both of these tests. Many patients with a positive rheumatoid factor may never have rheumatoid arthritis, although this is less common for anti-CCP. The best way to diagnose rheumatoid arthritis is by having your physician or rheumatologist listen to your symptoms and perform an appropriate physical examination.

DeAnna from Edmonton asks: Do I have to be in a pain flare to be tested for rheumatoid arthritis?

Rheumatoid arthritis is diagnosed by an arthritis specialist, usually a rheumatologist, after speaking to a patient, performing a physical examination, and reviewing any pertinent investigations. It is possible for all tests to be normal and still have rheumatoid arthritis. For a physician to diagnose rheumatoid arthritis, it does not have to be at its worst, or in a flare.

Jackie from Albuquerque asks: I am worried I may have been exposed to HIV. I also have rheumatoid arthritis and am on a biologic. I have tested negative for HIV, but could my biologic be interfering with the results?

There are a number of different tests for HIV. Some could be impacted by a biologic in early infection, although data is not clear. To be sure, it is best to discuss this with your physician and rheumatologist. Conversely, it is important to be aware that being on a biologic can increase your risk of a more active HIV infection.

Fanchi from Edmonton asks: I may have rheumatoid arthritis but have not been diagnosed yet. What can I do, if my symptom continues, before I meet a rheumatologist?
If I have to use expensive biologic DMARD, is there any way to find some insurance plans that can cover most of the cost?

For patients with rheumatoid arthritis, the use of disease modifying medications is key to control symptoms AND more importantly, the underlying disease. For a variety of reasons, it can take time for them to work, but there are other options to control symptoms, such as pain, while waiting. While best to discuss with your own physician, anti-inflammatories (NSAIDs) are a good first choice for many patients, such as ibuprofen or naproxen. Sometimes, cortisone injections into particularly painful joints, or even a short course of prednisone by mouth, could be used. Physical therapy also has an important role to protect joints in this early phase of rheumatoid arthritis.

While expensive, rheumatologists in Alberta are usually able to work with patients to find a way to fund biologic medications. It would be unusual to not provide needed treatment because of funding issues for most patients with rheumatic diseases in Alberta.