John from Prince George asks: I have been diagnosed with rheumatoid arthritis and have developed nodules on my elbows, hands and feet. Is this normal?

One of the manifestations of rheumatoid arthritis outside the joint is the development of rheumatoid nodules. These occur in just under 10% of patients with rheumatoid arthritis and is one of the more common skin manifestation of rheumatoid arthritis. They often occur on pressure surfaces e.g. elbow, but can occur elsewhere as well. For most individuals, they are asymptomatic and specific treatment is not necessary for them. Steroid injections or surgical removal is sometimes considered, although control of the inflammatory arthritis often improves the nodules too. Paradoxically, in some patients treated with methotrexate – the gold standard for rheumatoid arthritis treatment – the nodules can worsen, and stopping methotrexate can lead to improvement.

Anne from Calgary asks: I have recently been diagnosed with rheumatoid arthritis. I also have a lung disease. I was started on hydroxychloroquine, but shouldn’t I be on methotrexate?

With some types of lung disease, rheumatologists may be cautious using certain typical rheumatoid arthritis medications, particularly methotrexate. One of the rare side effects of methotrexate is to cause lung damage, something in particular to be avoided in an a patient with bad lungs in the first place. Fortunately, there are many other good options available to treat rheumatoid arthritis which are relatively safer from a lung point of view. Hydroxychloroquine is one of these options. In mild cases of rheumatoid arthritis, this may be an excellent option. For moderate to severe cases, further discussion with a rheumatologist should lead to an optimal treatment plan.

Elizabeth from Australia asks: I have rheumatoid arthritis and have been on traditional DMARDs. My rheumatologist is now considering a biologic DMARD, but they are expensive. In Alberta, how are biologic DMARDs paid for? What is the wait time to a see a rheumatologist in Alberta?

Biologic DMARDs are very expensive, with most costing approximately $20,000 annually. Alberta Health does not subsidize this cost directly, but currently, every Albertan is eligible to pay for medication insurance that would reduce out of pocket costs for biologics by about 90%. For most patients in Alberta, rheumatologists and their team are able to work with patients to find a way to get the medications they need to ensure their health.

Wait times to see a rheumatologist vary in Alberta between Calgary and Edmonton, and even among rheumatologists. However, most rheumatologists want to see patients with inflammatory arthritis within 3 months of a referral.

Gwen from Edmonton asks: I was diagnosed with fibromyalgia rheumatica 4 years ago….took prednisone ….tapered very slowly off this summer…….now all the symptoms are back…..how long does this disease last?

It is common to confuse fibromyalgia and polymyalgia rheumatica (PMR) – the first is a condition associated with chronic pain and can be treated with a number of non-pharmacologic options, while PMR requires low dose prednisone for approximately one year. In most cases of PMR, a slow titrating course of prednisone is effective, although there are times when symptoms return. For these cases, retreatment with prednisone, or the addition of steroid sparing medications, is considered. Equally important is to review your symptoms with your physician to ensure the correct diagnosis, or change in diagnosis.

Julia from Edmonton asks: What tests are done to confirm RA? Is it possible to have normal blood labs and still have this disease?

There is no test that confirms a diagnosis of rheumatoid arthritis. Your story and an appropriate physical exam by your rheumatologist is the best way to make a diagnosis. To answer your question, it is very possible and common to have completely normal blood tests and still have rheumatoid arthritis.

Carolina from Calgary asks: My husband has AS and may be starting a TNF blocker. We were told once he starts it, he will be on it for life, even if he goes into complete remission because the worst thing to do with biologics is to start and stop them since it may increase immunity to it. So, if after a while he is free of symptoms, can he to try to wean off the med or does he have to take it for the rest of his life?

Assuming a good response to a biologic for ankylosing spondylitis or rheumatoid arthritis, one can always try to see if the disease will remain under control off medication, be it a biologic or traditional DMARD. There is a risk of the disease flaring of course, and there is a risk of not having as a good a response to the same medications a second time. However, many patients do this and most do not have problems restarting their medications again.

Chris from Sherwood Park asks: I am taking methotrexate injections. folic acid and Humira for my RA. I seem to be getting many more canker sores lately. Is there anything else I can do besides taking the folic acid to prevent them?

Mouth sores can be a side effect from methotrexate and one you should discuss with your rheumatologist to determine the best way at treating them. Options include increasing the dose of folic acid, decreasing the methotrexate, or replacing folic acid with folinic acid. The choice is unique to each patient’s situation and should be discussed with your doctor.

Michelle from Sunny Island Beach asks: I have RA and Lupus and have been taking Methotrexate and Plaquenil in combination with rituximab. My insurance will no longer cover Rituxan but it will cover Humira or Enbrel. Is it possible to replace rituximab with a TNF blocker? My doctor told me I can’t “step down” from rituximab to another medication.

For rheumatoid arthritis, there is no clear evidence to suggest any biologic when used under optimal conditions is better than another. A patient would never be stepping down between different biologics, just switching. However, patients with lupus do need to be cautious with TNF blockers as they can exacerbate their disease. Rituximab is considered safer for lupus patients.