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Multiple Arthritises?
from Stephen T.

Hi there, interesting site. I have had psoriasis for about for about five years (I am 37 now) starting with an itchy patch on my lower leg which spread very slowly in the immediate area. Classically it mirrored itself on the other leg but in general it has never been that bad. It affects the creases around my nether bits and sometimes around my ears but in listening to other sufferers I am comparatively relatively lucky.

EXCEPT, until recently. About 8 months ago I felt a subtle stiffness in my hands and through web research realised that psoriatic arthritis existed as a condition. It worried me so I had the classic blood test for RA to rule it out and possibly PA in. I have virtually no visible swelling in any joints but felt my knees ached too much to be normal along with the pain in my hands. I also hobbled in the morning with Achilles pain but thought nothing of it as when warmed up it was much less of an irritant.

I visited a rheum and he did extensive blood tests which revealed a very high RA count! So do I have both? Neither? It worried me further but I was pleased that whatever I had was being caught early and I just didn’t want it to get worse. Because there is little obvious sign of arthritis, my rheum decided to experiment with me. Clinically he said he was not willing to rule anything in or out. He conceded there was inflammation based on the pathology, that I had limited psoriasis and that I was obviously in some form of pain. He then said that pain in my Achilles is classic to PA – which I never new and believed the tendonitis was just there by coincidence. He put me on a course of steroid tablets – Prednisolone and NSAIDS — diclofenacs (Volterol) for a month and it proved amazing. My limited but relevant to me pain vanished and no 45 second hobble in the morning when I got up from sleep or from my car as the Achilles warmed up, and no hand pain making me wary when I shook hands or opened a stiff jar.

The only problem is that after this experiment he mentioned that “as opposed to 20 years ago when arthritis was never detected early enough or treated well even when it was detected, we can now do so much more and we have caught me early, be it RA (count has since gone down on my second test but still three times normal!) or PA ... so let’s put me on voltarol and, wait for it, Methotrexate.” And this is where I am confused. He said the prednisolone was kind of a bludgeon steroid in that it affects all the immune system. Methotrexate attempts to affect the immune system relevant to the arthritic condition. Yes he said, we have to watch your bloods, so a monthly test is normal. No he said, it doesn’t stop you drinking the few glasses of wine a night but excess is not recommended. Yes he said if you were thinking of having a another child I would need to keep off the methotrexate for 3 months. Quite frankly, it scared me and I opted to leave it another month and just take the volterol if anything flared up. I did not fancy agreeing to a life of a drug and a life of monthly blood tests and, as for the drinking. I am m not sure whether he is right or wrong given what I have read. Conversely I do not want this thing to get worse. I have been disciplined enough to get it looked at early, so why let it get worse and worry about anything irreversible happening?

Interestingly, after the month without anything other than the odd volterol, my hands feel little pain and I think not as bad as before the prednisolone. As your readers quite rightly say it is hard to know what one gets used to and what is “normal.” However, my Achilles tendonitis on one foot especially is back to its normal painful self. I am due to meet him in two weeks to discuss tactics. I just hate the rather matter of fact fashion these guys take to putting me on what seems to be a strong drug, but excuse it by saying it will get rid of the pain. Thanks for listening. -Stephen T.

*****

Ed’s Response:  Hello, Stephen.  None of the red flags I'm aware of have been raised in your report.  I certainly agree with your Dr's suggestion that MTX (methotrexate) be postponed until you've determined less aggressive treatments won't do the trick.  I wouldn't suggest that MTX is any less dangerous than the systemic steroids (prednisolone) — it's just risky in a different way.  My own derm has been much more willing to have me on MTX for extended periods than on systemic steroids (ingested AND injected).  In the long run, neither MTX nor the steroids will cure you.  Some evidence has been reported that MTX may even mask continuing joint damage from PA — meaning that when the patient stops MTX (which, sooner or later, is inevitable) s/he may find the condition worse than ever.  Bear in mind I've only heard this, about MTX, recently and (so far) from a single (though credible) source. 

It is indeed possible that you have more than one form of arthritis at a time.  At this point, given the elevated RA, there's more evidence for non-psoriasis related arthritis.  It is ironic and unfortunate that the only sure test for PA is to determine if you DON'T have the markers for other forms of A but you do have physical evidence of psoriasis!

Please keep us apprized of how you fare.  I'll include your email — and anything you send between now and January — in the Jan-Feb update at FlakeHQ.  –Ed

*****

Ed:  Thanks for prompt response. Just after my writing this morning, my other half rang me to say that on daytime TV (we actually have fewer of these awful programmes than the US — although that says nothing of their credibility!) they will be talking about a new injection that cures psoriasis! I suspect it is linked to the increased awareness of P due to the forthcoming Singing Detective movie … where the world and his wife will claim they have all had P.

One last thing. Do you know the one comment that always annoys me when you happen to mention P or PA? Its when the response is “Well.  At least you don’t have something worse — like cancer.” Oh Please!

Have a good morning. –Stephen T.

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