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How I Found the Right RA Medication for Me: Jean’s Story
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North Carolinian Jean Bolduc, 57, was recovering from double knee surgery when symptoms of rheumatoid arthritis began to appear. “I woke up at about 4 a.m., and had this scorched-earth level of incredible pain and inflammation in my hands and wrists,” she recalls. Anxiety and fear also welled up. As a writer working on multiple projects, she needed the use of her hands.
Bolduc had to wait four long days to see a rheumatologist. “I was running a fever,” she explains. “I felt too hot, too cold, had no appetite and no energy, and whenever I would sleep for a couple of hours, I would wake up with this unbelievable and excruciating pain in my hands.”
Her doctor confirmed RA and recommended naproxen in addition to the pain medication she was taking for her knees. Prednisone would be the next step, but because Bolduc also has type 2 diabetes, she was concerned about the effect the steroid might have on her glucose levels.
“After about a week I called him and asked, ‘When is the relief coming?’ I was seeing no effect,” she recalls. She agreed to prednisone for a week, riding out the blood sugar roller coaster that resulted.
“The prednisone gave me a jump-start to getting everything to calm down,” Bolduc says. Six weeks after the onset of her RA symptoms, she was feeling better, but the symptoms weren't gone.
Her doctor decided to step up her treatment to methotrexate, a disease-modifying anti-rheumatic drug (DMARD), along with folic acid, which helps lessen the risk for side effects. Bolduc says this gave her an acceptable level of relief.
“I have no joint damage," she says. "I’ve had a couple of fairly significant flares, one of which had me going back on prednisone when my neck and shoulder locked up. But generally speaking, 345 days out of the year, it’s been okay and pretty well-controlled." As for side effects, Bolduc did notice that her hair became thinner when she took methotrexate. She is temporarily off the drug because of the results of a routine liver panel. Today, she controls her RA symptoms with naproxen.
RA Treatment: Not One-Size-Fits-All
For patients and doctors alike, the process of finding the right treatment can feel like a challenging puzzle.
While some find relief with first-line DMARDs, others will have to move on to combination therapies often involving biologics, according to guidelines set by the American College of Rheumatology (ACR). “DMARDs are the cornerstone of therapy for patients with rheumatoid arthritis,” says Leslie Harrold, MD, MPH, a rheumatologist and associate professor of orthopedics and physical rehabilitation at the University of Massachusetts Medical School in Worcester. “However, there will be patients who cannot take DMARD therapy or choose not to. These patients should work with closely with their provider, exploring other treatment options.”
If DMARDs aren’t working well enough, a doctor might recommend combination treatment with a biologic medication, but the ACR guidelines say that stepping down treatment is recommended if your RA is controlled.
Bolduc understands the concern people feel as they face a complicated menu of RA medications.
"I have to be onboard before I’m out of my doctor's office," she says. "I ask about the drug, the history, the side effects, and risks."
She also makes sure to talk to the members of her health care team before stopping a medication, even if there’s unwanted side effects. For example, her doctor recommended another DMARD, an anti-malarial that is often prescribed for RA and that may prevent joint damage, along with the methotrexate. Soon she was feeling nauseated and uncomfortable. After several days, with her doctor’s consent, she stopped taking it — and felt much better. Later, her orthopedist recommended using only one pain medication — a stronger prescription NSAID — instead of several, but she developed an itchy allergic reaction and went back to naproxen, with ibuprofen as needed.
How satisfied you are with your RA management — and how dissatisfied you might be with medication side effects — will factor into the treatments you choose. “Currently there are not many biomarkers or clinical factors to help us identify which drug will work in which patient," explains Dr. Harrold, "However, the good news is that for rheumatoid arthritis we do have many good options available,” she says. “Patients should express their goals of therapy. In turn, the provider should counsel patients on the risk and benefits of treatment based on each patient’s individual characteristics.”
“It’s all about the balance,” Bolduc says, explaining that she tries to weigh her symptoms against the possible side effects of medications. “I’m the one who has to live with the recommended treatment and comply with it.
Video: About Prednisone & Rheumatoid Arthritis
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