Last fall, Hospital for Special Surgery (HSS), in collaboration with the Arthritis Foundation, presented a symposium entitled “Essentials in Managing Rheumatoid Arthritis (RA): Treatments, Fatigue, Nutrition & Joint Protection.” Information on future and current medication, managing RA-related fatigue, nutrition and joint protection was presented by HSS rheumatologists, nutritionists, and occupational therapists. The following are a few of the questions that were answered by the speakers following the presentation.
The symposium, in its entirety, is available for viewing by clicking the following link: https://www.surveygizmo.com/s3/2503381/Annual-Chickie-Goldstein-Memorial-Lecture-Essentials-in-Managing-Rheumatoid-Arthritis.
Q1. Can you comment on your recommendations on the pneumonia vaccine that has been recently released versus the older one?
Dr. Susan Goodman: The more recent vaccine covers more of what we call the serotypes, which are the different strains of pneumonia that are out there. It provides broader protection for patients. If you’ve had the pneumonia vaccination before, you can still have this one. For a completely healthy person, it would be recommended 2-6 years later. If you have a suppressed immune system either due to RA or medications used to treat RA it could be recommended as soon as 6 months later.
Q2. How do you know you’re in remission?
Dr. Susan Goodman: It’s a really complicated question actually, and it’s difficult to design studies aiming for remission because of all the different definitions. From the perspective of the person with RA, they don’t notice any stiffness or pain, they notice their joints are stronger, there’s no swelling or redness and they feel well, and their energy is better. From a physician’s perspective we don’t see joints swelling, and if we were to do blood tests we wouldn’t see that the tests for inflammation were high. But we could really drill down and do MRIs of joints and ultrasounds and really prove you’re in remission and there is no joint inflammation, which might be appropriate for studies. But, basically, if you feel well, do not have joint swelling and your joint pain is pretty much pretty controlled, we would call that remission. However if you have remission with flares or the odd joint is still, even if it’s not painful, that means the disease is still there and you should not stop your therapy.
Q3. What is the difference between Methotrexate and Enbrel?
Dr. Vivian Bykerk: They’re both long term disease modifying therapies for RA. Methotrexate is an oral, now injectable, synthesized medication. It’s considered a synthetic or traditional Disease Modifying Anti-Rheumatic Drug (DMARD), as it is synthesized chemically; it targets many things and has been around for the last 30 years. Enbrel is what we call a biologic, it’s a protein, and is manufactured in complex biologic systems. It’s injected weekly, and has one specific target. Its newer, it has only been out since 2000.
Q4. I did a detox about a year ago. I stopped all sugars and did basically a Mediterranean diet, it took about 4 or 5 months to kick in and I felt better than I felt in a very, very long time. I have high cholesterol and then I was given a statin, and started taking that. Within 3 or 4 days I had a flare that I hadn’t felt in 9 months and I stopped it. I read that 10% of people have issues with statins if you have RA. It took a while for it to subside and I feel better than ever so I just wanted to share that.
Dr. Vivian Bykerk: So the issue is around taking a statin and experiencing musculoskeletal pain from the statin. Everybody who takes a statin could potentially get that side effect not just someone with RA. Most of the time that side effect is milder than what you experienced, but you can get muscle aching and pain from statins. I can’t tell you the percent; I want to put it in the more uncommon category. The problem with 10% is that when you do these trials 10% of people who got the drug got it, and 7% of people who got the placebo got it, so that’s really 3%. So you have to read the fine print on the labels that go to the doctors very carefully. We’ve all seen it; every physician has seen someone who takes a statin have a reaction, but that is because statins are so widely prescribed.
Q5. I have heard a lot of people from many different disciplines say that dairy increases inflammation. What are your thoughts on why people think that you should give up dairy such as yogurt?
Dana Pitman: From my standpoint and from what I’ve read, I would group dairy into one of the foods that can be a potential allergen, and I know that some people are sensitive to these things. Some do find that after cutting certain foods out of their diet, the level of inflammation within their body is decreased. That may be true for some and not for others. That’s what I’ve read as far as research is concerned.
Dr. Vivian Bykerk: Some of the fats in dairy actually promote inflammatory prostaglandins. So they’re not the omega 3 type fatty acids that you would find in fish that actually do work like anti-prostaglandins. Some people do notice very minor inflammatory effects. Most people do not develop symptoms when they eat dairy. There have been studies to support the use of probiotics in inflammatory arthritis, so I never recommend necessarily giving up yogurt.
Q6. I fell in love with dried mango, is this good to eat?
Dana Pitman: Dried fruit has many benefits as far as nutrient content. However, since all the water has been removed from the fruit, there is less volume, which means it is less satisfying. The problem with this is that the smaller volume contains the same calorie and sugar content, but now it will take a larger amount to actually satisfy you. So while you are benefitting from the nutrients found in dried fruit, the excess calories and sugar you end up taking in make it a less than stellar choice versus whole fruit.
Dr. Susan Goodman is a rheumatologist at Hospital for Special Surgery. She specializes in the treatment of patients with inflammatory arthritis such as rheumatoid arthritis, psoriatic arthritis, and spondylarthritis. Dr. Goodman is also the Associate Director of a team of specialists at the Inflammatory Arthritis Center at Hospital for Special Surgery.
Dr. Vivian Bykerk is a Rheumatologist at Hospital for Special Surgery. She has an active clinical practice and works with patients with autoimmune diseases causing joint and spine inflammation including rheumatoid arthritis, psoriatic arthritis, and spondyloarthropathies. She is also the Director of a team of specialists at the Inflammatory Arthritis Center at Hospital for Special Surgery.
Dana Pitman is a Registered Dietitian and a New York State Certified-Dietitian Nutritionist at Hospital for Special Surgery and a regular media contributor for the hospital as well as outside websites and publications.