If you look through my handwritten office notes, you will frequently find long lists of body parts. I seldom bother to write any explanation next to these long lists; it is simply understood that these are the areas that my patient complained were hurting at that visit.
On a recent visit, one of my patients complained about foot pain. With her electronic medical record, I opened her foot x-rays and, using the magnifying and panning features, I was able to zoom in on an erosion of her left fifth metatarsophalangeal joint. Metatarsalgia was one of her big complaints, and she and her husband were interested to see the ghostly radiographic image of her magnified toe joint.
By Dr. Larry Greenbaum
After this little bit of electronically facilitated show-and-tell, she complained about a "dip" of the proximal interphalangeal joint of her left pinky. She explained that she couldn’t flex her left middle, ring, or small fingers unless she used her right hand to bend these fingers into shape. I explained that the "dip" she had noticed in her pinky was called a "swan-neck" deformity.
I went on to point out the obvious: "Your rheumatoid arthritis is getting worse. You are developing deformities of your fingers and worsening hand function. Walking is becoming more painful and limited for you, even though you are taking a reasonable dose of methotrexate." These comments sound a lot like what I might tell a patient before I prescribe a biologic drug. I might use the same facts to appeal a parsimonious insurance company decision to deny coverage of an expensive drug. That was not the case at today’s visit.
The patient had been approved for adalimumab, but it had languished in her refrigerator for about a year since she remained terrified of giving herself her first injection. Some patients are afraid of the list of possible side effects they hear about in TV commercials, and others are turned off by the drug information sheets the pharmacy gives them. In the face of clear evidence that she was surely getting worse, my patient was finally ready to start her medication, although she asked me one last question – "My face won’t turn purple, will it?"
All current guidelines for the treatment of RA urge early treatment to control the disease, although things don’t always go so smoothly. The usual flavors of procrastination are patient reluctance, physician delay, or insurance company stonewalling, especially when expensive treatments are involved. Despite this generalization, some stalling tactics are truly unique.
Managing Rheumatoid Arthritis Medical Requests
Consider a 67-year-old woman whom I have been seeing for 5 years. She developed RA in 1994 and then became concerned that her treatment was unsafe, so she left her first doctor and found a family physician that treated her with a combination of intravenous clindamycin and oral minocycline. She found this treatment less threatening and did well for 6 years, until it seemed to quit working in 2002. A rheumatologist put her on methotrexate and gradually increased the dose to 25 mg a week. This didn’t work well. She went off the methotrexate and came to see me, hoping I would resume her antibiotic treatment.
As I previously mentioned in another column, my usual approach to patient requests can be summed up as "No reasonable request is refused." Unfortunately, IV clindamycin didn’t fall into what I would call a reasonable request for the treatment of her RA. She probably thought I was being narrow minded, but I pointed out to her on several occasions that I didn’t know any other rheumatologists who were using this treatment.
I also argued that, if she had to drive hundreds of miles to find a physician offering this treatment, it had to be an unusual practice. Even if this treatment were harmless, of which I was not certain, she also ran the clear risk that her disease would progress while she wasted time on an ineffective remedy. I wouldn’t prescribe intravenous antibiotics for her arthritis, but after some negotiations, I refilled her oral minocycline and low-dose prednisone. She did well again for a while, but I remained suspicious that her improvement had much more to do with the prednisone than the minocycline, although I have seen occasional patients have nice responses to minocycline.
Her improvement didn’t last long. Her RA got worse, and I had her resume methotrexate in November 2006. In June 2007 she was still doing poorly, and I suggested she start on etanercept. Instead of starting etanercept, she contacted the out-of-state physician who had originally treated her with IV antibiotics. She resumed oral minocycline and did well from 2007 to 2009, until she disappeared from my practice for more than a year. She later went off minocycline in part because I had expressed skepticism that it was helping and also because a dermatologist told her the medication was turning her nail beds blue!