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Arthritis and Rheumatism

Psoriatic Arthritis, Achilles Tendinosis

09/07/2007

Question:

I am a 61 year old male in generally good health. About 10 months ago, I saw a PM&R doctor complaining of pain & swelling (knots or nodules) in my achilles tendons and pain in my buttocks, back, and thumbs. I received physical therapy and began a regimen of daily stretches & exercises. After about 4 months with little improvement, I went to a rheumatologist, who took my history, ordered blood tests & x-rays of my ankles, diagnosed psoriatic arthritis, and started me on diclofenac (75mg 2x/day) and sulfasalizine (1500mg 2x/day). In the past 6 months, I have continued the exercises and meds and have seen improved range of motion, and perhaps a small reduction of pain. My achilles tendons are still sore on most days. My rheumatologist has now prescribed methotrexate (15mg 1x/week) and folic acid (1mg 1x/day) to replace sulfasalazine, while continuing diclofenac. After reading the pharmacist`s information about methotrexate, I am cautious about starting methotrexate. My questions: a- What might my prospects for recovery be if I were to continue with exercise and sulfasalazine/diclofenac, and not use methotrexate? b- Do the hoped-for benefits (end of pain and stiffness in achilles, buttocks, etc.) outweigh the risks associated with methotrexate? In your experience, is this the answer for me? c- My wife is a CF patient with the associated respiratory infections. With suppressed immune system from taking methotrexate, would I be at greater than normal risk of pulmonary infections? d- Are there other treatments available for resolution of my tendon problems?

Thanks so much!

Answer:

Unfortunately, your questions are intricate and are unable to be answered via the NetWellness website. It seems to me that the best place to seek answers is by consulting with your current Rheumatologist or by seeking a second opinion. The answers may be contingent on an understanding of your full clinical complex - history, exam, severity of the psoriatic arthritis (PsA), and diagnostics.

Here is one example of how the answers may change. The buttock pain may be indicative of axial (spine and central joint) disease associated with PsA. If there is truly inflammatory axial arthritis, then medications known as TNF-alpha antagonists [etanercept (Enbrel), adalimumab (Humira), or infliximab (Remicade)] may be a superior to diclofenac, sulfasalazine, or methotrexate.

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Go to the Arthritis and Rheumatism health topic, where you can:

Response by:

Raymond  Hong, MD, MBA, FACR Raymond Hong, MD, MBA, FACR
Formerly, Assistant Professor of Medicine
School of Medicine
Case Western Reserve University