Three Main Conditions that Space Coast Rheumatology Treats

Do you have joint pain? Do you feel tired all the time? Do you have an illness that is affecting multiple areas of your body? These are just a few of the many symptoms that bring patients into our office. Besides some rare diseases, the conditions that we see at Space Coast Rheumatology can typically be divided into three main categories: autoimmune diseases, mechanical problems, and chronic pain syndromes.

People most often think of rheumatoid arthritis as the reason to see a rheumatologist, which is frequently the case. However, other autoimmune diseases include systemic lupus erythematosus (lupus), Sjogren’s syndrome, vasculitis, psoriatic arthritis, and polymyalgia rheumatica or “PMR.” Rheumatoid arthritis is a disease where the immune system begins attacking the body, which is usually most visible in the form of severe joint pain and swelling that is the result of inflammation of the joints. If left untreated, rheumatoid arthritis can have crippling effects. Lupus or SLE is a systemic autoimmune disease that can cause widespread organ inflammation. Sjogren’s syndrome is a disease in which patients get dry mouth and dry eyes due to inflammation of the salivary glands and tear glands. Vasculitis is inflammation of the blood vessels and can be potentially life threatening, particularly in granulomatosis with polyangiitis (formerly Wegener’s granulomatosis), which is manifested in the form of inflammation in multiple organs.

Another large category of our patients are those who have mechanical problems with their joints. These patients tend to have osteoarthritis or degenerative joint disease, which can result in pain in any of the joints, including the back and neck. While osteoarthritis is not usually as aggressive as rheumatoid arthritis and is not an autoimmune disease, it can also be painful. In the case of spinal stenosis, degenerative discs and osteoarthritis of the spine can pinch nerves and cause numbness, tingling, and weakness in the limbs.

We are also able to treat patients who have chronic pain syndromes, such as fibromyalgia. Patients with fibromyalgia have chronic, widespread pain oftentimes in association with fatigue as well as tenderness to the touch. This is felt to be related to centrally mediated dysregulation of pain processing areas deep in the brain. Therefore, fibromyalgia is considered a “centrally mediated pain syndrome.” Patients may not be sleeping well and may find it difficult to exercise because they hurt. Patients most often have experienced their symptoms for a long time. Many times, fibromyalgia is seen with irritable bowel syndrome.

There are treatments for all three kinds of health issues. Most patients with joint aches and pains are already taking some kind of non-steroidal anti-inflammatory (NSAID), such as Aleve® (naproxen). They may also be taking Tylenol® (acetaminophen). In the case of the autoimmune diseases, we frequently use medications, such as prednisone, methotrexate, and Plaquenil® (hydroxychloroquine) to name a few at Space Coast Rheumatology. We also use a new category of drugs called biologics; examples are Enbrel® (etanercept), Humira® (adalimumab), Orencia® (abatacept), and Actemra® (tocilizumab). These drugs can slow down or stop the progression of rheumatoid arthritis and the other autoimmune diseases. It is important to get treatment as soon as you suspect any symptoms. Pain medication may be appropriate in some cases when other medications do not work, but these medications have to be used very cautiously given the addictive nature of these drugs. Space Coast Rheumatology works with each patient individually to find the right medication. There may not be an FDA- approved drug or there may be limited treatment options for some diseases, but Space Coast Rheumatology can often help treat patients’ symptoms, improve quality of life, and monitor for complications of the disease. This can be the case for a disease like Sjogren’s syndrome. Regular eye care and dental care can help with dry eyes and dry mouth symptoms. A website that has lots of information related to ocular and oral moisturizers and treatments for Sjogren’s syndrome is www.robertfoxmd.com. Space Coast Rheumatology takes into account effectiveness, cost, convenience, and side effects when choosing a medication for you. Non-pharmacologic or non-medication approaches can oftentimes be more helpful than medications, procedures, or surgery. There may be times when surgery is indicated, and Space Coast Rheumatology can help guide you to the right surgeon.

In the case of mechanical problems, which are often related to osteoarthritis, NSAIDs can provide some relief. Cortisone injections or shots as well as Orthovisc® (hyaluronan) gel shots can also be an effective way of dealing with individually swollen, painful joints. However, in some cases of neck and back pain, these medications are not sufficient. This is a situation when non- medication approaches like physical therapy, massage, and osteopathic manipulative therapy can be very helpful. If these conservative measures do not work, the next step may include non-narcotic or non-opioid medications like some anti-depressants, muscle relaxers, and pain relievers, such as Ultram® (tramadol). Again, chronic opioid or narcotic medication should be avoided if at all possible. Space Coast Rheumatology can refer patients to pain management clinics where they can get facet blocks and epidurals for neck or back pain. In some cases, neck or back surgery is the best choice.

In the case of fibromyalgia, holistic approaches and lifestyle changes can be just as important as medications. Serotonin-norepinephrine reuptake inhibitors (SNRIs), such as Savella® (milnacipran) and Cymbalta® (duloxetine) can be effective for fibromyalgia or nerve related pain. Gabapentinoids like Neurontin® (gabapentin) and Lyrica® (pregabalin) have also been shown to be beneficial. In addition, exercise, such as tai chi and aquatic therapy, can improve quality of life and help pain. Activities like tai chi that incorporate mindful meditation can be effective. Sleep deprivation amplifies the body’s perception of pain; thus, getting better sleep can be a key part of fibromyalgia treatment. Sleep can be improved with non-pharmacologic interventions like exercise and sleep hygiene. Medications like Desyrel® (trazodone) can also help sleep. Oftentimes, to best diagnose and treat sleep disorders requires a sleep study.

All medications have side effects. Even NSAIDs like Aleve® (naproxen) and pain relievers like Tylenol® (acetaminophen) have side effects. They may cause ulcers, cardiovascular problems, or liver damage. Stronger medications like methotrexate, Plaquenil® (hydroxychloroquine), and the biologics also have side effects. Space Coast Rheumatology may strongly suggest that patients with autoimmune diseases start a medication to slow down or induce remission of their disease. Ultimately, it is up to the patient to decide what treatment approach they are comfortable with. It is important to weigh the risk-benefit. Side effects may be mild to severe and may be rare or common. In the case of a serious autoimmune disease, the consequences of not treating the disease can be potentially life-threatening.
Two additional common diseases that Space Coast Rheumatology sees are osteoporosis and gout.

Osteoporosis is a disease that is the result of the weakening of bones. Elderly, Caucasian females tend to be most vulnerable, especially if they have taken steroids in the past. Once bone density is below a certain level or if patients have had a number of fractures, they may benefit from medications like Actonel® (risedronate sodium), Fosamax® (alendronate sodium), or Prolia® (denosumab), which can be used to reduce your fracture risk. Taking Calcium and Vitamin D is important to help maintain healthy bones. A useful tool for determining whether you may benefit from treatment is the FRAX risk assessment tool developed by the WHO, which can be found at www.shef.ac.uk/FRAX/tool.jsp?locationValue=9. This is useful when you have osteopenia (thinning of the bone) and you don’t meet other criteria for treatment. You may benefit from treatment depending on what your FRAX score is, which takes into account other clinical risk factors for fracture like your ethnicity, age, prior corticosteroid use, etc. It is essential to get treatment for osteoporosis as soon as possible so as to minimize bone fractures, which are particularly dangerous in the elderly population.

Gout occurs primarily when the kidney is not excreting enough uric acid or the body is overproducing uric acid. The people most at risk of developing gout are elderly with chronic kidney disease. Certain medications and dietary factors, such as beer and organ meat, are high in purines and can increase uric acid (http://www.mayoclinic.org/healthy-living/nutrition-and-healthy-eating/in-depth/gout-diet/art-20048524). Patients with gout will get swelling around their joints with painful tophi or lumps that are made of uric acid crystals. Gout can be treated with medications like Colcrys® (colchicine), which helps with the inflammation, and Zyloprim® (allopurinol), which lowers uric acid.

Because medications have many side effects, Space Coast Rheumatology likes to recommend lifestyle changes to all patients. It has been said, “The less you do, the more it hurts. The more it hurts, the less you do.” For rheumatoid arthritis, osteoarthritis, fibromyalgia, and most other rheumatologic issues, a healthy diet and exercise is important to improving health and feeling well. We at Space Coast Rheumatology hope we can help you feel as well as possible!