Ask the Doctors November 2004 Issue

Ask Dr. Marks: 11/04

Besides surgery, what can be done for carpal tunnel pain?

For those with chronic symptoms of carpal tunnel syndrome, surgery offers the best chance for long-lasting relief. However, there are other measures that will help in the short to medium term.

For patients experiencing relatively mild symptoms associated with a particular activity, behavior modification may be the only treatment necessary. If you find that you experience carpal tunnel pain after riding a bicycle, for example, choosing another form of exercise may be helpful. For patients with more persistent symptoms, wearing a night splint and taking a nonsteroidal anti-inflammatory drug (NSAID) may help the situation over a prolonged period of time.

If symptoms are more severe, an injection of dexamethasone, a water-based steroid, can shrink the tissue within the carpal tunnel, giving relief. If the patient benefits from injection, he or she is likely a good candidate for carpal tunnel surgery.

----------

I was recently told that I had palindromic arthritis and was prescribed a drug called novochloroquine. I was also told that it can affect my eyesight, so I’m reluctant to take it. What should I do?

Chloroquine (brand name Aralen) and hydroxychloroquine (Plaquenil) are frequently used for patients with rheumatoid arthritis and lupus. They are also used in palindromic rheumatism, typically brief attacks of inflammation. One rare side effect is visual disturbance, which is caused by deposition of the drug in the retina. The common signs of this are a change in night vision, color vision, and central vision. If the dose is less than 3mg/kg per day for chloroquine and less than 6mg/kg per day for hydroxychloroquine, these effects are extremely rare.

A visual exam (tangent screen exam) by an eye doctor can detect these changes early, even before the patient knows they are present. Discontinuation of the drug will reverse the changes. Although any drug that may affect vision is scary for the patient, doctors in this case usually feel that the potential benefits outweigh the small risk.

----------

I take methotrexate for my rheumatoid arthritis, but it doesn’t seem to work very well. Is there any other pain-reliever I can take instead, or in addition to, methotrexate?

Methotrexate is one of many drugs that are commonly prescribed for RA. When methotrexate alone is not effective, we usually use the drug in combination with other agents, such as Azulfidine, Plaquenil, and Arava. We also will increase the dose of methotrexate to 20-25mg per day. If these drugs do not work, the most effective agents are the “biologics,” including Remicade, Enbrel, and Humira, which are commonly used in combination with methotrexate. Biologics can be extremely effective, but they’re expensive (up to $1,000 per month) and can produce side effects, including infection.