Ask the Doctors February 2008 Issue

Ask The Doctors: 02/08

Can all patients with rheumatoid arthritis benefit from TNF inhibitors? If so, how soon can one expect to notice an improvement in symptoms—and are there any side effects I should know about?

TNF, or tumor necrosis factor, is a substance made by the body’s immune system. People with an immune disease, such as rheumatoid arthritis (RA), have excessive amounts of TNF in their bodies. A TNF inhibitor can reduce the amount of TNF to normal levels, helping to control the disease. TNF inhibitors are used in patients with RA who have not responded adequately to traditional therapy, such as methotrexate and plaquenil. Initial improvement tends to occur within a few days, and may continue to increase over a few weeks. Symptoms (pain, stiffness, fatigue) respond more quickly than physical signs (joint swelling). The main side effects of TNF inhibitors are infection and malignancy (especially lymphoma). Both are unusual. The frequency of lymphoma is also slightly increased in RA patients not treated with TNF inhibitors, so the origin of it in individual patients is not entirely clear. Pain at the injection site is common with etanercept (Enbrel) and adalimumab (Humira). Headache occurs occasionally with etanercept and can be severe enough that the drug must be stopped.

I’ve suffered from osteoarthritis in my shoulder for the past seven years. My doctor has recommended that I take ibuprofen once a day to keep my pain in check. Since I’m not big on taking pills, can I take ibuprofen only when needed—at the onset of pain—rather than daily?

Ibuprofen is one of a class of nonsteroidal anti-inflammatory drugs commonly known as NSAIDs. These drugs generally work best when their level in the blood is relatively high. This is best achieved by taking the drug regularly, and it may require a few days to reach optimally effective levels. Taking the drug only when pain occurs may help, but it does not employ the drug to maximum advantage.


After suffering for more than a year from painful swelling in my wrists, my doctor referred me to a rheumatologist, who diagnosed me with palindromic rheumatism. What exactly is it?

Palindromic rheumatism is an unusual episodic form of arthritis in which one or more joints become inflamed (complete with swelling, warmth, pain, and stiffness) for a brief period. Laboratory tests are usually normal, except that the sedimentation rate, which measures the speed at which red blood cells settle to the bottom of a test tube, is often transiently elevated, indicating the presence of abnormal proteins that stick to the red blood cells and cause them to sink to the bottom more quickly. This inflammation usually resolves quickly—generally within a few hours or a day, or at most, a few days, and the joint returns to normal with no residual symptoms or deformity. The cause is not known. The course has one of three outcomes, including complete remission, continued episodes, or the onset of more typical rheumatoid arthritis, which will require additional treatment.

I have RA in my fingers and, at a friend’s suggestion, have now been taking fish-oil supplements for four months, but to no avail. Do they work for some people and not for others?

In situations where the level of inflammation is mild, fish oil may supply enough anti-inflammatory activity to provide some relief from pain and stiffness, but when the inflammation is more severe, the benefit may not be noticeable. As with most medications, there may also be differences in a person’s susceptibility to the agent’s beneficial effects.