Chest X-ray

Methotrexate can affect breathing and so it's standard practice to get a baseline on lung function.  The walk-up X-ray facility at Addenbrooke's is a slick operation.  It's a pity you don't get to take the image home.

My last chest X-ray in 1991 showed an unusually large heart - 'big-hearted guy, hey'.  This time it was normal.  Do hearts shrink?  In 1991 I was cycle racing every weekend, maybe it makes a difference - seems unlikely.

The X-ray did show two cracked ribs which must have happened when I fell off on a descent of Coverdale in the Yorkshire Dales - way back in 2008.  I had a frozen shoulder for a week afterwards, though my GP swore that the ribs were fine!

Finally a diagnosis?

All those syringes of blood and no pointers to anything out of the ordinary, except for a high erythrocyte sedimentation rate which is an indication of systemic inflammation.

After an initial wobble about a missing blood test my consultant decided now was the time for action.  The clinical data indicate inflammatory arthritis and the lab test results help to rule out other candidates.  What type of arthritis?  In order of the most likely first: psoriatic, rheumatoid, ankylosing spondylitis, reactive.  For the first three, an exact diagnosis doesn't matter too much since treatment  is identical - a DMARD such as methotrexate or sulfasalazine.

Memorable quotes:

'with methotrexate, we don't like you drinking'

'so you've read the background literature on methotrexate side effects and it's probably scared the hell out of you'

My notes before the consultation:

U/S fingers?

What is the diagnosis?  Level of confidence?

Could this be reactive arthritis?

What is the best way to reduce the inflammation in the short term?

What is the best way to arrest the disease?

What is the therapeutic target?

If this is psoriatic arthritis, what is the likelihood of me developing skin psoriasis?

Treatment plan?

Options

- course of NSAIDs

- injection of corticosteroid, prof speed mentioned MRI scan would indicate my knees are a good candidate

- lance cyst to remove synovial fluid

- surgical removal of cyst

- mono-therapy with DMARD

- combined therapy

Which is the most effective combination of DMARDs for PsA?

- anti-TNF, biologics, e.g. Enbrel (etanercept), Humira (adalimumab), Remicade (infliximab) and Simponi (golimumab)

Is methotrexate effective?

What are the long-term risks associated with DMARDs?

What are the side effects?  See NHS website

Strategy:  start from a low dose and increase until improvement in condition, or start with high dose to trigger change?

What exercises might be beneficial?

Symptoms 21/9/14

Fingers on left hand stiff will not fully straighten or close

Stiffness in shoulders and upper spine

Knees very stiff - difficult to get up from sitting position.  Often click, sometimes painfully

Sleeping OK 

A wealth of medical literature

While waiting for my next consultation, I've been reading the medical literature on the diagnosis and treatment of inflammatory arthritis and created a small review. It's fantastic to be able to access scientific literature free online, albeit abstracts only for the BMJ.  Fortunately medical abstracts are comprehensive and seem to be written to a fairly consistent format.

The review did not exactly put a spring in my step:
- the disease is not curable, at best you can hope for its progression to be slowed or stopped
- treatment with NSAIDs has been phased out in favour of DMARDs
- the efficacy of the most commonly used DMARD, methotrexate is debatable
- recent results show that tumour necrosis factor (TNF) inhibitors are more effective than methotrexate but because they're far more costly are only likely to be prescribed if methotrexate fails
- it's important to start treatment early in the course of the disease, a so-called therapeutic window of opportunity

Back to the rheumatologist with MRI images of my knee joints

Great, the good news is that it's not cartilage wear and the bad news is that it's probably some form of inflammatory arthritis. To my surprise we also discuss gout as a possibility, rather sobering given I'm guilty of drinking a glass or two of wine every night.

To nail the diagnosis we need another round of blood tests which would blow the BUPA budget so it's better for me to get the tests on the NHS.  So, the BUPA cover is not sufficient to pay for the tests and consultations needed to reach a diagnosis, let alone administer the course of treatment.  Company group BUPA schemes might not be worth the extra tax they incur!

More tests . . .

My thoughts before the consultation:

Systemic?

What else could we test?

Gout seems unlikely, toe, redness. Alcohol close to allowance

Allergy? No change in lifestyle

Virus? Muscles ache. Swelling of fingers, stiffness in top of spine

What can we deduce from MRI?

No treatment yet.

NSAIDs? 

Muscle strengthening

Prognosis?

Into the MRI tunnel

Unlike X-rays, MRI scans really bring out the details of the soft tissue.  Beautiful images and full of inflammation

This article describes what a radiologist might be looking for

A visit to the high priesthood of the medical world

Consulting my rheumatologist feels like an appointment with a high-powered lawyer, piercing intellect and exorbitant fee rate.  The £ quickly tick away.  I'm glad that I've prepared my history beforehand because time is money.

I demonstrate my immobility by perching stork-like on one leg, and then have an ultrasound scan of my knee which indicates regions of inflammation.

Time for MRI scan, tricky thing to pin down this diagnosis.

Later I reflected that I was pleased with the choice of consultant, quick on the uptake, told it straight and gave the impression of being up to date in the field - maybe a tad light on empathy!