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Rheumatology . . . Page 2

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Thank you for sending along this very pleasant **-year-old woman.

History: She has had problems with joints for many years, getting gradually worse. She had her right hip replaced in the last few years and has been left with chronic lateral hip pain and has been told she has a trochanteric bursitis. The latter was injected with good result, however, the response was only a few weeks. She complains of pain in her shoulders, hands, knees,and feet. Her jaw gets sore, more on the right. Her joints ache all the time, especially at night and often keep her awake.

She mentions that she had a whiplash accident a few years ago which precipitated increased back pain as well as soreness in her jaw.

She has had five back operations and has severe degenerative disease.

She has had problems with her shoulders and has been found to have a calcium deposit on the left. She recently had a heart catheterization and with the automated BP during and after the cath, she developed a painful right shoulder which has continued to bother her.

She is taking glucosamine sulfate and chondroitin sulfate and is not sure how much benefit she's getting from that. She takes an occasional Aspirin but finds at times this upsets her stomach. Anti­inflammatories have been a problem. She tried Arthrotec which was very upsetting.

Current medications include Eltroxin, furosemide, Nitro spray, Gaviscon, Losec. She has been taking Didrocal and is on her third cycle, but is finding the calcium to be quite irritating and has put the box away in the bottom cupboard. I pointed out that if she is tolerating the Didronel component, that she could simply take that for two weeks every three months.

She has also been taking Minocin for rosacea, 50 mg twice weekly. She has been on higher doses of tetracyclines in the past with out problem.

Her other past history includes mastoid surgery when she was in her 40s. She has several environmental allergies and is also allergic to SULFA, SLOW­K, RANITIDINE and ZINC. She doesn't smoke.

She's married with no children.

On Exam:  BP today was 140/86. Head and neck exam was all clear. She had no oral or nasal ulcers. She had no lymphadenopathy or bruits. Heart sounds were normal and the chest seemed clear, as did the abdominal exam. Musculoskeletal exam disclosed widespread Heberden's and Bouchard's nodes. She had no swelling or stress pain at the MCPs. She was not tender at the CMC joints. She had no swelling in the wrist, elbows or shoulders. She had no soft tissue tender points. She has bilateral knee crepitus but only slight instability and no effusions.She had actually good range of movement of both hips. She was tender in the lumbar spine and has a scar at the lower lumbar spine from her previous operations. Her feet are somewhat flat with tenderness across the MTP joints.

I have sent her for some investigations today to look for other associations with her widespread aching.

It would appear that her primary problem is osteoarthritis and degenerative disease. There is some suggestion that the Minocin may be helpful for osteoarthritis, much like in rheumatoid, due to suppression of the metalloproteinase enzymes. Given that she is already tolerating the Minocin, I've suggested that she try increasing it gradually to 200 mg daily over the next few months and see if this helps with her sore joints.

If she finds that she can't tolerate the Minocin or her monthly blood work shows development of an abnormality, I will suggest the Minocin be cut back down her baseline two tablets a week. At that point, she might wish to try Plaquenil which again has been helpful for some patients with osteoarthritis.

In the next several months we should have the new Cox­2 inhibitor drugs available. These are hopefully going to be much less irritating to the stomach as they don't inhibit the prostaglandins there.

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