An efficient approach for rheumatoid arthritis management

MANILA, Philippines - Lorenza Santos has accomplished much in her life. From a successful 46-year marriage that resulted in four accomplished children and several grandchildren, to working as a real estate agent with her spouse, to enjoying an active lifestyle like aerobics and jogging daily, she has kept herself happy and, more importantly, healthy.

This is why it came as a surprise to her that when she turned 61 years old she began experiencing an uncomfortable pain in her knees and lower joints. At first, it was bearable, and she thought that perhaps she was just over-exerting herself. She tried to cut down on the physical exercise and take it easy. However, instead of getting better, the pain just continued to get worse. It got so bad that soon she could no longer walk without the aid of a cane.

Looking for a solution

Santos wanted to seek medical help as early as possible when she realized that her pain was not subsiding no matter how much she tried to relax and take it easy. For someone who has always been healthy and active, hardly being able to walk and becoming dependent on her cane was difficult for her to accept. In addition, she had worked hard to maintain her health and did not want to see it deteriorate.

She and her husband first saw a neurologist in 2009 as they worried that her worsening pain might be a nerve problem. The doctor advised her to get knee replacement surgery as he felt this might help alleviate the pain and return her to normal.

Her family though knew that the surgery was not only expensive, but had its own set of risks for someone her age and was wary against her having an operation. That, plus it was not a guarantee that she would get better. They decided to get another opinion.

They saw another neurologist who referred them to an orthopedic surgeon who initially drained the water from her knees and prescribed her with steroids for the pain. When this treatment, however, did nothing to stop it from returning, he referred them to Dr. Nympha Ribargoso, a rheumatologist at the University of the East Ramon Magsaysay Medical Center on Aurora Boulevard and Our Lady of Lourdes Hospital in Mandaluyong City.

They went to see Ribargoso in late 2010, a year after the pain first started. “When we saw her, she knew right away what was wrong and I was diagnosed with rheumatoid arthritis or RA,” Santos said. “It came as a shock to me because I did not think something like this would happen to me. I was healthy, and as far as I can remember, no one in my immediate family had it before me.”

Finding the right treatment

With the proper diagnosis made, Santos and her husband, together with Ribargoso, plotted out a course of treatment for her. They wanted something that would work, and at the same time could cause as little side effects as possible.

“She was in good health aside from her problems with RA,” Ribargoso said. “It gave us more treatment options since we did not have to worry about other health concerns like hypertension or diabetes. We decided to be aggressive with the treatment in the hopes of giving her back her normal life before the onset of the illness.”

Ribargoso started Santos on disease-modifying anti-rheumatic drugs (DMARDs) and pain relievers (NSAIDs). She was also taking steroids which had caused swelling of her face and other uncomfortable side effects.

“We started her on methotrexate and pain relievers for the pain and swelling, but the overall effects were not as good as we hoped for,” Ribargoso said.

“I also wanted to get her off of the steroids. Lorenza was also positive for rheumatoid factor. This makes her RA carry a more aggressive course. We decided that since she was in overall good health she would be a good candidate for a more aggressive treatment that could yield quicker results and would only need to be taken once a year,” Ribargoso added.

In March 2011, Ribargoso started Santos on rituximab infusions. She gave her two infusions and the effect of the medicine took place very quickly.

“After the infusions of the medicine, in about three weeks I could already feel the difference they made,” Santos related. “The pain began to subside and the inflammation started going away, too. It was slowly going back to the way I felt before the pain began. I could not believe it.”

Finding her way back

So after two years of struggling with the discomfort and the pain and swelling of her lower extremities, followed by discomfort and pain in her upper joints, and having to resort to a cane just to be able to walk short distances, Santos finally found the relief she had long been looking for.

Since her infusions with rituximab, life has finally gone back to normal. Not only can she walk again, but she has also started to get back to her old hobbies and pursuits.

“For the first time in years I can do aerobics again and enjoy walks with my husband,” Santos shared with a smile. “I try not to be too hard on my body, but it is good to be mobile again and be able to get around. It was hard for someone very active like me to suddenly not be able to move.”

With a successful first year of treatment, and follow up check-ups at three months, then six months, and a few maintenance medications, Lorenza’s condition continued to improve.

“She is healthy, strong, and has responded very well to the treatment,” Ribargoso said. “We can look at giving her infusions annually based on her treatment progress. It makes the treatment more efficient and the effects are long lasting.”

Rituximab is a unique therapy for rheumatoid arthritis, specifically targeting the B cell — a component of the immune system and key factor in autoimmune-mediated inflammation.

B cells trigger a variety of cellular processes, including generation of autoantibodies such as rheumatoid factor, which are strongly implicated in the pathogenesis of RA.

There are treatments available to manage RA such as biologic therapies with TNF inhibitors, but at least one-third of RA patients do not respond to TNF inhibitor therapy.

By targeting the B cell, rituximab provides patients who have had an inadequate response to TNF inhibitor therapy an alternative treatment that has proven success in the treatment of RA.

Rituximab is a prescription drug and should only be taken in accordance with the advice of a physician.