Biologic treatment the answer to repetitive joint pains caused by rheumatoid arthritis

MANILA, Philippines – As a dentist, Dr. Agnes Gemino was used to seeing several patients daily. She would service seafarers before they leave to fulfill contracts abroad and she was used to having her schedule fully booked.

The demands of her job kept her on her feet all day and she required some muscle power when having to extract teeth, and do routine cavity removal, and teeth cleaning. She handled them well and never had difficulty while at work.

That began to change, however, after her 50th birthday. She had remained in relative good health over the years so when she first began experiencing pain in her wrists and ankles, she did not think about it. She thought she was just tired and needed to rest.

Unfortunately, no amount of rest helped make the pain subside and soon it had spread to her knees and shoulders. Unsure of what the pain was, she put off seeing a doctor in the hope that it would improve. But instead, it only continued to get worse.

Extreme pain

“When I first started feeling the pain it was still bearable,” Gemino said. “I was still able to do my work and maintain our household. But as time passed, the pain just worsened and I found it harder and harder to even accomplish simple tasks like washing dishes or even walking for extended periods of time.”

The pain made it difficult for her to do her job and it caused her to worry and finally seek medical treatment. She could no longer stand for too long and the pain was almost unbearable when she had to use her hands to do her dental work.

“I cried from pain,” she said. “On a scale of one to 10, I was constantly at a nine.”

Gemino was initially referred to a doctor who diagnosed her with rheumatoid arthritis (RA) and she was put on steroid treatment and painkillers. While the painkillers helped, the pain never went away. It vacillated between painful but tolerable to extremely painful.

Due to her busy schedule though, she was unable to follow up and just continued on the steroid treatment. But soon the pain became unbearable. This time, she looked for another doctor and was referred to Dr. Ivy Catherine Rivera-Go, a rheumatologist at the Medical Center Manila, Mary Johnston Hospital, and Manila Adventist Medical Center.

Initial treatment

“Agnes Gemino was 53 when she first came to see me in late 2009,” Go recalled. “She had pain in her wrists and fingers, ankles, knees, shoulders, and even feet. It was always at high levels on the pain scale between 8 and 9 out of 10. The pain was already making it difficult for her to do her job and just making her life hard in every aspect.”

Go ran a series of tests on Gemino to ascertain her current position and she discovered that she had developed diabetes, most likely from prolonged steroid use. She had been on steroids for over two years.

Go’s immediate goal was to find a treatment for rheumatoid arthritis that will work while at the same time would taper her off of the steroids until she could remove them completely.

“I started her on a combination of hydroxychloroquine and disease-modifying anti-rheumatic drugs (DMARDs),” Go related. She put her on methotrexate and gave her painkillers as needed while lowering her dosage of steroids little by little.

Gemino responded to the medicine but not as well as Go would have liked. While her pain level went down from an 8-9 to a 4-5, it was still present. Additionally, Gemino’s erythrocyte sedimentation rate (ESR), a test that measures how much inflammation is in the body, was still high at 40. It was lower than her initial tests but also not at the level that Go wanted.

“The results were a definite improvement,” Go admitted, “but not as much of an improvement I was hoping to see. I suggested we go to biologic treatment in the hopes that we could reduce the pain even further and dramatically reduce ESR levels. Our goal was to bring her back to her normal life.”

Finding the right treatment

Go wanted to start Gemino on biologic treatment but due to her busy schedule, she was unable to come in for her follow-up appointments. She had become quite busy at work and the treatments she was currently on had made her pain tolerable enough to be able to work again.

However, after several more months, Gemino found she was having increasing difficulty at work and could no longer do things as she used to.

“She came back to see me in 2011 when she could no longer stand the pain in her wrists,” Go said. “We did a repeat X-ray and it showed further narrowing of the joints, limited wrist movements, and erosion in the bones. The degeneration was bad and, if left untreated, would only get worse very quickly.”

“It was really scary for me to see how my joints and bones were degenerating,” Gemino related, “especially for someone like me who relies on being able to use my hands for work. I decided it was time to try the biologic treatment Dr. Go wanted to give me. Luckily, through my husband’s insurance, we were able to afford the medication.”

She was given her first infusion of the biologic tocilizumab in December 2011. She was off hydroxychloroquine before tocilizumab was started.

The response was quick. After her first infusion her ESR rates went from 40 to 6 and her pain decreased dramatically as well. While a little pain remained in her left wrist, she was already starting to feel better and Go was able to reduce all her other medications.

After each infusion of tocilizumab, she showed vast improvements. Her pain continued to decrease. Go was able to taper off the steroids and eventually, even the methotrexate. She gave her painkillers as needed, but after a while, even those were no longer necessary.

“I really began to feel the difference by the third infusion,” Gemino said. “The pain was almost completely gone and I was back to work and even back to doing household chores like I did before.”

“She responded really well to the treatment,” Go said. “In the first month, she was already starting to feel better, by the second month she was displaying no more symptoms, and by the third month, she was completely off painkillers.”

It was a welcome return to normalcy for Gemino and through the returned mobility and energy she was able to go back to her long hours as a dentist and maintain her household at the same time.

“I’m really happy to be able to do the things I used to do before I first started feeling the pain. I am happy to be on a treatment that works and helps prevent further joint and bone damage,” she said.