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Forum Name: Rheumatology Topics

Question: Suspected RA in NIDDM patient on Plavix.


 techsasgirl - Wed Jan 28, 2009 5:52 pm

My 38 year old husband suffered an MI on Christmas. He had PTCA with 2 stents in the RCA and one Xience V stent in the circumflex. He now takes Plavix, Toprol, Simvistatin (currently held - you'll see why) Lasix, K+, Glucovance, ASA. 10 days ago he developed diffuse migratory urticaria. He refused to see a doctor. He's in school right now and "can't miss even an hour". I felt it was a bit late to be an allergic reaction to his medications 3 weeks into therapy, so I gave him benadryl and topical hydrocortisone. 3 days later it resolved. The very next day, he developed moderate diffuse muscle pain. It progressed over the next 2 days. I held his simvistatin, thinking it could be statin induced myalgias. He won't even CALL the doctor, let alone go see him. Absence of the statin didn't help. The pain has progressed to multiple sights. He has OA in his knee, but states that this isn't joint pain, its in the muscles around the joint. Hands, wrists, knees, hips, and shoulders are affected bilaterally. Last night he collapsed in pain. He has difficulty with ADLs and can barely tolerate driving or holding a pen due to pain.

Last night, he finally agreed to see the doctor. Since I am soooo smart and I already had all the differential dx in mind (statin induced myalgia, hypokalemia, rhabdomyolysis) and since the walk in clinic where his PCP works was closed, I took him to the Lubbock Heart Hospital where he had his PTCA and his cardiologist was actually on call. They wouldn't specifically tell me what labs were drawn, but reported that his liver enzymes were normal, metabolic panel was normal, his renal panel looked good, and they felt they had effectively ruled out the medications as the cause. Then they pointed out to me that his 1st digit on his left hand was significantly swollen and the distal joint was erythmatous. He was diagnosed with migratory polyarthralgia and was asked to see his PCP for a referral to a rheumatologist. The ER internal med physician is highly suspicious of RA. They didn't test for it since this would be a send out, and he didn't think the result would ever even get to us although the bills for testing would. (honest answer, huh?)

I worked in pain management for 3 years and RA seems like such a debilitating disease. I know that it won't always be like this. Here's my problem. This town only has four rheumatologists and I know from professional experience that it could be months before I can get him in with one, and even longer before a concrete diagnosis can be found. I have called in a favor from a friend of mine, and he is going to try to get my husband on the fast track to get in with one. I just don't know what to do with him in the mean time. He is in so much pain! He can't take NSAIDs due to the fact that he takes Plavix. They gave him solumedrol last night, and now I'm worried about his glucose levels. He's a very non-compliant patient, and his last A1c was 13. I'm not exaggerating. As a diabetic, the usual coctail of MTX and prednisone is off limits. Does MTX alone work well? He can't take any type of narcotic pain medications due to his job and school. Regardless, I've never known them to work very effectively and RA patients usually end up with intrathecal narcotics once other rheumatology treatments have failed. That's not an option for my 38 year old husband. I know that there's no telling how long this flare up will last and that it could go into remission for months or even years. But it's so unpredictable, I don't know how to help him. His current classes are in defensive tactics, and he has to practice physical altercations with suspects all day long. They are taking it easy on him right now, but they can't do that for much longer. He is afraid that he will lose his job.

He is aware of the risks associated with his medicated stent. Since he is typically so non-compliant, I explained to him how the endothelium is affected by the stent, and that if he doesn't take his Plavix, he could develop and embolus and it could be fatal. I did this to show him how important it is to keep taking his medications. Now he says he cannot and will not live in pain like this. He has stated that he would rather be dead. I am terrified that he will stop taking his medications in hopes of inducing an MI. How can I help him until the real help comes from a rheumatologist?
 Tom Plamondon PA-C - Sat Jan 31, 2009 6:35 pm

User avatar Hello,
Thanks for writing in.

You have reported that your husband had stents placed over Christmas time. He has hx of diabetes and dyslipidemia. 3 weeks post op, he developed muscle and joint pain throughout upper limbs and legs. General work up was negative and no change with stopping statin. Concern is about the possibility of RA and subsequent treatment and about general well being of your husband.

There are multiple patient issues here:
- his ability to continue working and taking class.
- s/p cardiac cath and acute MI
- new onset of polymyalgia and polyarthralgia
- possible thoughts of suicide
- medication non compliance
- poorly controlled diabetes
- caregiver stress

Regarding the polyarthralgia and polymyalgias, the first step is to do a basic screening panel which can be ordered by his primary care physician. This will give an idea if RA is probable. Labs include RF, anti-CCP, sed rate, CRP, and CBC. May also add ANA as a connective tissue disorder is part of differential diagnosis. May consider xray of the hands and feet. This will get the ball rolling so his visit to rheumatologist will be more productive.

Regarding the heart and diabetes issue, I will send a note to the cardiology section folks and ask them to review his case.

In the meantime, if he is indeed thinking of suicide, he will need to go to the ER or seed professional help.

Lastly, take good care of yourself and chronic illness can weary both patient and caregiver.

I'll send the case on to cardiology as well.

Take care and keep us posted.
 techsasgirl - Mon Feb 02, 2009 3:18 pm

So any suggestions to help manage his pain until then? He can't take NSAIDs due to Plavix and ASA use, APAP is no help, thermal patches don't stay on, transdermal lidocaine and dicolofenac did not help at all. The steroids didn't really help, but they were given IV, and that really isn't helpful at any one site anyway. The ER doc told him that the mornings he has defensive tactics and other physically demanding classes he could take a hot soak and one hour before activity take 600mg ibuprofen, but that he cannot do this often. He tried it one day. The soak, Ibuprofen and the solumedrol made one day very tolerable for him, but that's all.

I keep hoping this is statin induced myalgia, but I see more and more evidence pointing to RA like edemic, erythmatous joints. I also notice that this is actually progressing to more and more joints, and he's now 15 days off Zocor. If this were statin induced, wouldn't absence of the statin at least halt the progression of pain? I know it may take time to metabolize all of it out, but I wouldn't expect his pain to actually worsen at this point.
 John Kenyon, CNA - Mon Feb 02, 2009 4:12 pm

User avatar Hi techsasgirl --

I'm going to try and add a little to the already excellent response by Mr. Plamadon regarding the cardiovascular implications and what you might expect in this area, especially as complicated by diabetes.

First, it seems likely the initial MI was caused by not only poorly managed diabetes (owing to the diffuse CAD found and treated), but also probably triggered by a generalized inflammatory process (RA would be the prominent part of this right now, but it's likely invaded a number of body systems). Since pain is a significant issue, and since the stress of severe chronic pain adds a layer of risk for a patient with active heart disease, the introduction of MTX and Prednisone only adds to the body's stress response and may at best wind up being a wash, if not an actual disadvantage.

What may work best right now is early discontinuance of Plavix, which is not a permanent solution to the CAD problem anyway. Since it's equally likely the MI was precipitated by a ruptured plaque as by a traveling clot, Plavix may not be an ideal drug for use in a patient with so many comorbidities which need to be addressed. Of course the ultimate goal is to keep your husband alive, followed by keeping him well. He's not supportive of these goals himself, yet is unhappy with the current state of his health (and quite understandably so). His suicidal ideation is a concern all on its own, and I think if he (or his doctor) D/C'd the Plavix, this might actually allow for more comprehensive treatment of the RA, while only causing a small (but significant) increase in CAD risks. Plavix won't prevent a thrombus anyway (as would, say, Coumadin), but rather enables blood to flow through tighter spaces than it might normally (Plavix is a true "blood thinner" whereas Coumadin is instead an anticoagulant).

I believe it's probably most important right now to treat the most acute problems, which are the severe chronic pain of RA, along with addressing in a broad way the suicidal thoughts, under which one must list his general non-compliance, which may be interpreted as something related to a "death wish" if not literal suicidal thoughts. Psych intervention along with comprehensive anti-inflammatory therapy might well yield the best overall results in your husband's case, as the stented arteries have been opened temporarily and may actually benefit a good deal from successful anti-inflammatory intervention. Placing the potential CAD risks ahead of these other issues may have a lower benefit-to-risk ratio than might be apparent at first glance.

As Mr. Plamadon has rightly pointed out, continued expressions of any suicidal ideation or discussion of death wish will require emergent psych intervention anyway, and in this sense your husband has set himself up for failure by refusing not only to be medically compliant but by being unwilling to temporarily set aside his career goals in favor of keeping himself alive and healthy. These priorities are seriously out of order.

I'd recommend a consult with his cardiologist, rheumatologist and a psychotherapist in order to achieve a consensus as to which path would do the greatest good for the patient right now, and I suspect heart disease, as serious a matter as it may be, could come in second or third if this were broken down logically. Since rheumatology seems to be the most difficult hurdle in your area, the situation may only be manageable by treating this as a psychological emergency -- which, of course, raises a lot of issues which can be very stressful not only for your husband, but for you, since you'd be acting to save not only his life but to relieve his suffering, while he's placed career concerns first, relief from pain second, and staying alive third. Since this is not a reasonable arrangement, you can expect an unreasonable resistance to intervention, but it really is looking like a choice between emergent intervention (with a possible interruption of career goals) and allowing your husband to place his own life at far more serious risk from the cumulative problems (as opposed to "just" CAD).

I hope this is helpful. My short answer would be to re-order things with CAD dropped down to second or third behind suicide prevention and pain management.

Good luck to you both. Please follow up with us here as needed.
 Dan Abshear - Sun Apr 19, 2009 12:10 pm

I'm sorry to read your husband is in so much pain with multiple medical issues he has experenced in the past.

First, is his NIDDM well controlled? Lack of blood flow to various parts of the body happens with diabetic patients. when blood flow is limited, pain often results.

Is your husband overweight? If so, this may amplify his pain that he experiences, regardless of the cause of your husband's pain.

With RA, Average onset of this arthritis is one in their early 40s. While most frequent in women with RA, that does not mean that your husband does not have RA.

Yes, a blood test for RA, as well as inflammatory markers, such as CRP and WSR should be done, if not already.

A rheumotologist should evaluate your husband, and possibly a nerologist to rule out any muscular abnormalities that may not have been considered yet.

Good luck,

Dan

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