I’m Dr. Diane Lacaille, a rheumatologist - aka arthritis doctor - and it's Arthritis Awareness Month. AMA!

Help! I have rheumatoid arthritis and it’s hard for me to focus at work due to my pain and fatigue. Do you have any advice for work modifications or how to best have this conversation with my employer?

If your pain and fatigue are interfering with your ability to do your work, there are many things that can help. Making sure that your workstation is well set up ergonomically is really important. You can get an ergonomic assessment of your work through an occupational therapist, which is available through arthritis programs like the Mary Pack Arthritis Program in BC. They will suggest modifications to your work station so it is well suited to your arthritis and they can do this without having to go to your workplace. Some workplace and benefit plans also provide the services of an ergonomist that can come to your workplace. Other modifications that can be helpful are around how your work is organized, things like making sure the tasks that are more difficult for you are done at a time of the day when you have more energy and breaking them up, so you alternate them with other things that are easier to do. These are just some examples of what can be done.

In terms of how to best have this conversation with your employer, I suggest that you think of what would help you do your job more easily and come up with some concrete options. So that way you present the problem alongside with solutions. You also need to think of more than one solution that would be acceptable to you, so that your employer has options to choose from. Although your employer has a duty to accommodate your need, they don’t have to do only what you suggest. It is also useful to explain to your employer why the problem is an issue for you and in what way the new option will help. Think of how it will affect not only you, but also your work and other people. Win-win solutions are always the preferred ones. Vocational counsellors are also very helpful in helping you figure out what you need and what and how to ask your employer for job accommodations.

We have developed and tested a program at Arthritis Research Canada, called Making it Work™ to help people address issues they encounter at work. For more information, visit our website or send your inquiries to [[email protected]](mailto:[email protected])

Hi!
As someone diagnosed with ankylosing spondylitis, I've had great success in keeping it at bay with TNF-blockers.
However, in spite of exercise, I'm noticing a slow, but steady progression towards complete spinal fusion.
Is there active research on corrective surgery going on today, or is spinal fusion just something we'll forever have to deal with?

Medications for ankylosing spondylitis , like TNF blockers, are very effective at improving the pain and stiffness and reducing the inflammation. Studies have shown that they also do slow down the fusion of the spine, but unfortunately, as you have noticed, they don’t totally prevent it. There is ongoing research for new drugs with different mechanisms of action to prevent the fusion. But these studies take time because the fusion happens slowly over time. As you mentioned, exercise is also very important. Moving the spine in all directions on a regular basis helps to maintain the mobility of the spine. Unfortunately, there is no surgery to correct the fusion once it has happened.

What should people do who are having a hard time getting diagnosed? I was diagnosed before with ankylosing spondylitis, but now they don't know what I have. None of my doctors have any idea.

Diagnosis the specific type of arthritis a person has can be difficult. This is why it is important to see a rheumatologist to get a clear diagnosis. Sometimes we need to see how the disease evolves over time to be sure what exact type of arthritis it is. There is no specific blood test or other type of test that can diagnose arthritis.

What are some of the most common misconceptions you see from the public that you'd like to address?

The most common misconception about arthritis is that it is a disease that only affects older people. Unfortunately, young people with arthritis are often told by people around them, “you are too young to have arthritis”. That is not true. Rheumatoid arthritis, for example, often affects people, especially women, in their 30’s and 40’s, but can start at any age, even in childhood. Osteoarthritis is more common as people get older, but also often occurs in people younger than age 65, especially if they have had a sports injury in their youth.

Another misconception is that arthritis is just “normal aging” and that there is nothing that can be done for it. Even though osteoarthritis is more common as people age, people should not think of osteoarthritis as “normal aging”. Pain in your joints is not normal and people should see their doctor if their joints hurt for any length of time. We have very effective treatments for arthritis. In inflammatory types of arthritis like rheumatoid arthritis, the treatments are more effective if they are started early in the course of the disease, so it is important that people get diagnosed and start treatment early.

What is your response to those who have reservations about taking biologics, especially during a pandemic?

I understand that people feel vulnerable taking a biologic that suppresses their immune system during a pandemic. But so far, data from studies and registries that have followed people taking biologics suggest that their risk of getting COVID-19 or of having worse outcomes is NOT increased. Also, since the severe manifestations of COVID-19 are due to the immune system reacting against the virus, causing, for example, the inflammation in the lungs and the so-called ‘cytokine storm”, it is important for people with auto-immune diseases to have their disease well controlled, so their immune system is not “over-active’ to start with.

How did you decide to become a rheumatologist?

I decided to become a rheumatologist because the treatments we have can make a huge difference in a person’s life. Taking away a person’s pain and allowing them to do the things that matter to them, is extremely rewarding. I also like how I follow my patients for many years and get to know them well. And rheumatology is a specialty where we use our clinical skills a lot.

Recently my RA symptoms have gotten worse – the worst it has ever been since I was diagnosed. I have been doing my best to be consistent with working out as it helps with the pain. Even though it can be a painful activity for me, I don’t want to stop. Do you have any suggestions, besides taking my meds, that may help me deal with the pain?

Sorry to hear you are experiencing such a bad flare, it sounds like you need a conversation with your rheumatologist to look at your medications, maybe it is time for a change. But you asked about non-meds things you can do. It is good you are continuing to move around despite the pain, because immobility, as you know, makes things worse. Other things you can try is icing the joints, using braces to support the joints that are inflamed that you need to use for you daily activities, and using relaxation strategies. In addition to relieving stresses, these strategies have been show to help control pain. I am talking about things like deep breathing, guided imagery, progressive relaxation and meditation. Gentle yoga can also be useful, as long as you respect the range that your joints move comfortably and don’t push it beyond that. You may want to consider reducing your work out (i.e., less repetitions, less load, shorter work out), rather than stopping altogether, as physical activity and regular exercise reduces pain, protects the joints and recent evidence shows it may help control inflammation.

Some sites are inferring that some arthritis drugs may protect you from COVID. Is this true?

Some of the medications used for arthritis have been tried as treatment for COVID, to prevent or treat the “over-reaction” of the immune system to the virus, which is responsible for the severe complications of COVID. Some trials are still ongoing, but so far, none have been proven to be effective at preventing infection or the severe manifestations of COVID.

If inflammation is not controlled does it put people with arthritis at greater risk for heart disease or heart attacks?

Yes, inflammation that is not controlled is not only bad for the joints, causing damage to the joints, it is also bad for the rest of the body and can affect other organs in the body, putting people at risk of other diseases, like heart attacks, lung diseases like COPD, and diabetes. The good news is that studies have also shown that if we treat inflammation effectively, we reduce the risk of these complications. Use of medications like methotrexate and anti TNF agents, and good control of the disease, reduce the risk of heart attacks.

There is a lot of information out there and I'm not sure where to start or what is exactly relevant when searching.

Do anti-TNF medications such as Simponi make covid infections worse, or more fatal? Should the pandemic prevent me from taking my injection, or can i safely resume taking it?

Yes, indeed there is a lot of information out there and it can be hard to know what information to trust. Make sure you are reading information that is based on evidence, using sites from reputable organizations or universities where the information has usually been vetted by experts. Our website arthritisresearch.ca has information on findings from studies. Arthritis Consumer Experts joinhealth.org has excellent education information for people with arthritis. Rheuminfo.com also has useful information on medications that is written for patients that is written by a rheumatologist.

Yes, we strongly recommend that you continue your anti TNF. Please see my previous reply on taking anti TNFs during COVID19.

Can you recommend any exercises to help relieve the stiffness in my hands in the morning from my rheumatoid arthritis?

Exercises to move all the fingers of your hands, like making a fist and opening your hand fully, and doing exercises under hot water can be very helpful in getting rid of the stiffness in the morning.

I’m 45 and have OA in my knee and shoulder. Is there anything I can take to slow the degenerative process? I do exercise and I take naproxen PRN.

Maintaining a healthy weight is the most important thing you can do to slow down the progression. Being overweight is definite risk factor for developing osteoarthritis and for greater progression. Exercising regularly is also very important. Studies have shown that it reduces pain and improves function.

Hi Dr. Diane Lacaille,

My father was diagnosed with rheumatoid arthritis in 2016, and has been taking meds (Methotrexate +folic acid) since, however since 2 years ago he started developing rashed like bug bites all over his limbs. I've heard that with RA your immune system can attack your healthy cells and cause this.

Do you recommend any changes to his daily life to overcome these rashes? It recently started spreading more and being more apparent. He does use Taro Mometasone.

Thank you for hosting this! :)

It is hard to answer without seeing the rash. I'd suggest your father to show the rash to his rheumatologist. If they are not sure what is the cause, he should ask to see a dermatologist.

Does exercise reduce inflammation?

There is some recent evidence suggesting that regular exercise might reduce inflammation. Regular exercise also helps maintain healthy body weight, and studies have shown that fat cells release chemicals that promote inflammation.

Can arthritis come and go? Or is it always prevalent in a person, but go up and down in severity? Also, are there certain foods that exacerbate it? And lastly, is it hereditary?

Arthritis symptoms typically wax and wane over time, and sometimes people go into complete remission (ie have no symptoms at all), although this more commonly happens with medications, but occasionally can happen without medications. Unless you have gout or arthritis with Celiac disease, there is no clear data showing that certain foods make arthritis worse, but some people do report noticing more pain after eating certain foods. However, if you decide to avoid certain foods, it is important to make sure you continue to have a well-balanced diet. People with gout need to avoid red meat, sea food, sugary drinks and alcohol as all these foods can trigger a gout attack. Finally, certain genes make certain forms of arthritis more likely, so someone’s risk of rheumatoid arthritis for example is higher if they have a first degree relative with it, but it is not directly transmitted to your children like other genetic diseases are.

I started experiencing pain in my left hip, usually in the morning and sometimes at night. As soon as I start moving around, the pain disappears. After some x-rays, I found out it was arthritis. Is the pain due to the inactivity of lying in bed?

Definitely. Mornings are typical difficult times for people with arthritis, with increased stiffness and pain. This is due to the immobility of lying in bed overnight. Symptoms of inflammation (stiffness, pain, swelling) get worse with immobility, and better with gentle movement. That’s also why people with arthritis find they need to keep moving, break up the sitting time.

I have RA and do injections of my Biosimilar once a week. I find the injection hurts A LOT if I do it right out of the fridge, so I let it sit a bit to let it get room temperature. How long is it safe to leave it out for?

There is no problem leaving it out of the fridge for a few hours so it has time to warm up to room temperature, as long as it is not exposed to extreme heat (not a problem in Canada J ). In fact most biologics can stay out of the fridge for up to a day, although you should check this with the manufacturer if you need to keep it at room temperature for more than a few hours. But the important thing is that once it has been at room temperature, it can’t go back into the fridge and needs to be used that day.

What type of insufficient nutrient can cause arthritis?

There is no good evidence to suggest that arthritis is due to deficiency in any nutrient. There was some thought at one point that vitamin D deficiency might cause inflammatory arthritis, but findings from recent studies suggest there is no evidence to support this claim.

I have OA and have received mixed messages about whether it would be beneficial for me to see a rheumatologist. Any thoughts?

If you feel that the pain from your osteoarthritis is not well controlled, then yes, seeing a rheumatologist could be helpful. Some family doctors are comfortable managing osteoarthritis themselves, others prefer to refer to a rheumatologist. A Rheumatologist can prescribe some medications for pain, can inject the joints that are most painful with corticosteroids, if needed, and can refer you to physiotherapist for an exercise program. If your arthritis is very advanced, a joint replacement surgery might be indicated and the rheumatologist or your family doctor can help you with this decision, and refer you to an orthopedic surgeon, if appropriate.

Hi! Is arthritis more prevalent in one ethnic group than others? Are BIPOC people more susceptible to it?

Yes, arthritis and auto-immune diseases are more common in certain ethnic groups. Arthritis, especially rheumatoid arthritis but also other types like ankylosing spondylitis, are more common and more severe in Indigenous peoples. This is thought to be because genes that predispose to these diseases are more common in Indigenous peoples. Osteoarthritis is also more common. Some auto-immune diseases like lupus are more common in people of colour, and the disease manifests itself differently with more severe diseases.

What is the current consensus on usage of NSAIDs for ankylosing spondylitis? Why is it recommended to take NSAIDs continually during active disease instead of on-demand if they do not slow down the progression of the disease?

It is unclear whether NSAIDs prevent radiographic progression, and this is one reason why some people recommend taking them regularly. Also, when someone takes and NSAID here and there when the pain is really bad, then it works mostly as a pain killer. If one wants to have the full anti-inflammatory effect, it needs to be taken at the full therapeutic dose on a regular basis.

Hi! Thanks for doing this AMA :) Do you happen to have any thoughts/perspective on the findings that chronic inflammation may have some correlation or even potentially causal or exacerbatory relationship with depression?

Indeed, recent studies have clearly shown that people who have arthritis are at increased risk of depression. And unfortunately, this often goes unrecognized because some of the symptoms are similar, and people often think it is just their arthritis. There are a number of reasons why arthritis can cause or make depression worse. Pain and poor sleep make depression worse. Not exercising regularly because of joint pain can make depression worse. And also, people with arthritis are dealing with a lot of losses. Arthritis is a big change in a person’s life, and many have given up things that mattered a lot to them especially while the arthritis is not well controlled. It is important to treat both the arthritis and the depression.

Cool. I have both Seropositive Rheumatoid and Psoriatic Arthritis. How common is that and how likely is it for me to live pain free?

It is unusual to have both seropositive rheumatoid arthritis and psoriatic arthritis, but the two can present in very similar ways and it can be difficult to differentiate between the two if people have RA and psoriasis. The important thing though, is that the same treatments, for the most part, work for both RA and psoriatic arthritis. Living pain free is definitely a realistic expectation as we have very effective medications for both of these types of arthritis.

Thank you for hosting this important chat. We appreciate your time and knowledge.

I'm a 48 year old woman with primary RA, secondary Sjogrens. I'm currently experiencing Thumb Arthritis on my right hand as the worst daily problem of my RA and basically, when I'm awake I'm wearing the prescription support my rheumatologist prescribed for me and compression gloves at night due to pain, swelling, etc. I'm already on methotrexate and plaquenil, with Diclofenac that I try to use sparingly.

Unfortunately, I do need to type for my work. I've switched mousing to my left hand, scrolling on tablet, as well. I've switched to part-time, as well.

What else can I do to mitigate this? Living in a hand support doesn't seem like a very proactive way to handle this and I'm willing to try just about anything, as I do need my hand. Thoughts?

If you are having ongoing pain in your thumb that it interferes with your work, then it means the control of your arthritis is not optimal and your medications need more adjusting. You might also benefit from a cortisone injection in your thumb joint, if that is the most problematic joint for you right now. In terms of adaptations at work, you might want to make sure the support you have is a working splint (i.e. one that allows you to use your hand while immobilizing the thumb). You might want to look into voice activation software to reduce the amount you have to type.

hello! I have psoriatic arthritis that im currently seen a rhuemtolgist for however I see a lot of people who have identifiable triggers for a flare and I do not that I can see . Im never 100 percent pain free but severe pain and fatigue (seems like) can randomly hit me out of nowhere . why is that? amd my 2nd question is why is enthesitis so darn painful ..its almost worse then the joint pain .thank you have a great day !!

Sometimes people can identify a trigger to their flare, and sometimes not. It is also the nature of this disease. You should discuss with your rheumatologist strategies to use when you are hit with a flare. Things like resting, icing, taking anti-inflammatories (if you have no contraindications) can help you get through a flare. If the flares are happening often or are pretty bad, then it means your arthritis is not yet well controlled and you need to discuss with your rheumatologist whether your DMARD regimen needs to be changed. Keeping track of your flares (how often, how long, which joints) can help you and your doctor make that decision together. Enthesitis is part of this disease and can be difficult to treat.

Im 20 years old and have been diagnosed with arthritis, I’ve been declining physically for the past 2-3 years and it affects my mental well-being. Do you have any advice for someone that’s been diagnosed at a young age?

First I would like to say it is common for arthritis to affect people’s mental well-being. You have probably been experiencing a lot of changes and losses. If you think you are experiencing depression, it is important you speak about it with your family doctor and get the help you need. Getting arthritis at a young age is hard and poses some unique challenges. You might want to connect with other young people who have arthritis through online forums or support groups. If you live in Vancouver or Victoria, you could also see a social worker through the Mary Pack Arthritis Program. They can help you with strategies to manage the symptoms of arthritis, and coping with all the different ways it impacts your life. I think it is important that you learn as much as you can about your disease. The more you understand it, the more you will learn how to manage it and figure out how to do the things that are important to you. The Mary Pack Arthritis Program has arthritis education classes (not sure right now with COVID if they are online), physiotherapists and occupational therapists. There are also good educational resources online (see links on previous posts). And of course, it is important to treat your arthritis so it is well controlled.

Hello and thank you for taking the time!

I just wanna ask about Gout. I know diet is the best preventive measure but I feel like diet has stopped working for me. Before when I would have a gout flare up, I could just eat greens and drink only water for a month, and I'd be good. Now it feels like its not enough and the pain just doesn't go away completely. Is it possible the chronic gout has caused a different type of arthritis in the toe? I've been to the doctor a couple of times but I only ever get prescribed anti inflammatories and told about diet.

Sorry I know gout isn't as serious as other forms of arthritis, but its just slowly changing the activities I feel I can participate in.

Glad you asked. Gout is a very painful and serious form of arthritis, and often undertreated. If the pain is no longer going away completely after an acute attack, you may be entering a more chronic phase of gout and you may need medications that prevent attacks of gout and lower the uric acid in your blood that is causing the gout attacks in the first place. Diet is important, but for many people with gout, it is not enough and allopurinol is needed to control the uric acid level. Colchicine can also help to prevent attacks, especially while the level of uric acid is changing (going up or down), which is a time when people are more prone to acute attacks.

I’m new to my journey with “inflammatory arthritis”, symptoms began at 19 and have slowly progressed to now 23 where I’ve only had my rheumatologist 6 months. I now have a malar rash I’m waiting for tests on, but I’m wondering if it’s possible to present as inflammatory arthritis, and wind up years later with lupus instead and still be responding well to methotrexate? (I’m really hoping to only have one autoimmune disease!)

It is possible, but very rare to have both rheumatoid arthritis and lupus. The more common scenario is similar to what you describe, where people present initially only with inflammatory arthritis, and later develop other symptoms of lupus. And then we realize it was lupus all along. The disease can take time to manifest itself enough to make the diagnosis.

Hi! What first steps would you recommend to a woman with RA who’s thinking about the possibility of one day having kids? Should any testing be done beforehand? Should she go off of her meds?

There is no specific testing that is required before getting pregnant if you have RA. The good news is that RA often gets better during pregnancy. Some medications can be safely continued during pregnancy and others, like methotrexate, need to be stopped months before conceiving. So it is important to discuss this with your rheumatologist and plan the pregnancy at a time when your arthritis is well controlled, in case you need to stop or switch to medications that are safe in pregnancy.