Your questions on drugs and specific conditions

Q) I have been offered a choice of biological therapies for ankylosing spondylitis, which I have severely, but don’t feel I have sufficient knowledge to make the decision about which might work best for me. Can you offer any advice?

Mark, West Midlands - 2014

A) You will be aware that I can only offer the most general advice about this. Treatment choice is a matter for discussion between clinician and patient and should be an individualised decision. I would think that your rheumatology department has skilled nurses who can spend time with you and who can go over the various treatment options with you. The cost and potency of biological drugs mean that there are certain conditions to fulfil before you can be offered them, and these will have been taken into consideration by your rheumatologist. It is usually necessary for you to have not responded to two different disease-modifying anti-rheumatic drugs (DMARDs) and to have a certain level of disease activity, as judged by your doctor. If you have a history of tuberculosis, multiple sclerosis or cancer then these drugs are generally not advisable. Generally, all the biological drugs given for ankylosing spondylitis work by blocking TNF (tumour necrosis factor) and they all have similar efficacy, so choice depends a little on frequency of injection (most are self-injected) or, if a patient feels they can’t self-inject, there is an intravenous preparation.

This answer was provided by Dr Philip Helliwell in 2014, and was correct at the time of publication.

Q) I'm a 73-year-old woman, diagnosed with fibromyalgia 20 years ago. I've generally been able to manage this and take no medication other than vitamin supplements. My GP has begun treating me for hypertension. As I've recently been diagnosed with sicca syndrome (and am awaiting the results of a test for Sjögren’s) this provoked a major flare-up of the fibromyalgia. I wonder if other fibromyalgia patients experience difficulties in adapting to hypertensive drugs?

June, Gloucestershire - 2011

A) I don’t think this is a problem confined to fibromyalgia patients. People often take several anti-hypertensive drugs before they find one that suits them. The side-effects can be quite strange and cover a lot of symptoms. Fibromyalgia can be associated with dry eyes and mouth (sicca symptoms), both as an associated symptom and as a side-effect of drugs used to treat the disease, such as amitriptyline. Many people on amitriptyline (this class of drugs are known as tricyclics) complain of dryness.

This answer was provided by Dr Philip Helliwell in 2011, and was correct at the time of publication.

Q) Help! I'm just recovering from yet another attack of gout. During the past six years I've had attacks of gout approximately once a year but from January 2009 have had frequent attacks, occurring every three weeks, in the big toe, ball of the foot joint and other parts of the foot. In January my doctor prescribed a daily intake of allopurinol 300 mg, and in mid-August they increased the dosage to 600 mg. Can you shed any light into why I'm still getting attacks? Blood tests have shown lower levels of uric acid. I'm 84 years of age.

Mrs Collins, Essex - 2010

A) This is a difficult one. Allopurinol lowers the level of uric acid in the blood and tissues. This clearing of uric acid may take some time to happen and can be associated with new attacks of gout while the clear out is occurring. This is well recognised and usually stops after about three months. However, in some people, and particularly those people with large deposits of gouty crystals in their tissues, called tophi, this process can take longer. If you have these tophi, this may apply in your case, but don’t despair, things will improve eventually.

There are other reasons why you might be getting more attacks of gout. Even while you're taking allopurinol certain other drugs can work against it. These drugs include low-dose aspirin, which is commonly prescribed nowadays. A high alcohol intake will also work against allopurinol, as will kidneys that don’t function too well (also common in the elderly). So plenty of reasons there, and best to discuss with your doctor which may apply in your case.

This answer was provided by Dr Philip Helliwell in 2010, and was correct at the time of publication.

Q) I'm 77 and have quite severe osteoporosis. I've been taking alendronate once a week. A recent bone density scan showed little improvement, although it's no worse. My GP recommended a daily dose of risedronate but I found I wasn't so well on that, so I'm back on the aledronate. Which one do you think would be more beneficial? My GP is open to whatever suits me.

Olive, West Midlands - 2011

A) Alendronate and risedronate are called bisphophonates, and there are others in the class, some of which are only taken annually by injection. That you haven't lost bone is good, as the natural tendency at your age is to lose bone density, so the alendronate is working to some extent. In changing drugs there are many factors to consider. If you've been on these drugs for 10 years or more it may be time for a change. If you've recently had a fracture this might indicate that a treatment change is necessary. And there's your lifestyle to consider – smoking and alcohol accelerate bone loss and if you tend to have falls it's important to keep your bones as strong as possible. There's no easy or simple answer to your question as each case must be considered on its merit.

This answer was provided by Dr Philip Helliwell in 2011, and was correct at the time of publication.

Q) Could you tell me please if spondylolisthesis or cervical spondylosis can become or turn into arthritis? Or do they have no connection to arthritis at all?

Cheryl, Shropshire - 2012

A) These terms are confusing and doctors often use them to mean different things. Spondylolisthesis is one vertebra slipping on the next. This can occur because of minor abnormalities in the bones that are present at birth, or because of arthritis in the joints between the vertebrae. Spondylosis is another term for arthritis of the spine.

This answer was provided by Dr Philip Helliwell in 2012, and was correct at the time of publication.

Q) Can a whiplash injury cause spondylitis? I was in a crash over a year ago and I am still in incredible pain, with numbness and tingling in right hand.

I never had pain before the accident, and my research points to spondylitis. My doctors are baffled, so I'm trying to diagnose myself. They're giving me a TENS machine.

Lesley, via email - 2015

A) Let's clear up a bit of unhelpful terminology here. Spondylitis is a bit of a useless term, in my opinion. It refers to inflammation of the joints of the neck and it's used as a diagnosis for a lot of neck problems. But it's a bit of a catch-all phrase that doesn't properly describe what's happening to you – pain in your neck with radiation to the right arm and hand.

What you have by the sounds of things is whiplash (an injury caused by forced forward and backward movement of the head) causing neck pain, probably from the muscles and ligaments that support the spine and, by the sounds of it, some irritation, pressure or injury to the nerves that pass out from the neck. Pain that radiates from the neck to the hand, particularly associated with numbness and tingling, is pretty much the hallmark of injury to the nerves as they leave the spine. 

If you've had symptoms for a year and no clear cause has been identified, you need further investigation – an MRI scan firstly and then nerve conduction studies (also called EMG – electromyelography) if the MRI doesn't fully explain what's happening.

That said, a TENS machine is a reasonable suggestion for your pain. It's safe and effective, and can be started while you're waiting for investigations. But the full range of treatment options can only be known when you have a proper diagnosis. If your doctor is baffled, then they need to refer you to someone who can give you a proper diagnosis, explanation and management plan.

This answer was provided by Dr Tom Margham in 2015, and was correct at the time of publication.

Q) Is there any connection between hypermobility in joints and arthritis? I'm 43 and I've suffered knee pain for years and have also herniated two discs in the last 10 years. This seems to be a lot of problems for someone my age. Saying that, I did get knocked down by a car in 1985 and was told I would get arthritis early on. I would appreciate your opinion please.

Sue, Halesowen, West Midlands - 2011

A) Professor Howard Bird, who has just recently retired after a long career working as a rheumatologist in Leeds, spent much of his early career looking at the relationship between hypermobility (bendy joints) and arthritis. He found that hypermobility predisposed people to a number of rheumatic complaints, one of which was a tendency to develop osteoarthritis at a younger age. Although the term hypermobility covers a 'mixed bag' of diagnoses, those people who inherit the tendency can get other problems such as varicose veins, piles and slipped discs. This may be because the 'tissue scaffold' is weaker than normal. Although people with generalised hypermobility are born like that, it's possible to acquire hypermobility in just one or two joints with use (or abuse if you like). There's no doubt that hypermobility can convey advantages in certain activities such as ballet, music and gymnastics, but it's a double-edged sword and it requires careful management to avoid future problems.

This answer was provided by Dr Philip Helliwell in 2011, and was correct at the time of publication.

Q) Has polio been investigated as a possible illness to influence arthritis becoming inevitable? The summer after I was born in 1924 I contacted 'infant paralysis'. It affected my right hip and leg, which grew two-and-a-half inches shorter than my left. As a child I wore a built-up boot and callipers. I developed osteoarthritis in my forties in my hip, knee, ankle, neck and arms and have been unable to walk for the past 20 years so have been confined to wheelchair.

Doris, Great Holm, Milton Keynes - 2013

A) There are no formal studies but the association between polio and arthritis has long been recognised. Polio is a disease of the nerves and, if it happens in childhood, affected limbs and spine do not develop fully. In later life this, of course, alters the mechanics of both the affected limbs and the unaffected limbs, putting additional strain on the bones and joints. Premature osteoarthritis of the major joints and spine is the result. Some of the worst cases I have seen have been in ex-polio sufferers. Thankfully, as polio is eradicated, this is becoming an increasingly uncommon occurrence.

This answer was provided by Dr Philip Helliwell in 2013, and was correct at the time of publication.