To Your Good Health: RA patient hasn’t found a medication that alleviates joint pain

I was diagnosed with rheumatoid arthritis, but my rheumatologist hasn’t been helpful in finding a medication that I’m not allergic to for alleviating joint pain. I seem to be allergic to most meds that I’ve tried. I’m only 68. I saw the phrase “biological medication” for RA in one of your recent columns. What is this, and do you have any advice?

RA is an autoimmune disease that may affect other organs besides the joints, including the heart and lungs. While initial treatment for RA may include powerful conventional medicines against the immune and inflammatory systems, such as methotrexate or hydroxychloroquine, a biological medication is made from live-cell systems.

These medicines mostly include monoclonal antibodies that bind to active biological molecules — called cytokines — but they also include fusion proteins that block cytokines before they bind to their receptors.

For RA, the major biological medications bind to important cytokines such as tumor necrosis factor, or TNF, interleukin-6 and interleukin-1. But they may also act on stimulants to antibody-producing cells, or B cells, as well as T cells, which are the other major part of the immune system that’s responsible for cell-based immunity.

Biologicals have the potential for serious side effects, including infections — especially tuberculosis, but also pneumonia, skin infections, hepatitis B and sepsis.

For this reason, biologicals are generally used after a person has failed other treatments. Allergic reactions are uncommon with biologicals.

RA requires an expert for treatment. I have great respect for RA, having seen terrible outcomes in people who weren’t treated early enough. For this reason, I can’t say whether a biological is appropriate for you.

Your rheumatologist is monitoring your blood tests and clinical findings to balance the damage from RA against the potential side effects of treatment. It’s really the disease activity that determines whether a powerful agent is necessary.

I’m a 99-year-old man in good health who suffered a heart attack in 2014, which was caused by an artery blockage. After inserting a stent in my artery, my cardiologist recommended statin drugs. I tried a few, but they were so painful that my insurance company finally authorized me to use a PCSK9 inhibitor. The inhibitor worked well for a couple of years, but then I started experiencing terrible hip pain upon standing or walking. The good news was that there wasn’t any pain when I was sitting or lying down. So, the question for me became: Should I keep using the PCSK9 inhibitor despite the hip pain, or should I stop using the inhibitor and risk another heart attack or maybe even a stroke?

Congratulations on doing so well at age 99. Because PCSK9 inhibitors rarely cause muscle or joint pains, I’d first try to be sure that the medicine really is the cause behind your pain.

I hope your doctor did X-rays to look for arthritis or even an MRI, since conditions like a torn labrum should be considered.

If there isn’t another cause, and the pain stops when you pause the medication, then it’d be likely that the medicine is causing it.

Since there are three PCSK9 inhibitors — evolocumab, alirocumab and inclisiran — I recommend trying a different one. If they still cause problems, then I recommend trying something else entirely.

At age 99, your quality of life seems to be the most important issue to me. I’d also give you a trial of bempedoic acid, which works similarly to a statin without the muscle aches that some people experience.