Understanding Arthritis So You Can Effectively Manage Your Pain with Dr Elaine Husni

Podcast Transcript

Nada Youssef:  Welcome to Health Essentials, a Cleveland Clinic podcast. There's so much health advice floating around online, among friends, but who can you really trust? Trust the experts. Listen to the world's brightest medical minds our very own Cleveland Clinic experts. We ask them real questions, tough and intimate health questions, and we get real answers. All originally recorded live.

 Hi, welcome. Thank you for joining us, I'm your host Nada Youssef, and today we have the vice chair of rheumatology and director of the arthritis and musculoskeletal center, doctor Elaine Husni. Before we get started please remember this is for informational purposes only and not intended to replace your own physician’s advice. Thank you so much for being here, Doctor.

Elaine Husni: Thanks, it's great to be, welcome.

Nada Youssef: Yeah if you can just give us a few minutes just introducing yourself to our viewers.

Elaine Husni: Sure, you just made a nice introduction, I'm a rheumatologist, I practice in a rather larger practice, and I love what I do. I think what I learned most is actually from the questions I get from patients so I'm excited to hear what everyone has to ask.

Nada Youssef: Perfect, all right. Well let's start by talking about what arthritis is, it's an inflammation of the joints and it's usually very painful. Correct?

Elaine Husni: I think people have all different types of arthritis so it's important to get properly diagnosed of what type of arthritis you have and then proper treatment can then help the patient the most.

Nada Youssef:  Sure.

Elaine Husni: I think pain is perceived differently by different people so I think it's hard for me to say that everyone's gonna have intense pain. I mean there are some and there's some people that just have mild gnawing pain and some people that have the intermittent pain so I think it varies.

Nada Youssef: And it depends on your pain tolerance, I'm sure as well. Right?

Elaine Husni: Correct.

Nada Youssef:  Yeah, yeah. Well it's hard to measure but I mean it effects more than 50 million American adults and 300,000 children according to the Arthritis Foundation. For treatments I mean there are a hundred types of arthritis so how do we know what kind of arthritis?

Elaine Husni: Yeah great question. As you know we all have joints and we all want to move our joints and when they hurt you wonder, "Oh my gosh is this arthritis?" And I think the most important thing is to really think of arthritis as really many different types of diseases. The most common is called osteoarthritis and that is wear and tear, simply put it's your cartridge kind of wears down and the bones in your joints get closer together without the cushioning, so that's osteoarthritis, that's the one that effects over 25 million Americans.

Nada Youssef: And that's more with age?

Elaine Husni: Usually we see that with age, people that may have overused or repetitive syndromes, people that may have previous injuries. Right? Those are what makes osteoarthritis more common in that joint.

Nada Youssef: Sure.

Elaine Husni: Then the whole other family of arthritis is what we call more of the immune mediated or the inflammatory arthritis. Those are people with, you might have heard of, rheumatoid arthritis, psoriatic arthritis, lupus can fall in that category. Those are sort of the two broad categories, it would take the whole hour for us to go through each of those so that's in general. One is sort of what we call a non-inflammatory arthritis, that's the osteoarthritis was the wear and tear and then the other group is what we call the inflammatory arthritis and treatments are very different for those.

Nada Youssef: That was actually my next question because wear and tear is different from inflammation so it's not like it's just one treatment for all.

Elaine Husni: Correct.

Nada Youssef: It all depends.

Elaine Husni: Correct.

Nada Youssef: I see. Okay well that answered my next question, thank you. Do we know what causes arthritis and is there a cure?

Elaine Husni: Great question. Arthritis in general, we have ideas of why patients might break down their joints and cause pain. In terms of knowing exactly what causes it we are not there yet so there is a lot of research going in to trying to better understand who's at higher risk and who might need more aggressive treatment and then eventually some of these arthritis can be more or less cured by surgery so you can actually replace the joint.

Nada Youssef: Great. Besides medication is there something that a person can do to minimize the pain?

Elaine Husni: Sure so I think many of us do undergo maybe you know just overuse or doing a little bit more exercise than they should have and they get pain in their joint and you know the first thing that they do is what? They kind of hold off or stop so there's many things that we can do to manage pain. When we have a lifelong disease like maybe more of an inflammatory arthritis what do you do because you still have to go to work and still have to take care of your family? That's where it becomes a little bit more of looking at educations, you get properly diagnosed, you understand how the arthritis effects you and what you can do to manage the pain.

Nada Youssef: Sure.

Elaine Husni: That's really where what we spend a lot of our time in patient appointment to go over, to understand where your goals are, and what you can't do the most, and what we can do to make it better. We have both medical treatment, like with pills, we have injection therapies, and then we also have non-drug alternatives. Right? We have a lot of physical therapy and rehab that we can recommend and work with the patient as well.

Nada Youssef:  Great. Now Cleveland weather today surprisingly nice and warm but I've heard a lot about arthritis or the weather affecting your joints and arthritis can flare up from that. Is that a true story because I kind of hear both sides?

Elaine Husni:  Yeah so that's really interesting. We actually have tried to look at that, how weather might affect and we do know many people who say, "Oh I know the rain's coming," or "I can feel it in my joints before you even know what the weather is," and how good can we be at predicting weather based on our joint pain? I do believe that there's probably a lot to do with barometric pressure and humidity so temperature and the way the weather is does change some of the atmospheric pressure.

I believe that many people may have changes in their joint capsule so the joint capsule is just a fancy word for that fine lining that encapsulates your joint and that is an enclosed space so I'm sure that depending on the type of weather that can maybe influence the way that your joint capsule might feel either enlarging it or squeezing upon it and then possibly certain people can feel a change in their joint. Those have nerve endings around it and so therefor then can cause some sort of pain or pressure in that area. But unfortunately our science isn't quite there yet that we can say that people can actually predict when or maybe what the temperature exactly might be based on joint pain.

Nada Youssef:  Sure. Okay and I kind of want to go over kind of like a myth buster because I heard a lot of conflicting things for arthritis. I'm gonna ask you some questions, just let me know the truth.

Elaine Husni: I'll try.

Nada Youssef: First of all is it to blame for all joint pain, is arthritis to blame? Sorry I have to actually move this right here.

Elaine Husni:  So I think that it's probably a little more complicated than we'd like, you know we wish that if we had joint pain in that one area we would just say yes, no to arthritis but there's a lot of things also around the joint so the joints do include the bones as you think of that helps us move, help us kind of bend, extend, and flex your joint but there's also muscles around the joint, there's also tendons around the joint, so your joint the musculoskeletal system sort of acts as a unit together with the bones, the cartridge, the tendons, the muscles so something the pain can be in different areas. Also some people can be a little more sensitive to pain where their nerve fibers can be more sensitive so even if their arthritis might be more mild but their reaction to their nerves could be higher and therefor their pain threshold they can have and experience more pain than others.

Nada Youssef: Right, right, right. Great, thank you. Okay so someone like I actually crack my knuckles quite a bit, does that cause arthritis because you know you hear about that when you're younger, your mom tells you not to do that and you never know why, but is that a factor at all?

Elaine Husni: Yeah it's interesting, you know we know that it's quite habit forming so we know that people that actually crack joints tends to do it under certain circumstances so it's almost a habit forming for cracking knuckles. Really that the sound that it makes doesn't necessarily emanated just from the joint, it's actually studies have shown where the tendons can kind of slap against the bone, so it's kind of happening around the joint so I think that's a very hard question, I think the jury's still out on whether it actually causes arthritis. As you know there's many people that get arthritis that don't crack their joints so I think it is difficult to pin down but obviously it's in that general vicinity and the noise comes from the joint so it's really natural for us to think whether or not, it could be maybe not cracking the knuckles but the way that they use their joint and overuse their joint could maybe contribute to arthritis in that area but I wouldn't be able to say with certainty.

Nada Youssef: Sure, well very good to know. Okay let's talk about exercise. You know it's recommended for our health but can it aggravate joint pain for someone that has arthritis?

Elaine Husni: You know I get that question every week probably, like oh you know should I exercise more, well it doesn't make sense, it hurts. Actually we are a big believer in using your muscles and your joints, we think that's how you're gonna get long term benefits in terms of function. There's gonna be times where you can't do that right? Because there will be times when your arthritis flares depending on what type of arthritis you have and we'll probably advise you to modify your exercise at those time but then there are times overall that we want you to keep your range of motion, resistance training, and keep your joints moving. We think overall in the long-term that's gonna lead to better function. I think that's a two sided question, so yes we want you to exercise but we also want you to modify it during certain times.

Nada Youssef: Sure, sure. Would you say something like maybe swimming or like the aerobic exercises underwater would that help with joints? I'm trying to think of what kind of exercises wouldn't be too painful.

Elaine Husni: Sure so what you're referring to is sort of the exercise that we see that is sort of a non-weight bearing. Right? There are definitely exercise, that's actually a good point. I think exercise means different things to different people. Right?

Nada Youssef: As long as I'm moving it’s probably I consider that exercise.

Elaine Husni: Well I cleaned my house today so I exercised. Right?

Nada Youssef: Right, exactly.

Elaine Husni: I was only doing the elliptical for an hour today, for an hour and a half, I'm like wow, so I think it is important to be evaluated for exercise so there are therapists, physical therapists, exercise physiologist. There's many people that exercise is what they do for a living and they can evaluate you to see what kind of exercise you might want to focus on. You know is it your large muscle groups, is it your small muscle groups, you know where you are maybe weak. You know?

Nada Youssef: Sure.

Elaine Husni: Then after that there's also people that have never exercised before. Where do you even begin, right? Maybe they have to start with water therapy which is what you were alluding to, some sort of less resistance so there's water based therapy, land based therapy, and then obviously there's people that are a lot more high functioning who have been exercising lifelong and they need to get to maybe a next level where they can use different forms of exercise maybe focusing on core. Then don't underestimate the other sort of maybe little more nontraditional exercise like stretching and yoga, things like that.

Nada Youssef: Sure, walking.

Elaine Husni:  And walking.

Nada Youssef: Like the steps. Great well it sounds like there's a lot of customization based on the patient, you probably deal with a variety of patients and kind of pain.

Elaine Husni: Right but the message is that exercise can be good and we have to modify it and adjust it and personalize it.

Nada Youssef: Sure, it should be there, yeah. Okay and how about diet, is that a huge factor in preventing arthritis, is that true or false?

Elaine Husni:  Yeah so I think diet is something that's so powerful because you can control what you put into your body so I do think it's a really important topic in general. Whether or not we're at a point where I can pinpoint a certain grocery list that's good for arthritis or bad for arthritis we're not there yet but I think we do know a lot about nutritional sciences now that we may not have known before. There are certain over indulgences that can lead to not feeling as well and increasing how fatigued you might be. Those that really focus on a lot of sweetened and processed foods aren't gonna be as good as whole foods.

Nada Youssef: Right, of course.

Elaine Husni: Foods that you shop for that you need to shop for everyday, foods that really stay on your shelf for three weeks you wonder how good it can be.

Nada Youssef: How could it stay?

Elaine Husni: You really want to have a plate full of very varied diet where you see multiple colors, things that are a whole foods fresh vegetables, those are always better than trying to limit the drive through line and certain fast food you know where the salt and the sweet and the fried intake is just being less controlled. Overall we know a lot about eating more with whole foods are gonna be helpful.

Nada Youssef: Sure.

Elaine Husni:  As you know that's a topic that we could spend the whole half hour on.

Nada Youssef: That could be the whole podcast, maybe the next one.

Elaine Husni: I think talking with your doctor about you diet I think is a great start and then depending on what other chronic illnesses you might have we're gonna tailor that diet as well.

Nada Youssef: Sure and I'm guessing that has to do with inflammation like rheumatoid arthritis like an antiinflammatory diet would be probably good for that. Correct?

Elaine Husni: Correct so there's a lot looking at that so I think the best way is really to have a more personalized approach so I think some people that have severe rheumatoid arthritis I think the diet will help but they will also need some of the medications that a rheumatologist might recommend so it'll be a combination of things. Their exercise program might looking differently than someone with mild rheumatoid arthritis that might be on a different medication.

Nada Youssef: Okay, great, great. Then speaking of diet through can losing weight ease your joint pain?

Elaine Husni: Right so I think we have a lot of studies looking at weight and osteoarthritis which is the noninflammatory. We know that in osteoarthritis that weight plays a big role in accelerating the cartridge loss than having excess weight I should say can increase the rate that osteoarthritis can form. Perhaps in those patients that are overweight that have osteoarthritis your weight becomes a bigger priority especially if your osteoarthritis is in a weight bearing joint so that means hips, knees, ankles you might want to consider and you have excess weight then that's where we will focus on that.

Nada Youssef: Sure, sure. Great to know. All right well I'm gonna go ahead and jump on to some live questions that we're getting. I'm gonna go to Kareem, "Is there any more research being conduct on arthritis pain?"

Elaine Husni: Yeah so I think research means many things to different people.

Nada Youssef: Yes, it's true.

Elaine Husni: We do a lot of research here at the Cleveland Clinic trying to find many different ways to attack arthritis, try and improve the ways that we look at, try to improve patient outcomes. Many people might think of research of oh am I gonna be a guinea pig, this is an experimental, but research really has a large set of rules behind it and that we only conduct research that is really following the NIH guidelines and so it's important to see if you qualify for a research study and to have a conversation with your doctor to see if you would be a good candidate to be in a research study. If you are we learn lots, I mean this is how we excel in our understanding of research is to get patients in and involved but at the same time not every clinical trial or research study is for you so it's important to just get the knowledge and just because you don't qualify for this one doesn't mean you might not qualify for another one. Research is sort of a dynamic process that you should be looking out for different studies.

Nada Youssef: If the patient wants to get involved in a clinical trial, talk to your doctor. Correct?

Elaine Husni: Yes.

Nada Youssef: Okay.

Elaine Husni: Yeah so there are very strict ways that we look at which patient might respond to which trial so it's gonna be important to see if you quality and then also you know how much time you might have at this time to participate in a trial. We don't really just want people to sign on the dotted line and then decide oh I'm going to vacation and so it might not be a great time then you find another time so this is all a just really fact finding and seeing which trial might fit for you. I do think it's important to get patients excited about research.

Nada Youssef: Sure, that's great. Them knowing that it helps both sides of the patient and the doctors.

Elaine Husni: Yes.

Nada Youssef: All right and I have Cecelia, "My mother's 86 years old and her knees are always aching. Is that arthritis?"

Elaine Husni: That is something that's so hard to know just over the phone or on the internet. One of the best ways that we know whether or not you have arthritis is actually to come to get a visit but a rheumatologist and the reason for that is because we look at all different things. We look at how you're reacting to pain but we also may get an X-ray because we want to kind of look at the bones and see what they're doing and we might want to do an exam so we want to see what's going in the joint and how well it's moving compared to someone else that we see in your same age group. All of those play a role into how we diagnose so it's not just the pain but we might get some laboratory markers, we might get some X-rays when we do an exam. We kind of take all of that together with the patient and then we can help diagnose more accurately.

Nada Youssef: Great. Then Jeff, "I have diagnosis of RA and fibromyalgia. Are these commonly diagnosed together, what causes the extreme fatigue, and what can one do about it? Thank you."

Elaine Husni: Sure so rheumatoid arthritis is probably one of the more common inflammatory arthritis so one that we'll hear about a little bit more than some of the others. It is a immune mediated or autoimmune disease so we don't know what causes it and some people have mild RA, some people have moderate, and some people have very severe RA that requires more aggressive treatment.

One of the, what we call comorbidities or commonly associate symptom with rheumatoid arthritis can be fibromyalgia, they can be other things such as Sjogren's where you get dry eyes, dry mouth. There's a whole list of other sort of comorbidities or associated diagnosis that goes with rheumatoid arthritis. If you have more than one than we might tailor our treatment to helping somebody with not just the RA but also with the fibromyalgia so you might get two different treatments in that particular case.

Nada Youssef: Sure, sure. Great to know. Phil, "Can you actually get arthritis off the spine?"

Elaine Husni: Yeah so arthritis can, great question, can ... most common when we think of arthritis as those joints that we sort of bear weight on so the knees, ankles, you know hips are common, but certainly you can get arthritis in the hands, in the shoulders, in the neck even so just as a question yes you can get arthritis in the spine as well.

Nada Youssef: Sure, okay.

Elaine Husni: Low back is also a very common are for osteoarthritis.

Nada Youssef: Low back is?

Elaine Husni: Yes.

Nada Youssef: I didn't know that, great. Then Barbra, "What drugs are available to ease the pain or arthritis?"

Elaine Husni: That's gonna depend on the type of arthritis. We have a whole list of medicines that we might use in the noninflammatory, in the osteoarthritis category, and then we have a whole list of other drugs that we can use in the inflammatory arthritis like rheumatoid arthritis or lupus.

Nada Youssef: Okay great. I have Barbra again, "Can you have arthritis pain in your calves?"

Elaine Husni: Calves are usually in the area where it's muscle so you can have a calf muscle. Muscles do attach to joint so in that particular area I would say it's hard to get arthritis in the calf but calves are sort of ... the calf is related to the ankle and the knee so sometimes we do have to kind of do the exam to see what's going on. Arthritis in the calves probably not but there's associated symptoms.

Nada Youssef: Great. Then Kelly, "I have screws in my ankle and my knee that are holding in a rod from a motor vehicle accident years ago. Recently the screw in my ankle started hurting really, really bad and can I have arthritis in it? I've had an X-ray that shows no problems."

Elaine Husni: Great so this is sort of in that category that I remarked about earlier that you can get osteoarthritis from injury as well. Right? There's many different things you could be, you know you could have a lifelong being overweight that can accelerate osteoarthritis, you can have injury, so a motor vehicle accident would sort of fall into that category and depending on how you might have ... so with screws I would imagine that they had surgery after the motor vehicle accident and depending on how bad the injury was and how complicated the surgery was then that may or can determine how much osteoarthritis you can get over time. It is reassuring that the X-ray, for example, did not show arthritis at this point so maybe there might be other reasons that we need to look for the pain.

Nada Youssef: Sure, sure. Great. Patty, "How do you tell which type of arthritis I have, which tests are done?"

Elaine Husni: Sure. When a patient comes in to have an evaluation by us in rheumatology we don't go by just the pain and where it is but we actually take a history and see when does the pain effect you. Is the pain more just in the morning and really just eases up at the end of the day or is the pain all day long or does the pain only occur when we're active? All of those are very helpful questions for us and help us determine whether you're once again in that sort of inflammatory group or the noninflammatory group and based on that and where they are. Are they in the small joints, are they in the large joints. All of these go into what we call history taking and then we do an exam and then we also look at labs and X-ray data and we become much more confident in what I'm about to tell you what kind of arthritis once we have all of those sort of checklist of items.

Nada Youssef: Sure. You would say like the very first appointment if someone's seeing a rheumatologist what to expect it would be first kind of like with the questions that you just mentioned?

Elaine Husni: Get the history.

Nada Youssef: Okay.

Elaine Husni: Get the history, get the exam, and then we'll determine whether or not you do need X-rays or labs. The most important thing to hear and maybe a little unsettling is that you can actually have more than one type of arthritis. Right? There could be something going on in your knee maybe from an injury from sports from a long time ago but then you can also develop another type of arthritis so it is important to know that it might not just be one type and so a formal evaluation would be helpful to sort all that out.

Nada Youssef: Just like you said and depending on the body part your joints are like hiding between a bunch of stuff, you still have to literally ask so many questions or a lot of tests to find that out.

Elaine Husni: Correct. Sometimes people can just have their bursa inflamed, you can have a bursitis which is a fluid filled sac that's right next to your joint. Sometimes we could just take care of the inflammation in the bursitis and you do much better and it has nothing to do with arthritis in the joint for example.

Nada Youssef: How often do you get that? Like I have joint pain, they come to you, and then you find out it's not arthritis they have bursitis?

Elaine Husni: It happens, it happens. Yeah so we do really do need to look at the exam, get the history, and not just go by pain itself. Pain is important to know about but that's not the only thing that we look at.

Nada Youssef: How about carpel tunnel, is carpel tunnel considered any kind of form of arthritis or that could lead to if someone has carpel tunnel?

Elaine Husni: Probably not. Carpel tunnel is more to do with the median nerve so it's just a nerve that's near a joint so near your wrist joint so that's why there can be some confusion is it arthritis in your wrist or is it carpel tunnel. That's a great example of some common things that are near the joint and not associated with arthritis so that can be pretty easily examined and looked after with a good visit.

Nada Youssef: Sure, sure, great. Rob, "I'm having bad gout flare ups in my foot, what are the best treatments for this?"

Elaine Husni: Sure so gout is another type of arthritis that's more in the inflammatory-

Nada Youssef: Category?

Elaine Husni:  -category that we were talking about.

Nada Youssef: Yeah.

Elaine Husni: People with gout it does affect their joint, it's actually one of the most painful, probably one of the most common things we see that actually enters the emergency room so we know it really hurts because it kind of stops you in your track and gout is really due to an excess of uric acid crystals and so our goal is to actually take a little fluid out of that joint and look at it under a microscope and confirm that this is due to gout and once we know that then we can treat and it's very, very treatable.

Nada Youssef: You said uric acid?

Elaine Husni: Crystals.

Nada Youssef: Crystals. What is that exactly?

Elaine Husni: Those are crystals, we have many different actually types of crystals that can form and cause joint pain, gout would be the most common. The other ones that people might have heard of is pseudogout which is a different type of crystal that can also cause arthritis, but gout by far is the most common.

Nada Youssef: The most common one, great. Let's see, and then William, "How do I know if I have arthritis, how do I tell the different between pain and arthritis?"

Elaine Husni: Right so that is why we need more than just knowing about pain so that's going back to getting the history so where's the pain, when does it occur, what makes it worse, that's the history part. Then we also look at family history and things like that and then of course going back to the exam and then looking at X-Ray and laboratory data and putting those together we become a lot more confident to tell the patient what type of arthritis they have.

Nada Youssef: Great. Lena is asking, "What is the relationship between psoriasis and arthritis?"

Elaine Husni: Right so that's actually an interesting area for me because I study a lot of people with psoriatic arthritis. There is a form of arthritis that can occur in people that have psoriasis so normally many times people don't even see the connection so we are still trying to study what that is all about but basically you could have arthritis for almost 10 years before you might even develop any symptoms of psoriatic arthritis. It doesn't always happen at the same time and that's probably what makes it a little bit more difficult for us to diagnose but we are learning a lot more about it so not everybody with psoriasis is gonna get psoriatic arthritis but about a third of patients with psoriasis might end up with psoriatic arthritis.

Nada Youssef: Is this a thing where psoriasis always comes first or it's always?

Elaine Husni: The majority of cases like maybe about 80% of the cases yes the skin condition comes before the arthritis.

Nada Youssef: Right.

Elaine Husni: In very, very rare condition the arthritis can occur before the skin and then there's another 10% maybe where they occur together.

Nada Youssef:  Sure, sure. Okay and then Sherry has a question, there's a lot of letters in here, "If you test positive RNP once and positive ANA, DNA, and double DNA does that make you positive for MXCTD and lupus?" I'm gonna ask you to just define everything I just said because I'm not sure if everyone-

Elaine Husni: Sure so we call that the alphabet soup so we do that for a living, we do a lot of autoimmune testing if we find that the patient comes in with a history that seems very probable for one of these diseases so such as lupus or rheumatoid arthritis we will start ordering some of those lab tests that I talked about. It is like an alphabet soup and so depending on what we feel that the patient has more likely we would order a set of those lab test. We just don't blankly order a bunch of every single lab test so we do sort of personalize it to what they're complaining about.

In this particular just sort of throwing out some of these alphabets so a positive ANA, a positive Anti-DNA, or a positive RNP those are all in what we call sort of the lupus family and then within the lupus family she was alluding to you can have an undifferentiated type of connective tissue disease, you can have a mixed connective tissue disease which is the MCTD.

Nada Youssef: Okay.

Elaine Husni: These are in that family so we look at these markers and depending on how many are positive and how the titers are positive we can then become more confident about what kind of disease they fit into. Those are very different than if you came in for osteoarthritis, we would not order any of those tests so it's just important to know the difference. These markers are just helpful for us to know what kind of category you might be falling into.

They're not that definitive so what I mean is there could be 10% of people in the US population that have a positive ANA and never develop lupus so you have to take this all together so this isn't as simple as one blood test can definitely decide what you're gonna have so we usually put that all in context. We do look at the blood test, we look at the X-rays, and we looked at the history as well as the joint exam itself.

Nada Youssef: Sure. That's crazy I mean hundreds of arthritis types and you're going through every test and based on the pain and everything I mean it must be really difficult, I mean hard.

Elaine Husni: Well it's actually one of my favorite parts of the job because no person-

Nada Youssef: No two people are the same.

Elaine Husni: Yeah so it's fun, you're kind of a detective. You get their history and so after a while it's not as confusing you know as it sounds and I think that's what makes people maybe a little bit not comfortable going to see because they look on the internet and they say, "Well I'm not sure which one I fall into. I don't even know if I should go," but really if you are having joint pain that's lasting for more than a couple weeks, interfering with your daily life, you need to see somebody.

Nada Youssef: Sure.

Elaine Husni: You know would I come every time I just have a fleeting 30 second of knee pain and think I have arthritis? No. You really want to kind of think about prolong pain, pain that's interfering with things that you're used to doing everyday, changes in your pain pattern, those are all important things that we want to know about and that you should get help for.

Nada Youssef: Great. All right well I'm gonna do one more question.

Elaine Husni: Okay.

Nada Youssef: I have Mike, "I was newly diagnosed with RA, I'm 66 years old, and now taking 10 week methotrexate. I go offshore fishing and my wrist and hands and fingers swell and it hurts afterwards for about three days. Is this normal?"

Elaine Husni: Rheumatoid arthritis, like I said, is one of our more most common type of inflammatory arthritis and really our goal is to get people in what we call low disease activity or as close to remission as possible. If you're taking these drugs and you're still having a lot of joint swelling and you're not able to do the things you want to do then we would say that you may need to come in for a visit and you may need to talk to your doctor about either adding a medication, escalating to a different medication. Our goal is to always start slow and move on up so we don't really want to always start with the most aggressive form of medication.

Methotrexate is what we call our anchor drug, you know, it's the drug that's been around for 30 years, we're very familiar with it, it's a great drug, so I would say every 10 patients that come in with rheumatoid arthritis I would say more than half of them do really well on methotrexate alone. We have that history, we know how to monitor it, we know how to treat you, but like I said not all 10 patients are gonna respond to methotrexate so there's gonna be another three or four patients that we know may need more. If you do then you follow up with your rheumatologist and based on what's going on with your exam and your blood test and your X-rays we might decide to add a med or escalate a med, switch out a med, so the good news is for rheumatoid arthritis when I started in med school there was only maybe one or two drugs that I had to learn how to use and now 10, 15 years later which isn't even that long, we have over a dozen medications for rheumatoid arthritis. It's an exciting time for us.

Nada Youssef: For just rheumatoid arthritis not all arthritis?

Elaine Husni: Just rheumatoid, right.

Nada Youssef: Wow, wow.

Elaine Husni: There's new drugs for psoriatic arthritis but in terms of rheumatoid arthritis we have new drugs so it's a good time to have RA. You know we encourage people to really be able to communicate with their rheumatologist and we want to know the things that you can or cannot do so that we can tailor treatment. Sometimes it's not just the X-ray alone we need to hear from patients, we need to kind of put all our sort of categories together labs and X-rays and exam and how you're doing and what you like to do. Fishing, you want to do fishing, so we want to be able to get people in low disease activity.

Nada Youssef: Sure, sure. That's great.

Elaine Husni: But it's gonna take time.

Nada Youssef: Yeah, yeah. A lot of investigation, a lot of time, open mindedness because there's so many different things.

Elaine Husni: A little bit of trial and error with the medication is to be expected and doesn't mean that you have something wrong with you, it's just how we treat. We have really lifelong relationships with our patients and we are very used to them and very comfortable with that.

Nada Youssef: Sure, sure. Well you've been very, very useful. This is very great information but before I let you go is there anything you want to tell our viewers that maybe I didn't touch on?

Elaine Husni: Yeah so I think the best thing to do is really to get properly diagnosed. Right? If you are sitting there with joint pain and you think you have one type but you really have another type it's gonna be very difficult because you're gonna feel very discouraged by the things you read or a patient or a friend that you have in church-

Nada Youssef: The friend, yeah.

Elaine Husni: -who has a different type who's responding to Advil and you're not or a nonsteroidal. Maybe you are having a different type of arthritis or maybe your arthritis is more severe so the biggest message is to get properly diagnosed, see your doctor, start with the doctor that ... you know an internist or a primary care physician or you have access to a rheumatologist people will get you there, you just have to get properly diagnosed and just not assume you have one type or arthritis, I think that's an important message.

Nada Youssef: Yeah and I think another one you're saying it's okay to go to a primary doctor and complain about arthritis pain, it doesn't mean you need to go straight to a rheumatologist.

Elaine Husni: Correct, it just depends on where you live, what you have access to, what your relationship is with your current physician, and usually if you have one of the more difficult arthritis most people will be seeing a rheumatologist who specializes in arthritis.

Nada Youssef: Sure, sure. Thank you, thank you so much, this is all very good information. For more health tips information make sure you follow us on Facebook, Twitter, Instagram, and Snapchat at Cleveland Clinic, just one word, and we'll see you again next time.

This concludes this Cleveland Clinic Health Essentials podcast, thank you for listening. Join us again soon.