In this column, our panelists discuss the possible use of older disease-modifying antirheumatic drugs (DMARDs) in managing rheumatoid arthritis (RA), whether nutrition can have an impact in these patients, and the role of magnetic resonance imaging (MRI) in diagnosing RA and monitoring patient progress. Without further delay, here is what our panelists had to say.

Q: Are there patients for whom you have used older DMARDS such as gold or D-penicillamine? Is there a role at all for these medications?
A: Alan Kivitz, MD, recalls that gold injections became increasingly difficult to obtain from manufacturers back in the pre-biologic era of RA treatment. Given the lack of availability at that time and the availability of other oral agents, Dr. Kivitz says parenteral gold gradually disappeared from his practice. In regard to penicillamine, Dr. Kivitz says it was “always a challenging drug to use,” based upon its toxicity profile and the length of time needed for a response.

Is There A Place For MRI In Diagnosing RA?

“In the current biologic era of RA treatment, we no longer have patients who receive either (gold or D-penicillamine),” notes Dr. Kivitz. “Even in the case of a patient who is not a candidate for biologic therapy or methotrexate, other options still abound that have eclipsed the need for these older agents.”
Nathan Wei, MD, says he has heard about a resurgence of gold at recent conferences. He adds that he is currently trying gold in one patient with RA who has failed a variety of other therapies but has not seen a response as of yet. Dr. Wei notes gold may be worth a try in a small subset of patients but agrees with Dr. Kivitz that the advent of biologic medications have ushered in a “new era” of RA treatment.

Q: What do you tell your patients with RA about the role of diet?
A: This is a controversial area as there is no exact science when it comes to nutrition and its impact on RA, explains Ronald J. Rapoport, MD, Pc, FACR. Dr. Rapoport says numerous anecdotal reports point toward the importance of olive oil, oil rich fish, fruits and vegetables. He also notes that in 2004, an article in The Proceedings of the Nutrition Society mentioned that foods high in polyunsaturated fatty acids, such as fruits, vegetables and other foods high in antioxidants, might be helpful for inflammatory conditions such as RA.¹ On the other hand, Dr. Rapoport says one prospective analysis cited red meat as a risk for inflammatory arthritis.²

Dr. Rapoport concedes that some studies have shown that regardless of the dietary intervention, when patients are involved in the treatment of their condition, they get better. He also notes that if a patient is overweight, “that obviously will have an adverse effect on arthritis pain in weightbearing areas.”

Dr. Wei cites a 1980 study that evaluated 22 patients with RA who consumed a diet that excluded common “food allergens.”³ Twenty patients had an improvement in symptoms and 19 stated that specific foods made their symptoms worse. The most common symptom-provoking foods were grains, milk, nuts, beef and eggs.³ Yet Dr. Wei notes that in a 1992 double-blind, controlled study, researchers showed that only nine out of 78 patients with RA who completed the study had a favorable response to diet modification and those nine patients experienced subsequent disease flare during re-challenge.⁴

While Dr. Wei agrees that the results in the aforementioned studies as well as others in this area vary in the findings. He says the studies overall “seem to suggest that the avoidance of different types of foods might benefit a subset of patients with RA.”^5,6

Accordingly, Dr. Wei says food allergy testing is a “viable weapon in the arsenal” of clinicians who treat RA. In his clinic, Dr. Wei considers food allergy testing when patients have symptoms that do not respond to conventional therapies.

Dr. Kivitz is a board-certified rheumatologist and director of the Altoona Arthritis and Osteoporosis Research Center in Altoona, Pa.
Dr. Yocum is a former Professor of Medicine in the division of rheumatology at the University of Arizona. He is now a Director with Genentech.
Dr. Rapoport is the owner of the Truesdale Clinic in Fall River, Mass.
Dr. Wei is a board-certified rheumatologist. He is the Clinical Director of the Arthritis and Osteoporosis Center in Frederick, Md.