Question
45 year old male — I’ve had joint pain and muscle pain /weakness for the last year. The rheumatologist has vacilated on the diagnosis going from suspecting ankylosing spondylitis, MS and now diagnosing rheumatoid arthritis. He wants me to start methotrexate therapy. So far the signs/symptoms are shoulder pain, knee pain, difficulty climbing stairs, severe stiffness, decreased range of motion in hips and sacroiliac joints with pain on movement, hyper reflexes in legs, severe neck stiffness and ataxia or balance problems. The clinical tests included MRI — brain was clear, cervical MRI showed moderate spinal stenosis with bulging disks. EMG was only slightly abnormal but ruled out ALS, Myesthenia Gravis etc. Xrays of hips were normal. Blood work was normal with the exception of continuing elevated ESR (39), slightly positive rheumatoid factor and 1:80 ANA. HLA B27 was negative as well as other immune markers. Previously ran 3 miles + daily for 20 years, but current weight bearing activities are severely limited. Still aerobically active with bicycling etc. Should methotrexate be started or is there a more definitive test that should be done for RA? Dr. says the physical limitations, stiffness, elevated ESR and slightly positive rheumatoid factor are enough to start the DMARD. He also stated that the axial presentation was more in line with AS but the negative genetic marker precluded this. Should Methotrexate be started?
Answer
This is not a straight forward case and I am in no position (literally and figuratively) to second guess your rheumatologist. However, as you have presented things, it seems reasonable to try methotrexate.
