How RA patient got her life back

MANILA, Philippines – Jedidiah Trasadas was no stranger to hard work. Having come from a big family of 14 brothers and sisters, she was working ever since she was young and she continues to work until now.

“I keep myself busy with several things,” she shared. “I run my sister’s pawnshop and all of its daily operations. I always have things to do.”

In addition to running the pawnshop, she also resides alone in the same building as the business while the rest of the family lives outside the city. Due to this, this resilient and reliable woman took care of herself and the business on her own.

She was able to do this with ease. However, after turning 50, she began to notice that one by one, parts of her body began to experience swelling and eventually pain. Having a very high tolerance for pain, she thought nothing of the pain episodes. However, as time progressed, the pain began to worsen.

Trasadas first noticed the symptoms of rheumatoid arthritis (RA) when she turned 50. This also coincided with her being post-menopausal.

The symptoms started with a slight swelling in her hands. The swelling was accompanied by itchiness and discomfort but not yet painful. “I noticed that my hands had started to swell,” she said. “And the itchiness was very distracting.”

Still she thought nothing of it and managed to go about her business normally. After eight months of on-and-off swelling and discomfort, she began to notice that the symptoms started to get worsen.

One and a half years after the onset of her first symptoms, she noticed her ankles as well as her toes beginning to swell, too. Along with the itchiness that she had grown accustomed to came a slight feeling of pain and discomfort. Still, with her high pain tolerance level, she was able to manage.

But then, the swelling began to spread out over her whole body. The discomfort and pain in her ankle had spread to her shoulders and the pain was worse than before.

“When the pain and swelling had spread to my shoulders, I could not ignore it anymore,” Trasadas confided. “It was excruciating. A simple touch could cause tremors of pain and it could easily make me cry. It felt like my entire body was swollen.”

From then things went from bad to worse. With the pain intensifying, Trasadas found she could not even do simple tasks such as sit normally, brush her teeth or comb her hair. Every movement caused her pain.

“The final places that the swelling and pain spread to were my wrists and elbows. They felt very deformed and extremely painful. It was as if razor blades were slicing through them,” she said.

At this point, Trasadas, with the help of her sister, began to seek medical help, hoping to be able to stop the pain. “When I first sought medical help, we looked around for a doctor I felt comfortable with,” she recalled. “I wanted someone who would explain what was happening to me and take me through the treatment without just prescribing me medication.”

It took a while for Trasadas to find a doctor she was comfortable with. She saw several physicians, but at times she felt that some of them would not truly take the time out to explain the disease, medication, and treatment plan with her, and she was not satisfied in being a passive participant in her own therapy.

Finally, she found Dr. Evan Vista, a rheumatologist from UST Hospital, who made her feel like a partner in her treatment plan. “I really felt comfortable with Dr. Vista because he explained every step to me thoroughly. He listened to my opinion and he took the time to answer all my questions,” she said.

“When I first met Ms. Trasadas, she had impaired movements and diffused pain, including swelling of the knees which greatly affected her mobility,” Vista said.

“I think this is the reason she sought out treatment. The instant itchiness she mentioned could be qualified more as a discomfort noting that she also presented initially with vasculitic rash on both lower extremities, a variant seen among a subset of RA patients. Her serologic and inflammatory markers were also markedly elevated. Pain-wise, she is very tough and bears it, but her work and daily routine were impaired so it became important for her to take steps,” he added.

Early diagnosis

Vista stressed the importance of distinguishing RA from other common arthritis and the need to diagnose and treat afflicted patients early to prevent long-term functional disability.

He initially modified her disease modifying anti-rheumatic drugs (DMARDS) and painkillers, which she had already started taking with the other doctors. After an overall assessment, the medications were not yielding enough positive results.

“She had been on methotrexate and prednisone for the pain and swelling, but the overall effect was not as good as we had hoped for,” Vista said. “She also had to pair these medications with a coxib for the pain. The treatment, as a whole, was not working as we had hoped it would.”

“I was taking several medications, but the results were not what I thought they would be,” Trasadas said. “I still had swelling and I still had pain, which were discouraging since I was taking many pills already. Plus I noticed small side effects such as memory impairment. Since we were not getting the results we wanted, Dr. Vista put me on biologics therapy. He explained it might help me get faster and longer lasting results.”

Getting back on track

With the new treatment plan in place, in February 2011, Vista began Trasadas on tocilizumab. Within two weeks after infusion, her inflammatory markers dramatically reduced by more than a half and the chronic discomfort she feels eased out.

“By the third month of the treatment I started to see the effects of the medication,” Trasadas said. “My mobility was returning and the pain was noticeably decreasing.”

“She responded very well and very quickly to the tocilizumab therapy,” Vista said. “Her functional capacity markedly improved and she was even able to go back to work; in other words, she regained her productivity and became a truly functional person once more.”

Trasadas continued her tocilizumab therapy for six months and though she had an occasional flare-up of symptoms once in a while, her overall condition continues to improve.

“We were able to get very satisfactory results from the treatment,” Vista said. “Through it we were able to bridge active RA disease activity to sustained complete remission. That is the goal of RA treatment to obtain sustainable remission and controlled joint degeneration.”

Through the biologics therapy, Vista was also able to remove Trasadas’ steroid use, thus decreasing the number of medications she had to take. “It took me awhile to open my mind to this new type of treatment,” she said, “but I am very glad I did.”

Vista told Trasadas that tocilizumab, usually in combination with methotrexate, is indicated for the treatment of moderate to severe active RA in adult patients who have either responded inadequately to or who were intolerant to previous therapy with one or more DMARDs or TNF antagonists — two classes of drugs used to slow down RA progression.

In these patients, tocilizumab can be given as monotherapy in case of intolerance to methotrexate or where continued treatment with methotrexate is inappropriate.

Vista said RA is a chronic immune mediated disease that affects people usually during their productive years. He also stressed the importance of distinguishing and treating RA patients to lessen the impact of disease burden and improve their productivity.

He said tocilizumab is a prescription drug and should only be taken in accordance with a doctor’s advice.