Right medication helps rheumatoid arthritis patient live normally anew

MANILA, Philippines - Jean Vasquez was a hard worker at the University of the East Ramon Magsaysay Medical Center. She was a cashier in the outpatient clinic and was accustomed to meeting different types of patients and seeing many different types of conditions.

For years though, she was able to count herself lucky as she remained active and healthy. However, when she was 50 years old, she began experiencing joint pains in her left knee, and soon found it difficult to concentrate on her daily work and maintaining the household. Then daily fevers followed accompanied by severe pain. She knew they were no ordinary pain and fever and quickly sought medical attention.

Having worked in the medical industry, Vasquez was one of the lucky patients who knew how important it was to see a doctor right away. “I did not wait for the pain to become completely unbearable,” she said. “I knew it was important to seek help as soon as possible.”

She saw her first rheumatologist in 2001. By then, her pain and discomfort had spread quickly. Not only were her knees painful but her other joints such as her wrists had begun to hurt and swell as well. Vasquez’ doctor tested her for rheumatoid arthritis (RA) based on her symptoms and was officially diagnosed with RA in 2001 as she was turning 51.

She was first given oral medications, methotrexate and hydroxychloroquine, steroids and pain relievers. However, her RA progressed rapidly and soon alongside the worsening pain, she started to develop deformities in her joints, which led her to use a splint on her hand.

In 2003, Vasquez’ original doctor was scheduled to migrate abroad hence she was referred to another rheumatologist, Dr. Nympha Ribargoso. The two doctors collaborated and studied Vasquez’ case and saw that her original medications of methotrexate combined with hydroxychloroquine were not working sufficiently for her.

“We needed to try her on something else,” recalled Ribargoso, a rheumatologist in UERMMC and Our Lady of Lourdes Hospital. “We just were not getting the results we wanted from her first line of treatment.”

Vasquez received her first intravenous medication, infliximab infusion in 2004. Infliximab is an anti-TNF alpha, one of the first biologic treatments that became available for RA here in the Philippines. She finished nine doses of the medicine. The joint pain and stiffness decreased and her anemia improved. Her ESR also went down to 80.

It was good, but it did not last. After six months, the RA symptoms were back. Ribargoso decided to try another round of infliximab in 2005 wherein Vasquez once again finished nine doses. She saw some improvements that lasted for a year. The improvements through were not as much as Vasquez and Ribargoso would have wanted, the pain was still there and she still needed steroids and painkillers.

In 2008, Ribargoso tried Vasquez on etanercept injections for 10 months. There was progress on her joint pain, swelling, and stiffness. Her ESR, however, remained high. Again they were not satisfied with the results.

“We were looking for the best way to treat the RA and up to that point, none of the medications were giving the results we wanted,” Ribargoso said. “Though the pain had subsided, it was only momentary. We were looking for something more lasting. We wanted to achieve remission.”

Since Vasquez was not responding well enough to the anti-TNF medications (infliximab and etanercept), Dr. Ribargoso looked for other possible treatments such as use of anti-B lymphocyte, rituximab or the newer biologic agent at the time which is an anti-IL-6, tocilizumab. They decided to try tocilizumab.

“We did not get to try the medication right away though,” Ribargoso said. “The three years of anti-TNF medications had exhausted Vasquez’ funds and we had to wait for a while before beginning the treatment. During this time, Vasquez’ pain and swelling worsened. She was experiencing severe pain in her knees and shoulders and her orthopedic surgeon already told her she would need bilateral total knee surgery which she was already planning to schedule.”

In May 2010, Vasquez received her first dose of tocilizumab. Her ESR prior to the first treatment was 100 and her hemoglobin was 96. By her second infusion, her ESR was already 31 and her hemoglobin was 117. Her joint pains and swellings have subsided. It was the best improvement she had seen from her medications and she was very happy. 

“I was surprised at how quickly the medicine worked,” Vasquez said. “Prior to the treatment, I had been on a cane and had difficulty walking and moving around. But after my first few infusions of tocilizumab I could walk longer, I felt immediate relief, and I could even go up the stairs. I started to feel a little like my old self again.”

It may have taken a few years, but finding the right treatment was the most important step in helping Vasquez get back to the life she knew before she was diagnosed with RA. The tocilizumab continued to work on her until she finished a round of six monthly infusions. Her joint pains and swelling disappeared, no longer needing her steroids or the two additional painkillers she had needed previously. Her ESR remained at 30-40 levels and her hemoglobin remained normal. Due to the improvements she saw on the treatment, her knee surgery did not push through and she continued to walk with more ease.

Tocilizumab, 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 disease-modifying anti-rheumatic drugs (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.

Tocilizumab is a prescription drug and should only be taken in accordance with the advice and supervision of a physician.