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    Enbrel vs. Rituxan
    yoga717 posted:
    Hello Dr. Zashin,

    I'm a post-menopausal south asian woman older than 50 years of age, and I have had RA for about 15 years now. I have taken Methotrexate, Arava, and I am currently taking Imuran to control my RA. However, they aren't working as well as they should be for me. So, my rheumatologist then suggested that I take TB medication before I take the medication Enbrel, because I have BCG in my bloodstream. Another rheumatologist has told me to start on Rituxan, which is a much harsher and newer medication, and I am hesitant to go down this route. My main concern with taking the TB medication are the risks associated with getting an infection, like pneumonia. How concerned should I be with this? In your expert opinion, what medication, Enbrel or Rituxan, would you recommend to a patient like me, and why? Thank you so much for all of your help Dr. Zashin, I look forward to your reply.
    Scott Zashin, MD responded:
    In my practice I tend to use the TNF blockers before Rituxan. As a result, if someone has evidence of latent TB-I will ask them to get treated and one month after treatment has started, begin the TNF blocker. Typically I will use the TNF blocker Enbrel because it may be less likely to reactivate TB than monoclonal antibodies such as Humira and Remicade. Nonetheless, all have been assoicated with an increased risk of reactivation of TB. On the other hand, you are correct that Rituxan works by a different mechanims of action (B cell depletion as opposed to inhibiting the function of TNF-tumor necrosis factor) and is felt to not be associated with an increased risk of TB reactivation.Finally, I will often recommend a consultation with an infectious disease doctor in treating my patients with evidence of latent TB to get the most up to date expert opinion regarding optimal therapy.
    yoga717 replied to Scott Zashin, MD's response:
    Thank you for your response, Dr. Zashin. I had some follow-up qquestions. After I start taking the TB medication, and then begin Enbrel, how long do you think I will have to continue to take the TB Medication? Is this indefinitely, or until my cell count levels are at some healthy level? Also, does Enbrel cure RA? In other words, when people take Enbrel for an extended period of time, and then stop it, does their RA come back, or is it gone or weaker? Thanks again.
    Scott Zashin, MD replied to yoga717's response:
    In patients who have been exposed to, but do not have TB(positive skin test or positive blood test), the treatment time varies from 4-9 months depending on the medication used and physician preference. In answer to your second question, there is no medication at this time that can cure RA. So, in most patients once the medication is stopped, the symptoms will return.There are a few patients whose RA does not return after stopping meds,but this is uncommon. Some patients whose symptoms resovled after stopping medications may not have had RA in the first place.
    DesprateDaughter replied to Scott Zashin, MD's response:
    I know this is slightly off topic but my mom has a 600 RA score and is going through liver failure. She has been allergic to every medicine they have given her and the next step was Orencia. However, the doctor said that could kill her and won't give that to her now either. All she is taking not is Pregnazone. She found out that at sometime in her life she had Hepititus B and that is why they don't want to give her Orencia.. Do you have any suggestions? Every doctor she has seen has said there is nothing they can do for her. I feel like we are living that movie "John Q" except we have insurance! Please help, she is ery ill and I can't just watch my mom die.
    Scott Zashin, MD replied to DesprateDaughter's response:
    As you have found out, many of the newer medications for RA are contraindicated in patients with activie Hepatitis B. If I were taking care of a patient with active Hepatitis B, I would have a conversation with the patients liver doctor. Some medicatons used for RA that do not commonly affect the liver might include plaquenil or gold injections( a older treatment that has not used much any more) I am not recommending either of these therapies, but your mom could discuss them with her treating doctors to see if they feel the benefits of the medication outweigh the risks.Possibly the liver doctor would have knowledge on whether or not they thought it was safe.One thing to keep in mind, some patients who have severe liver disease may have a positive RF from the underlying liver problem-a "false positive rheumatoid test"

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