It's a rarity to get such an understanding rheumy. Hang onto him, but I hear your sighs and hope you won't fall into such a pattern as I have.

What has been your history with Methotrexate and/or Immuran, or discussions with the doc about those?

I was on methotrexate for a while, but then for a couple of years I had to stop mtx due to a non-joint, non-blood issue, and took Immuran and then added Arava to it instead. But my wrist damage was progressing pretty fast during those two years being off the methotrexate, and then I got some actinic keratosis (precancerous skin spots)and got nervous about continuing the Arava (leflunomide) and Immuran because of that. So after much research regarding mtx side effects, and discussions with my doctors regarding my test/procedure results, I finally decided to switch back to taking mtx again and have been back on it for the last 5 or so years. I had added Kineret injections to the methotrexate for several months at one point, but like the other biologicals, infections are an issue and I did run into that.

It (mtx – and probably prednisone) does help my joints a lot in terms of that burning/soreness type pain (I still have pain but of different quality and fatigue), but unfortunately I am still progressing, despite having increased the dosage. Besides infections, money and insurance coverage is a big factor in my not starting a biologic right now. If you have good coverage for biologicals though, perhaps you should give them a try sooner rather than later. At least you'll know you tried it when you could, even if it doesn't work out. Ask your doc what the main reason(s) is/are that his patients have stopped their biologicals and see what he says.

Sometimes it takes adding prednisone, and/or switching to different NSAIDs (there are lots to try if one doesn't seem to be cutting it for you) and/or adding Tylenol Arthritis to the mix to help in lessing that pain. Narcotics are another option but a last ditch resort, and of course none of these should be used in place of changing/adding dmards to try to get the pain under better control and slow progression. Daypro (oxaprozin) was a good NSAID for me when I was covered under insurance. It's generic, but not on the $4 dollar lists at the
pharmacies. That is a once-a-day NSAID. These may help with that pain, but won't stop the progression though. I would love to be able to get off of the NSAIDs and Prednisone and hope to some day to avoid the ong terms side effects of those. Knock on wood, I don't seem to have any yet, despite having been on them for over a decade.

I do recall that burning and soreness quality as I had that in the first years, my pain is of a different quality now (I occassionally get the burning/sorness still but nothing like before), some of which comes from the damage that has already occurred and some from tenosynovitis and some from swelling. But that burning/soreness was bad in the beginning before I got to this point and so I hope you will continue to let your doctor know how uncomfortable that is, that you're
still concerned it's a sign of progression, and pursue discussing the further options with him on a timely basis, ie don't let it drag on too long if the pain is still bad or if you see/feel progression. I regret not realizing to be more aggressive and faster/aggressive in getting my symptoms under much better control,
because, at least in my case, it's led to damage I'd rather not have to deal with now. I know we have to live with some pain, but maybe sometimes we're too accepting of how much pain we have to live with. I wish I could include a picture of my wrists with this so you could see what I'm talking about.
Chelsea

Rheumatology (Oxford). 2010 Jan;49(1):91-8. Epub 2009 Nov 16.

A systematic comparison of combination DMARD therapy and tumour necrosis inhibitor therapy with methotrexate in patients with early rheumatoid arthritis.
Ma MH, Kingsley GH, Scott DL.

Department of Rheumatology, GKT School of Medicine, Weston Education Centre, King's College London, 10 Cutcombe Road, London SE5 9RS, London, UK.

OBJECTIVE: We examined how combination DMARD therapies and TNF inhibitors therapies plus MTX (TNF/MTX) affect clinical and radiological outcomes compared with MTX monotherapy in early RA.

METHODS: We systematically searched EMBASE, PubMed and Ovid Medline for randomized controlled trials (RCTs) of combination therapy in early RA. We evaluated ACR responses, withdrawals for inefficacy and toxicity, HAQ and radiographic progression. Meta-analysis using Review Manager evaluated random effects odds ratios (ORs) and random effects weighted mean differences (WMDs) between treatments.

RESULTS: A preliminary search identified 2029 citations; 15 were relevant RCTs
(4200 randomized patients). Patients with active disease were enrolled. Compared with MTX monotherapy, both combination DMARDs and TNF/MTX increased ACR20-70 responses (OR 1.64-2.02 and 2.03-2.30, respectively), reduced withdrawals for inefficacy (OR 0.52 and 0.29), reduced HAQ (WMD -0.17 and -0.16) and reduced annual X-ray progression (WMD -1.20 and -0.84%). DMARD combinations increased withdrawals for toxicity (OR 2.69; there was no difference with TNF/MTX). The only
head-to-head RCT showed comparable efficacy for combination DMARDs and TNF/MTX combinations.

CONCLUSIONS: In early active RA, both combination DMARDs and TNF/MTX are more effective than MTX monotherapy. DMARD and TNF/MTX combinations had equal efficacy on ACR response, withdrawals for inefficacy, disability and erosive progression. There is an apparent advantage for TNF/MTX combinations in the effect on toxicity with fewer consequent patients. We conclude that there is strong evidence in favour of combination treatment for RA but there is still uncertainty about which
regimen is preferable.

Ann Rheum Dis. 2009 Jan;68(1):33-9. Epub 2008 Jan 29.

The effectiveness of leflunomide as a co-therapy of tumour necrosis factor inhibitors in rheumatoid arthritis: a population-based study.

Finckh A, Dehler S, Gabay C; SCQM doctors. Collaborators (62)Colla F, Suter JB, Chamot AM, Lehmann T, Martin A, Wicht F, Marbet Grierson G, Tinner H, Aellen P, Elmiger B, Hafelin F, Muller-Werth B, Wiedersheim P, Buchler I, Gerster JC,
Rappoport G, Cunningham T, Brucker R, Kloti R, Glenz D, Pancaldi P, Diethelm U, Sturzenegger J, Zenklusen C, Buchard PA, Altermatt R, Messikommer M, Fluck A, Wuest P, Sauvain MJ, Frey D, Pfister S, Thiebaud G, Eigenmann B, Muff L, Keller F, Brunner H, Schwartz GM, Buchs N, Ziehmann M, Gut C, Maager R, Raccaud O, Saxer M, Maclachlan D, Laubscher A, Reich-Rutz C, Schaub K, Schlor-Dorr U,
Widmer M, Baumgartner E, Davoine GA, Christen B, Kowalski M, Gratzl S, Bodmer F, Hunkeler M, Gaeumann U, Caravatti M, Lamoth M, Schonbachler J, Seglias J.
Division of Rheumatology, Department of Internal Medicine, University Hospital of Geneva, 26 Av. Beau-Sejour, 1211 Geneva 14. Switzerland.

BACKGROUND: Randomised trials have demonstrated that the efficacy of anti-tumour necrosis factor (TNF) agents is significantly increased by concomitant methotrexate (MTX) in rheumatoid arthritis (RA). In clinical routine, anti-TNF agents are commonly prescribed with other disease-modifying antirheumatic
drugs (DMARDs) than MTX, however their effectiveness in combination with anti-TNF agents is not well established. OBJECTIVE: To compare the effectiveness of leflunomide (LEF) and other conventional DMARDs with MTX as co-therapy to anti-TNF agents in RA.

METHODS: All patients on anti-TNF agents and conventional DMARDs within the Swiss Clinical Quality Management (SCQM)-RA database were included (n = 1218) and categorised according to the type of co-therapy into anti-TNF+MTX (n = 842),
anti-TNF+LEF (n = 260) and anti-TNF+other DMARDs (n = 116). Drug discontinuation rates and incidence of toxic side effects were analysed using Cox proportional hazard models. Progression of radiographic damage, the evolution of functional disability and the improvement of RA disease activity were analysed using longitudinal regression models, adjusting for potential confounders.

RESULTS: The overall discontinuation rates of anti-TNF and conventional DMARD combination therapies were relatively high with a median survival of only 16 months (interquartile range (IQR): 10-37), but they did not differ between the three regimens (p = 0.69). The progression of radiographic damage (p = 0.77),
functional disability (p = 0.09) and RA disease activity (p = 0.33) were also similar between the different regimen. In addition, no significant difference in the frequency of adverse events emerged.

CONCLUSION: Overall these results suggest that LEF and potentially other conventional DMARDs offer an effective and safe alternative to MTX as co-therapy in combination with anti-TNF agents.

Has anybody heard/seen a site like a search engine[/b][/url] – and produce web phone search engine services. What is the best cellphone search engine?

n(E U N U T) = n(E) + n(N) + n(T) – n(E/N) – n(E/T) – n(N/T) + n(E/N/T)

where U=union and / = intersection

so

100 = 45 + 50 + 70 – 30 – 30 – 20 + 10
100 = 95 which is a contradiction.

Hence he is Right

I think there is little hope of reconciliation.

In the US, religion insists basic science on the age of the universe, its creation and the evolution of life is wrong and a trivially falsifiable story in a book written by uneducated shepherds is right.

Religion is at total odds with science.

Remember, now that you own a business, you are 'evil' and deserve to pay lots more in taxes and fees.