Here are some of the questions and answers addressed in our recent webinar with Dr Jonathan Marks. Please see the bottom of the article for a link to the full recording!
Disclaimer: The information in this article is for educational purposes only and should not be taken as medical advice. Please consult your doctor before making any changes to your lifestyle, medications or health.
How early would you need to stop JAK inhibitors prior to surgery?
JAK inhibitors are tablet therapies and there are very clear guidelines for all drugs when it comes to orthopaedic surgery. In theory, you only need to be off these for 2-3 cycles of the drug, for JAK inhibitors we usually advise 2 weeks before, which is technically longer than one would imagine. Being off these types of drugs for more than a couple of weeks does increase your chance of a flare up and you also would have to stay off your treatment post-surgery. Please view this chart for more information on this and confirm with your doctor when you should stop taking any medications you are on before doing so as they will know best.
Steroid injections in the knees: is there a chance of damage to the ligaments?
Knee injections are a common procedure and there has been some concern that injecting steroids into a joint might cause the arthritis to progress, which was based on studies performed years ago. However, damage to the ligaments is not a concern. We don’t really know if steroids can cause arthritis to progress, but if the knee is inflamed, you are likely to be better off having that inflammation reduced with steroids than to leave it unchecked. Rheumatologists will have preferences in their personal practice, and will consider the benefits and disadvantages of a treatment for your specific case so that you get the best care for your condition.
How successful is an osteotomy? Is it worth going through the procedure or should I use a brace?
Osteotomy is not an option that’s often offered. If your team is offering it, that must be because they think it will make a significant impact on symptoms without proceeding to joint replacement. To some extent, it is a big operation. You can ask your surgeon how many times they have done that in the context of your condition and their success rate and failure rate. You should not be afraid to ask questions like this! You will find most surgeons will share that with you.
Why is it necessary to come off of biologics for surgery?
Biologics double your risk of a serious infection, however that risk begins quite small. In the context of surgery, infection is the surgeon’s main worry. If you put a joint in and it becomes infected, the only real option at the end of the day is to take it back out. This is why surgeons are worried about infections, which is why it is best to reduce your chances of an infection post-surgery and coming off of biologics helps to reduce this risk. Your surgeon wants to set things up for the best possibility of success.
If a knee is damaged but not really painful, would you leave it be?
Yes. The indication for surgery is very individual. An x-ray is not a great way to judge. We know that some people who look like they have mild arthritis in their x-rays are quite disabled by their symptoms and some people who appear to have severe arthritis have less symptoms than you may expect. Three things we look for is when considering surgery is if the pain is not under control, quality of life and function is being impaired, sleep is being affected due to pain, these are all things we look at when deciding if something requires surgery. The time to have surgery is when it’s starting to impact function, before you become disabled by it.
Have you seen anyone benefit from platelet rich plasma in knee joints?
Platelet rich plasma comes from a more sports-science background, for players who want to get back to playing their sport like football. My reading of the research is that any good quality studies in this area show this doesn’t really work. It’s difficult to understand the biological mechanism for which it would work because it doesn’t really make sense as to why it would work. I have had patients who have had it done and who have found it beneficial, I don’t personally recommend it. It’s not available on the NHS as it hasn’t been proven to be effective.
COVID booster: After each vaccine, I have had an RA flare, I’ve been given steroids for if a flare occurs post vaccine, how long do you recommend before starting a steroid to give the vaccine the best chance of working?
In general, vaccines are well tolerated even for people with conditions like RA, but some people undoubtedly get flare ups of their symptoms as they do when they catch COVID or anything that stimulates their immune system. The challenging thing is everytime you take steroids you’re exposing yourself to another additional risk as the steroids themselves offer risks. This is a very individual question, as if you’re struggling for weeks with active symptoms you will need to get that under control one way or another. Maybe one week, however I would trust the patient to be the expert in that situation.
What are flare symptoms that are worth flagging to your team?
To me, flare is when the patient cannot self-manage their symptoms themselves. That may not be the definition you have in your head, but anytime you cannot manage the symptoms, you should be flagging it to your team and reaching out for help. Flares can be short-lived, they can last just hours, or they can last weeks or more, anything that lasts more than a couple of days and you can’t manage is worth reaching out to your team about.
I’m Type 1 Diabetic and have RA and OA, I have pain in my toe ends, is this diabetes or arthritis?
This is tricky to answer. There are various things that could cause this type of pain. It could be arthritis, it could be nerve-related, RA related, diabetes related, it really requires careful consideration with a doctor, who can help differentiate between these things.
To hear the answers to more questions like these, view the recording of our Q&A session with Dr Jonathan Marks.