Question
I received an R.A. diagnosis 2 years ago. X-rays of the hands and feet taken at that time showed no erosions. I have been taking 17.5/mg. of methotrexate since that time, and have been feeling quite well. A month ago, I had new X-rays taken. The rheumatologist called with the results. She said there was an erosion in a toe. She commented that the radiologist reported other things, but she said they often “overread” the films. I asked for a copy of the report, and was dismayed to read that the radiologist detected “erosions throughout the hands.” Yesterday I made an appointment to meet with my doctor to discuss the possibility of going on a biological med. Even if the radiologist erred, wouldn’t the erosion in the toe be enough to suggest that the methotrexate alone might not be doing the job? The toe erosion happened silently–no redness, swelling, or pain. I should add that I had a strong positive CCP test result, so I know I’m at risk for more erosions. My questions: Based on the above description, do you think a biological med would be a good choice? Do radiologists frequently overread X-rays? What should a patient do when a rheumatologist and radiologist disagree? Do you have suggestions on how to best communicate with my doctor about trying a biological medicine?
Answer
Reading x-rays for erosions is an inexact science at best and there often can be differences in interpretations even among different rheumatologists and radiologists as well as between the two. Although this sounds biased, in general the rheumatologist usually is more accurate or I should say is more likely to give a clinically significant interpretation of the x-rays mainly because he/she is able to correlate the x-ray findings with the clinical exam. I think most radiologists would agree.
The decision to start/add a biologic agent is difficult based on the worsening of x-rays alone, when the patient is otherwise doing well. Other factors such as bloodwork, joint deformities, and overall severity of the disease need to be taken into account. I would bring the x-rays to your rheumatologist and review them with him/her.
