Hey Mike.

Sorry to hear that you're flaring so badly. Remember my posts about bilaternal knee effusions (among others) on internal medicine the summer of 2004? God, I was terrified. Sadly, I haven't had the benefit of a biologic, so I can't imagine the psychological factor of being pain-free and then having the pain reappear - I imagine that's really tough though. That being said, I've managed to get through 4 years of medical school with solely NSAIDs and DMARDs and pain meds. You can get through this, you just have to tackle each day one at a time, and try not to look too far ahead.

I've been on Arava since my huge flare the summer of 2004. It's not a cure all, but I've had some benefits from it. Sadly, I've also had loads of s/e. The nausea was overwhelming when I was first on it, and it's half life is super super long, so it was difficult to get it under control. I'd suggest starting it really slow, and gradually building the dose (which I did after withdrawing from it completely, waiting a few weeks and restarting). I'd also recommend having an rx of metoclopramide around, just in case. I tolerate the Arava better now, but my threshold for nausea is MUCH lower than it was before. I've also had other GI involvement (not going to spell that out for you, but let's just say it's better when I'm on opioids than not), so keep that in mind.

Arava is a pyrimidine synthesis inhibitor, whereas MTX interrupts folic acid synthesis, so it won't likely produce a folate defeciency anemia like MTX can, but it's job is to stop new cell growth just in a different way. You need routine blood tests, especially to look at liver and kidney function. You can drink moderately on both drugs, though I chose to opt on the side of caution and drink minimally more than moderately (insert reminder of low threshold for nausea here).

Re: hip replacement. Stop putting the cart in front of the horse Mike! This is the first time you've had hip pain, so I'm fairly certain you don't have nearly enough damage there to require a THR. And like Evelyn says, the hip is a tricky area, it's so hard to know exactly what is going on there, it may be a soft tissue issue. And remember Mike hip replacements have a finite life span. You're young. Unless it's absolutely necessary do you want to sign up for a life of serial replacements? Not to mention the fact that it's a serious surgery with a long recovery time.

I know it's scary. Give the arava some time to work. Consider some pain meds and alternative therapies (weren't you the one who suggested yoga in call rooms). It's really hard to remember the basics some times after long periods of wellness, but it's all in there. Dig deep, and find some of those gems of old. You know we'll be here when the going gets rough.

Best wishes,
Jeanna