Dear Dr. Cockroach — My son is experiencing what he thinks is a neuropathy in his arms and fingers. He is currently experiencing sharp pain in his fingers. He also feels tingling. The orthopedic surgeon’s office puts him on meloxicam, and he wears arm braces and computer braces. Is meloxicam used for these problems? Or are there other medications or tests that should be given / performed to relieve the pain? It prevents him from sleeping. Do you have any suggestions?
Dear reader — Neuropathy is a general term that means “there is a problem with one or more nerves.” Pain, numbness, and tingling are common early symptoms. Weakness is slow and a more serious symptomatology. In the case of otherwise healthy arm and finger pain, the most common neuropathy is compression neuropathy of the arm, which extends to the fingers. Carpal tunnel syndrome causes neuropathy of the median nerve and supplies it to the thumb and three middle fingers. Ulnar strangulation, on the other hand, is also called ulnar tunnel syndrome and is caused by compressive neuropathy of the ulnar nerve. The ulnar nerve supplies nerves to the little and ring fingers. Although less common, one or more nerves can be compressed in the brachial plexus of the neck or armpit.
Most general doctors, or specialists such as neurologists and orthopedic surgeons, can usually make a correct diagnosis by physical examination. Taking anti-inflammatory drugs such as wrist braces (for carpal tunnels) or elbow braces (for ulnar strangulation) and meloxicam is often a rational first-line approach. Injections and surgery can be considered, but there are other medications that can be tried to relieve symptoms. Unless there is weakness or atrophy, a careful approach is wise and it is not wise to perform surgery in a hurry.
Further tests often include EMG (electromyography) and nerve conduction studies before surgery or if the diagnosis is unclear. These are the best ways to accurately determine which nerves are involved.
Dear Dr. Cockroach — Your recent article on immunosuppressant vaccination has gone home. My wife is taking Rituxan every 6 months for rheumatoid arthritis. Twenty-one days after the last Rituxan (needed twice every six months within two weeks), she received her first vaccination. She received a second vaccination (Moderna) 28 days later. How soon can she safely receive a booster vaccination after the last vaccination? If you wait 6 months after your last vaccination, you will need another Rituxan injection. It’s catch 22.
Dear reader — There is no evidence of the effectiveness of booster shots, and there is no clear evidence that rituximab (Rituxan) is blocking the action of the vaccine, so it cannot be answered accurately.
However, based on my understanding of the effects of rituximab on vaccines and antibody-producing B cells, it is advisable to ask a rheumatologist about repeating the vaccine 4-6 weeks before rituximab. This gives the longest time since the last injection and gives the vaccine enough time to function before the next injection.
Physicians must make the best decisions in areas unknown to some individuals with a particular medical condition. Five months from now, the situation for COVID-19 in North America may be quite different from what it is today, and there may be better guidance for vaccination of immunosuppressed people.
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