Liver MRI results – all clear!

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My liver MRI is completely normal. No masses, no lymphadenopathy, no ascites (no signs of cancer), no cirrhosis, no dilated ducts, or visible blockages, pancreas, kidneys and spleen all look normal.

So that’s good.  Very good.

But it’s a problem.

The best outcome would have been some small stones lodged in the biliary ducts. That’s the kind of simple problem with a simple, surgical solution that medicine excels at.  Unfortunately it’s not the kind of problem I usually have.

So I have no idea why I get ongoing upper GI pain. Whatever caused the pain, also caused liver damage, which appears to be healing (according to bloodwork) with no permanent damage, according to scans.  I still have some upper GI tenderness, dark urine, nausea, bloating.  But it is much improved.  There is no question of brushing it off as nothing, but it is definitely improving.

But it will happen again.

And the big question is, did Xeljanz contribute?

No one will know. They will guess. My rheumatologist will say ‘Nope!  Xejanz didn’t do it. Restart it.’

My GP (I suspect) will say “I don’t know.  But I suspect that Xeljanz had something to do with it.  I’m not sure we should restart it”

I tend to lean towards my imagined GP’s response.  I’m not sure I’m game to start it again.  I’ve seen others stop medication because it gives them indigestion or a rash. I’ve been forced to keep taking medications that cause suicidal depression, extreme anxiety, bipolar disorder head to toe skin infections and rashes, constant, unrelenting nausea…things like indigestion aren’t good enough reasons to stop a medication.  Not in my world.  Not in my rheumatologist’s world.  She is much harder line about continuing with a medication than most it seems.

But Xeljanz is the only medication that has made a noticeable difference to my arthritis pain and swelling.  It’s hard to give up on a medication that helps.

My guts say leave it alone though.

Either way, there’s a big decision to be made. I would love to sit down and talk it through with someone, pros and cons.  My doctors don’t have time for that. I don’t have the kind of friends who will listen and help me make a decision.

So I’m going to do a prednisone burst, because either way, I’m off medication for a while.  Until a decision is made about what to do next. My rheumy said we’d do a biopsy next, before being cleared to start back on Xeljanz. She often changes her mind though.  Forgets.  It will be easiest for her if I just start Xeljanz again.  She’ll tell me we’ll monitor it closely, and all will be well, I’m sure.  But I don’t trust her anymore. I don’t trust that she’s right.

A bit more prednisone will get me on my feet again. I hate the couch. I hate being this debilitated.  I want to get back to gym. Back to functioning.  Get my house in order.

Prednisone will allow me to breathe easier, literally.  I’m going to assume that my lung problems are just allergic asthma.  Which is very likely because everyone is struggling with allergies and hayfever this year. I never used to have allergies, but now I do. Life’s like that.

My rheumatologist will get the results this afternoon. She probably won’t look at them until Monday.  She will call me on Wednesday or so. Make an appointment for fortnight Friday to discuss what to do next.  I can’t stay in this shape.  I am too sick right now, and prednisone will help a lot of it. I’ll have some energy, less pain and I’ll be able to hear better and have less tinnitus.  Even the neuropathy in my hands and feet will improve.  My eye flare will end.  Prednisone makes a world of difference in many ways.

Bottom line, I don’t really have a choice. I’m not coping.  My doctors do not understand how sick I am, or what life looks like right now.   Prednisone helps.  I’ll just bump it up a little, while I wait.

10 COMMENTS

  1. First I am delighted that your liver test is clear. Big relief. I know many people who sustain prednisone for long periods of time. I hope your Rhuemy agrees with you or has a better idea.

  2. I’m so pleased your liver results were normal. Prednisone may be a case of better the devil you know,for now at least to give you some much needed relief.Any luck getting in to see the new Rheumy? Take care

  3. RxList.com

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    Xeljanz Side Effects Center

    Medical Editor: John P. Cunha, DO, FACOEP

    Last reviewed on RxList 11/23/2016
    Xeljanz (tofacitinib citrate) is a Janus kinase (JAK) inhibitor used to treat adults with moderate to severely active rheumatoid arthritis (RA) who have not responded well to methotrexate, or cannot tolerate it. Common side effects of Xeljanz are:

    upper respiratory tract infections,
    headache,
    diarrhea, and
    cold symptoms such as sore throat, runny or stuffy nose.
    Tell your doctor if you experience serious side effects of Xeljanz including:

    feeling very tired,
    yellow skin or eyes (jaundice),
    loss of appetite,
    vomiting,
    dark urine,
    clay-colored stool, or
    skin rash.
    The recommended dose of Xeljanz is 5 mg twice daily. Xeljanz may interact with aprepitant, bosentan, conivaptan, haloperidol, imatinib, isoniazid, St. John’s wort, ticlopidine, antibiotics, antidepressants, antifungals, hepatitis C medications boceprevir or telaprevir, heart or blood pressure medicines, HIV or AIDS medicines, medications to treat excess stomach acid, medicines to prevent organ transplant rejection, nonsteroidal anti-inflammatory drugs (NSAIDs), other arthritis medications, seizure medications, or steroids. Tell your doctor all medications and supplements you use.

    Our Xeljanz Side Effects Drug Center provides a comprehensive view of available drug information on the potential side effects when taking this medication.

    This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

    Xeljanz in Detail – Patient Information: Side Effects

    Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficult breathing; swelling of your face, lips, tongue, or throat.

    Serious and sometimes fatal infections may occur during treatment with tofacitinib. Stop using this medicine and call your doctor right away if you have signs of infection such as:

    fever, chills, tired feeling, night sweats;
    stomach pain, loss of appetite, diarrhea, weight loss, or a change in your bowel habits;
    pain or burning when you urinate;
    body aches, sore throat, flu symptoms, sores in your mouth and throat;
    stabbing chest pain, wheezing, feeling short of breath, cough with mucus or blood; or
    skin redness and swelling.
    Tofacitinib may also cause severe liver symptoms. Call your doctor at once if you have any of these liver symptoms:

    low fever, itching;
    upper stomach pain, loss of appetite;
    dark urine, clay-colored stools; or
    jaundice (yellowing of the skin or eyes).
    Common side effects may include:

    headache; or
    mild cold symptoms such as runny or stuffy nose.
    This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

    Xeljanz FDA Prescribing Information: Side Effects
    (Adverse Reactions)

    Clinical Trial Experience
    Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not predict the rates observed in a broader patient population in clinical practice.

    The clinical studies described in the following sections were conducted using XELJANZ. Although other doses of XELJANZ have been studied, the recommended dose of XELJANZ is 5 mg twice daily.

    The recommended dose for XELJANZ XR is 11 mg once daily.

    The following data includes two Phase 2 and five Phase 3 double-blind, controlled, multicenter trials. In these trials, patients were randomized to doses of XELJANZ 5 mg twice daily (292 patients) and 10 mg twice daily (306 patients) monotherapy, XELJANZ 5 mg twice daily (1044 patients) and 10 mg twice daily (1043 patients) in combination with DMARDs (including methotrexate) and placebo (809 patients). All seven protocols included provisions for patients taking placebo to receive treatment with XELJANZ at Month 3 or Month 6 either by patient response (based on uncontrolled disease activity) or by design, so that adverse events cannot always be unambiguously attributed to a given treatment. Therefore some analyses that follow include patients who changed treatment by design or by patient response from placebo to XELJANZ in both the placebo and XELJANZ group of a given interval. Comparisons between placebo and XELJANZ were based on the first 3 months of exposure, and comparisons between XELJANZ 5 mg twice daily and XELJANZ 10 mg twice daily were based on the first 12 months of exposure.

    The long-term safety population includes all patients who participated in a double-blind, controlled trial (including earlier development phase studies) and then participated in one of two long-term safety studies. The design of the long-term safety studies allowed for modification of XELJANZ doses according to clinical judgment. This limits the interpretation of the long-term safety data with respect to dose.

    The most common serious adverse reactions were serious infections [see WARNINGS AND PRECAUTIONS].

    The proportion of patients who discontinued treatment due to any adverse reaction during the 0 to 3 months exposure in the double-blind, placebo-controlled trials was 4% for patients taking XELJANZ and 3% for placebo-treated patients.

    Overall Infections
    In the seven controlled trials, during the 0 to 3 months exposure, the overall frequency of infections was 20% and 22% in the 5 mg twice daily and 10 mg twice daily groups, respectively, and 18% in the placebo group.

    The most commonly reported infections with XELJANZ were upper respiratory tract infections, nasopharyngitis, and urinary tract infections (4%, 3%, and 2% of patients, respectively).

    Serious Infections
    In the seven controlled trials, during the 0 to 3 months exposure, serious infections were reported in 1 patient (0.5 events per 100 patient-years) who received placebo and 11 patients (1.7 events per 100 patient-years) who received XELJANZ 5 mg or 10 mg twice daily. The rate difference between treatment groups (and the corresponding 95% confidence interval) was 1.1 (-0.4, 2.5) events per 100 patient-years for the combined 5 mg twice daily and 10 mg twice daily XELJANZ group minus placebo.

    In the seven controlled trials, during the 0 to 12 months exposure, serious infections were reported in 34 patients (2.7 events per 100 patient-years) who received 5 mg twice daily of XELJANZ and 33 patients (2.7 events per 100 patient-years) who received 10 mg twice daily of XELJANZ. The rate difference between XELJANZ doses (and the corresponding 95% confidence interval) was -0.1 (-1.3, 1.2) events per 100 patient-years for 10 mg twice daily XELJANZ minus 5 mg twice daily XELJANZ.

    The most common serious infections included pneumonia, cellulitis, herpes zoster, and urinary tract infection [see WARNINGS AND PRECAUTIONS].

    Tuberculosis
    In the seven controlled trials, during the 0 to 3 months exposure, tuberculosis was not reported in patients who received placebo, 5 mg twice daily of XELJANZ, or 10 mg twice daily of XELJANZ.

    In the seven controlled trials, during the 0 to 12 months exposure, tuberculosis was reported in 0 patients who received 5 mg twice daily of XELJANZ and 6 patients (0.5 events per 100 patientyears) who received 10 mg twice daily of XELJANZ. The rate difference between XELJANZ doses (and the corresponding 95% confidence interval) was 0.5 (0.1, 0.9) events per 100 patientyears for 10 mg twice daily XELJANZ minus 5 mg twice daily XELJANZ.

    Cases of disseminated tuberculosis were also reported. The median XELJANZ exposure prior to diagnosis of tuberculosis was 10 months (range from 152 to 960 days) [see WARNINGS AND PRECAUTIONS].

    Opportunistic Infections (excluding tuberculosis)
    In the seven controlled trials, during the 0 to 3 months exposure, opportunistic infections were not reported in patients who received placebo, 5 mg twice daily of XELJANZ, or 10 mg twice daily of XELJANZ.

    In the seven controlled trials, during the 0 to 12 months exposure, opportunistic infections were reported in 4 patients (0.3 events per 100 patient-years) who received 5 mg twice daily of XELJANZ and 4 patients (0.3 events per 100 patient-years) who received 10 mg twice daily of XELJANZ. The rate difference between XELJANZ doses (and the corresponding 95% confidence interval) was 0 (-0.5, 0.5) events per 100 patient-years for 10 mg twice daily XELJANZ minus 5 mg twice daily XELJANZ.

    The median XELJANZ exposure prior to diagnosis of an opportunistic infection was 8 months (range from 41 to 698 days) [see WARNINGS AND PRECAUTIONS].

    Malignancy
    In the seven controlled trials, during the 0 to 3 months exposure, malignancies excluding NMSC were reported in 0 patients who received placebo and 2 patients (0.3 events per 100 patientyears) who received either XELJANZ 5 mg or 10 mg twice daily. The rate difference between treatment groups (and the corresponding 95% confidence interval) was 0.3 (-0.1, 0.7) events per 100 patient-years for the combined 5 mg and 10 mg twice daily XELJANZ group minus placebo.

    In the seven controlled trials, during the 0 to 12 months exposure, malignancies excluding NMSC were reported in 5 patients (0.4 events per 100 patient-years) who received 5 mg twice daily of XELJANZ and 7 patients (0.6 events per 100 patient-years) who received 10 mg twice daily of XELJANZ. The rate difference between XELJANZ doses (and the corresponding 95% confidence interval) was 0.2 (-0.4, 0.7) events per 100 patient-years for 10 mg twice daily XELJANZ minus 5 mg twice daily XELJANZ. One of these malignancies was a case of lymphoma that occurred during the 0 to 12 month period in a patient treated with XELJANZ 10 mg twice daily.

    The most common types of malignancy, including malignancies observed during the long-term extension, were lung and breast cancer, followed by gastric, colorectal, renal cell, prostate cancer, lymphoma, and malignant melanoma [see WARNINGS AND PRECAUTIONS].

    Laboratory Abnormalities
    Lymphopenia
    In the controlled clinical trials, confirmed decreases in absolute lymphocyte counts below 500 cells/mm³ occurred in 0.04% of patients for the 5 mg twice daily and 10 mg twice daily XELJANZ groups combined during the first 3 months of exposure.

    Confirmed lymphocyte counts less than 500 cells/mm³ were associated with an increased incidence of treated and serious infections [see WARNINGS AND PRECAUTIONS].

    Neutropenia
    In the controlled clinical trials, confirmed decreases in ANC below 1000 cells/mm³ occurred in 0.07% of patients for the 5 mg twice daily and 10 mg twice daily XELJANZ groups combined during the first 3 months of exposure.

    There were no confirmed decreases in ANC below 500 cells/mm³ observed in any treatment group.

    There was no clear relationship between neutropenia and the occurrence of serious infections.

    In the long-term safety population, the pattern and incidence of confirmed decreases in ANC remained consistent with what was seen in the controlled clinical trials [see WARNINGS AND PRECAUTIONS].

    Liver Enzyme Elevations
    Confirmed increases in liver enzymes greater than 3 times the upper limit of normal (3x ULN) were observed in patients treated with XELJANZ. In patients experiencing liver enzyme elevation, modification of treatment regimen, such as reduction in the dose of concomitant DMARD, interruption of XELJANZ, or reduction in XELJANZ dose, resulted in decrease or normalization of liver enzymes.

    In the controlled monotherapy trials (0-3 months), no differences in the incidence of ALT or AST elevations were observed between the placebo, and XELJANZ 5 mg, and 10 mg twice daily groups.

    In the controlled background DMARD trials (0-3 months), ALT elevations greater than 3x ULN were observed in 1.0%, 1.3% and 1.2% of patients receiving placebo, 5 mg, and 10 mg twice daily, respectively. In these trials, AST elevations greater than 3x ULN were observed in 0.6%, 0.5% and 0.4% of patients receiving placebo, 5 mg, and 10 mg twice daily, respectively.

    One case of drug-induced liver injury was reported in a patient treated with XELJANZ 10 mg twice daily for approximately 2.5 months. The patient developed symptomatic elevations of AST and ALT greater than 3x ULN and bilirubin elevations greater than 2x ULN, which required hospitalizations and a liver biopsy.

    Lipid Elevations
    In the controlled clinical trials, dose-related elevations in lipid parameters (total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides) were observed at one month of exposure and remained stable thereafter. Changes in lipid parameters during the first 3 months of exposure in the controlled clinical trials are summarized below:

    Mean LDL cholesterol increased by 15% in the XELJANZ 5 mg twice daily arm and 19% in the XELJANZ 10 mg twice daily arm.
    Mean HDL cholesterol increased by 10% in the XELJANZ 5 mg twice daily arm and 12% in the XELJANZ 10 mg twice daily arm.
    Mean LDL/HDL ratios were essentially unchanged in XELJANZ-treated patients.
    In a controlled clinical trial, elevations in LDL cholesterol and ApoB decreased to pretreatment levels in response to statin therapy.

    In the long-term safety population, elevations in lipid parameters remained consistent with what was seen in the controlled clinical trials.

    Serum Creatinine Elevations
    In the controlled clinical trials, dose-related elevations in serum creatinine were observed with XELJANZ treatment. The mean increase in serum creatinine was < 0.1 mg/dL in the 12-month pooled safety analysis; however with increasing duration of exposure in the long-term extensions, up to 2% of patients were discontinued from XELJANZ treatment due to the protocol-specified discontinuation criterion of an increase in creatinine by more than 50% of baseline. The clinical significance of the observed serum creatinine elevations is unknown.

    Other Adverse Reactions
    Adverse reactions occurring in 2% or more of patients on 5 mg twice daily or 10 mg twice daily XELJANZ and at least 1% greater than that observed in patients on placebo with or without DMARD are summarized in Table 4.

    Table 4: Adverse Reactions Occurring in at Least 2% or More of Patients on 5 or 10 mg Twice Daily XELJANZ With or Without DMARD (0-3 months) and at Least 1% Greater Than That Observed in Patients on Placebo
    Preferred Term XELJANZ 5 mg Twice Daily
    N = 1336
    (%) XELJANZ 10 mg Twice Daily*
    N = 1349
    (%) Placebo
    N = 809
    (%)
    Diarrhea 4.0 2.9 2.3
    Nasopharyngitis 3.8 2.8 2.8
    Upper respiratory tract infection 4.5 3.8 3.3
    Headache 4.3 3.4 2.1
    Hypertension 1.6 2.3 1.1
    *The recommended dose of XELJANZ is 5 mg twice daily.
    Other adverse reactions occurring in controlled and open-label extension studies included:

    Blood and lymphatic system disorders: Anemia

    Infections and infestations: Diverticulitis

    Metabolism and nutrition disorders: Dehydration

    Psychiatric disorders: Insomnia

    Nervous system disorders: Paresthesia

    Respiratory, thoracic and mediastinal disorders: Dyspnea, cough, sinus congestion

    Gastrointestinal disorders: Abdominal pain, dyspepsia, vomiting, gastritis, nausea

    Hepatobiliary disorders: Hepatic steatosis

    Skin and subcutaneous tissue disorders: Rash, erythema, pruritus

    Musculoskeletal, connective tissue and bone disorders: Musculoskeletal pain, arthralgia, tendonitis, joint swelling

    Neoplasms benign, malignant and unspecified (including cysts and polyps): Non-melanoma skin cancers

    General disorders and administration site conditions: Pyrexia, fatigue, peripheral edema

    Clinical Experience In Methotrexate-Na�ve Patients
    Study VI was an active-controlled clinical trial in methotrexate-na�ve patients [see Clinical Studies]. The safety experience in these patients was consistent with Studies I-V.

    Read the entire FDA prescribing information for Xeljanz (Tofacitinib Tablets) »

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    © Xeljanz Patient Information is supplied by Cerner Multum, Inc. and Xeljanz Consumer information is supplied by First Databank, Inc., used under license and subject to their respective copyrights.

    Last reviewed on RxList: 3/7/2016
    This monograph has been modified to include the generic and brand name in many instances.

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    Ok so are you on an antidepressant? What antidepressant? Going to look up hepatic steatosis…that has something to do with your liver. Pred burst is good.

  4. So basically reading that you can try reducing the amount of Xeljanz you take and you might not suffer the liver issues. I would stop taking mtx if you are and reduce from 2 pills a days to one if the rheumy leaves you on it. And don’t ask tell her/him if she/he is telling you to stay on it.

  5. What are your instincts telling you? If you are not sure now, I am sure you will feel an emotional reaction to whatever the rheumy tells you – if you find yourself more upset than expected at the advice, that’s possibly a sign that your instincts are telling you it’s not the right option. If you are feeling fairly settled about the advice then that is probably the best thing to do.

    Whenever reviewing treatment options, I need to remind myself of the important question that so often gets overlooked in these conversations: “What if I/we do nothing?”

    Maybe also look at quality of life issues – e.g., I used to say to myself “What’s the point in being able to get out of bed if I feel too nauseous to think clearly?”

    Those lists of side effects and drug interactions look scary but they can also give you a clue as to what might be going on with your symptoms. Sometimes it is a trade off between symptoms and side effects in what you are willing/able to tolerate and what you definitely cannot tolerate.

    I’m sorry that you are in this predicament. Prednisone is ‘a devil you know’ as someone mentioned earlier. It is also a devil that has been well known for a long time. At least while you are on it, you know how it acts on your body and it will help you with the detective work about whether your liver issues are from your autoimmune processes or medication . I did read in that list that the Xeljanz may interact with steroids so you would want to make sure it was right out of your system before your emergency prednisone.

    I hope your body can heal well before your next rheumy appointment so you can start again from a healthier position. All the best xx

  6. Glad your liver is good! Great news. 🙂 I’ve not read all your blog, so please forgive if this is a redundant question, but you speak of your breathing and lung issues. Have your doctors considered you have RA-Lung, or done HRCT to see if that is part of your issue? When my RA-Lung was diagnosed, my Rheumy immediately took me off MTX. My RA, which for 10 years before was well managed. Very well managed. Then I got the RA-Lung. And everything changed. Now, I’m literally falling apart. Just got out of hospital again, after a lung flare that cracked two ribs, I ended up in ICU with blood clots in my legs and lungs, both lungs. It never ends……we just move through each day.

    As for the xeljanz, if it works, do it. I’m in the same boiling cauldron you are, and sometimes the relief we get from the demonic drugs (Prednisone) far out weighs the other stuff. Be well!! As well as you can. ((Soft Hug))

    • Hi Melissa, that’s a very good question. I am actually going for lung function testing today, that I almost forgot! MTX lung was mentioned as likely, so thank you for reminding me! I’m hoping its just asthma and allergies, far mpore treatable. I’m sorry you’re going through so much! Lung involvement has always scared me. I would love to know more about MTX lung, if you don’t mind talking about it? I don’t even know if there’s a treatment or the damage is reversible. Clearly your case is very severe, cracked two ribs! I’m so sorry. I hope there is something they can do for you, sorry for my ignorance. I did have a CT about a year ago, and apart from a few small old nodules, it was fine. Docs consider it clean. My lungs are improving, quite by themselves, so I am hoping my breathing issues are an allergic reaction. I’ll find out more today I guess. Thanks much for posting, excellent timing! I seriously would have forgotten about my tests today!!! Best to you Xx

      • None of my doctors will “commit” that the MTX was a factor, but yet the Rheumy immediately took me off it. MTX over the long haul has been known to scar the lungs. When that happens, from all that I’ve read, it is not reversible. RA-ILD (Intersticial lung disease aka RA-Lung) can bubble and simmer in the back ground, with little to no symptoms for years. By the time you feel the symptoms (in my case, a horrendous lung infection last year with two plural effusions and two lung drains), the ILD is already well on its way. That is why it is SO IMPORTANT to insist on a lung x-ray once a year. Even if your doctors drag their feet and say its not necessary. Take my advice IT IS necessary. Like RA, it is incureable, and there’s no stopping it, only managing the symptoms. My doctors also will not commit to a “time limit” for me, but from all that I’ve read and researched, 2 to 4 years is the average life span after the ILD diagnosis. I was diagnosed December 2015, last year. My lung function just in this last year has diminished greatly. And now that I have infarction with the clots (that’s where the tissues has already died), I will never breath the same again, and I will only get worse until my lungs stop functioning completely. RA-Lung is the #2 killer of people with RA, heart disease being #1. But it all comes from the same thing…..RA. When I was diagnosed, I Googled my tail off, I even read papers written by medical students, and sometimes I think that really ticks my doctor off. He keeps telling me “but you’re in great shape! All things considered. You’ve got time. Stay off WebMD.” As I sit there about ready to eat my hair from the pain of TWO busted ribs from a lung flare. I’m no doctor, but I know how I feel. I told him I felt bad, I told him. One week later, I’m in the ER with Pulmonary Embolism. One thing I’ve learned over these last 11 years with RA, doctors don’t know everything. And nobody knows our bodies, like we do. There is a ton of good info out there on RA Lung, there’s also some not so good. One thing I will say, once the RA goes systemic (begins to affect the organs), every thing changes. I know that’s a downer, I know. God I know. But one thing I’ve always said is that I would face this head-on. No putting my head in the sand, and if my doctors won’t keep me informed because they don’t want me to worry or for whatever reason, then I’ll do the research myself. I will be informed. I survived a DVT in my left leg with a complete obstruction back in 2012. This time it was the lungs. Twice now I’ve walked away from a serious clot issue, and I’m convinced the Humira is making my blood thick. My pulmonologist even said he’d read that some of the biologics will do that. So it appears I still have work to do, I’m still here 🙂 . I have to fight the urge to punch people when I hear them say “yeah, but RA won’t kill you” or “oh yeah, my gramma has that in her left knee/pinky/big toe (pick one)”. Be well!

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