instruction: hello doctor ra patient for 13 years and on treatment with methotrexate leflunomide then suffered from aplastic anemia and at treatment done with partial recovery presently on cyclosporine on the advice of hematologist and hcqs on advice of rheumatologist yeti man chemotherapy was done since then ra was in remission until january 20 lab reports show creatinine 0 urea 39 uric acid 59 hemoglobin 7 tac 26 platelets 168 now the patient is having typical attacks of ra in various joints like hip knee shoulder and neck etc feels lethargic early morning finger joints are swollen with severe pain taking aceclofenac100 with paracetamol 325 almost daily if the pain is less she takes paracetamol 650 please advise medication during lockdown
output: hello I have gone through your reports it seems her arthritis is flaring up again eventually cyclosporine and hcqs are both very mild when it comes to arthritis management she may have had a prolonged suppression due to rituxan injection at this stage my suggestion would be to restart leflunomide as the tac total leukocyte count is still low methotrexate may not be the best choice secondly she can take injection kenacort 80 my triamcinolone intramuscular once a week for two weeks it will settle the inflammation fast thirdly use minimum pain killers as they are not a wise option when aplastic anemia is in the background I hope this helps