Q: I am a female aged 70 years and a patient of R. arthritis with BP of 160/90 for more than 10 years. i take aten-50 and Enapril HT tabs every day for BP. I am taking Arava 20 mg for the last 6 months and joint pains have reduced very much. However I understand that the above drug is banned in UK. My blood results: LFT - within range. ESR - 69, serum creatinine - 1.5. My ankles and legs are always swelling. Now I don't have much control on urine retention and take Roliten 2mg for a week. Sometimes I get pain near heart and bottom, but ECG is normal. I take Omez tabs also every day. Recently blood is coming through nose. How should I manage? Should I stop arava? There is lot of cost difference in US Arava and Indian arava. Which is better? Please advise.

A:1. Blood pressure is under control. Aten-50 is fine. Enapril-HT is a brand name that contains two medicines: enalapril (5mg) and hydrochlorthiazide (25mg). It is preferable to take the two drugs separately rather than in one tablet. The advantages are that we can titrate the dose such as increase enalapril and decrease hydrochlorothiazide (a diuretic to produce more urine) or vice versa. In any case 25mg of hydrochlorothiazide is too high for BP patients. It has been established that even 12.5mg is adequate. Secondly we prefer a low-dose long-acting diuretic that acts at two levels: decrease BP and produce more urine slowly over 24-hours. Thus one could take enalapril 5mg (Brand name: BQL) and indapamide 1.5mg (Brand name: Indicontin Continus). 2. Arava is the brand name of leflunomide. Despite its side effects, I am afraid there is no acceptable, effective alternative for patients of Rheumatoid arthritis (RA). Contrary to your information it is not banned in UK. There is no difference between Arava sold in USA and the one sold in India. Hence you can continue with the less expensive one. I think an attempt can and should be made to reduce the dose to 10mg if it is effective. 3. Tolterodine (Brand names: Roliten, Detrusitol) is being given to you for loss of control over passing of urine. It is quite expensive. I am not sure if your doctor first tried flavoxate (Brand name: Flavate by Overseas Healthcare). 4. One of the side effects of omeprazole (sold under various brand names including Omez) is arthralgia (joint pains). Even though it is uncommon, one should avoid it in RA patients. An equally effective drug belonging to the same class is pantoprazole (Brand name: Pantodac). You can safely take Pantodac 40mg once daily. This is being given to you to counteract gastric side effects of other drugs.