rheumatoid arthritis treatment

Rheumatoid Arthritis Treatment

Patient Management Skills

A treatment plan was decided upon by following an evidence-based approach. Once the diagnosis of rheumatoid arthritis was established, the patient was started on therapy immediately following the evidence-based guidelines of the American Rheumatism Association (23,24). Therapy was guided with these principles, and individualized to the goals of the patient. The goals of therapy for rheumatoid arthritis where initially proposed to the patient. These goals consisted of the following: to control inflammation; relieve pain and stiffness; maintain function and lifestyle; prevent joint damage; and early intervention with Disease Modifying Anti-Rheumatic Drugs (DMARDs) to prevent further joint damage. The patient was educated and counseled about rheumatoid arthritis, its diagnosis, prognosis, and course, treatments and management, including drug side-effects, and the role that other disciplines, including occupational therapy OT and physiotherapy PT would play (25,26). The patient did not have any difficulties in accepting the plan, and she was eager to being the process. There was no interaction with any friends or family, as the patient did not have any immediate family or close friends.

Our initial plan was to get an assessment by PT and OT. A PT referral was done to provide the patient with ROM exercises, improvement in ambulation, pain control, and muscle strengthening, as well as to provide further education of her situation from a different perspective. OT was also involved, in order to provide the patient with education regarding joint protection, energy conservation, and assistive devices. These included splints and devices to help her through her activities of daily living (ADLs), in addition to ergonomic improvements of her workplace (25,26). To provide immediate symptomatic relief, we recommended that she start on a non-steroidal anti-inflammatory drug (NSAID), such as Ibuprofen. This would provide symptomatic relief of her pain rapidly by inhibiting prostaglandin-mediated inflammation and pain. She had been on Celecoxib in the past; however, had to discontinue it due to numerous side-effects. The side-effect profile of Ibuprofen (eg, anorexia, nausea, dyspepsia, abdominal pain, ulcers, GI bleeds, and drug hypersensitivity reactions) was also discussed with the patient and any risk factors for NSAID-induced ulcers were assessed (2).

Rheumatoid arthritis will cause articular damage in almost every patient; however, how much damage will occur is variable and usually can be determined by how early treatment is initiated. Disease Modifying Anti-Rheumatic Drugs are added to NSAIDs as soon as the diagnosis is determined (23). Used early, these drugs are more likely to be effective, as the majority of erosive damage occurs rapidly in the first two years. Slowing the progression of the disease is the main goal of Disease Modifying Anti-Rheumatic Drugs. In a few, there can also be complete remission of their condition. Monitoring the effectiveness of these medications is done through physical examination. The number of swollen and tender joints, length of morning stiffness, disabilities and physician assessments are usually used as measurements (23). Mrs. TT was immediately started on hydroxychloroquine 200mg alternating with 400 mg daily. In addition, methotrexate was added, increasing the dose weekly by 2.5 mg to a maximum of 20 mg weekly. She was counseled on potential side effects, as well as given a handout describing the indications and potential risks associated with methotrexate, such as teratogenicity, nausea and vomiting, mucosal ulceration, lung, liver, and bone marrow toxicity. Folic acid 5 mg everyday, except on her methotrexate day was advised. The side effects of hydroxychloroquine were also discussed (eg, retinopathy, neuromyopathy, GI, skin rash). Mrs. TT had a corporate health benefits plan, so the financial costs of her treatments were completely covered.

A follow-up appointment was booked after one month, in order to ensure continuance of care. Laboratory requisitions were given for weekly CBC, creatinine, and LFTs over 4 weeks, and then monthly for the next 6 months. We will monitor for any changes in her bloodwork over that time and see the patient in the clinic within a month. Subsequent visits would be at 2-3 months intervals, until the patient’s rheumatoid arthritis has become inactive. If she has any adverse effects, she has been instructed to discontinue the medication and call the clinic. Mrs. TT was satisfied and in full agreement of the treatment plan.

References:

  1. Ryan S. Sharing care in an outpatient clinic. Nurs Stand 1995, 10: 23-25.
  1. Lubeck DP. Patient-reported outcomes and their role in the assessment of rheumatoid arthritis. Pharmacoeconomics 2004, 22; Suppl. 1: 27-38.
  1. Anonymous. The burden of rheumatoid arthritis. Based on a presentation by Fredrick Wolfe, MD. Am J Manag Care 1999, 5; Suppl. 14: S852-9; discussion S866-9.
  1. Silman AJ. Epidemiology and the rheumatic disease. In Maddison PJ et al (Eds). Oxford Textbook of Rheumatology. Volume 2. Oxford, Oxford University Press. 1993
  1. Arthur V. Nursing care of patients with rheumatoid arthritis. Br J Nursing 1994, 7: 325-331.
  1. Nadura A. Self efficacy-towards a unifying theory of behavioural change. Psychol Rev 1977, 84: 191-215.
  1. Marnji AN. What do rheumatologists do? Br J Rheum 1990, 29: 295-298.
  1. Gabreil SE, Crowson CS, Campion ME, and O’Fallon WM. Indirect and nonmedical costs among people with rheumatoid arthritis and osteoarthritis compared with nonarthritic controls. J Rheumatol 1997, 24: 43-48.
  1. Blumenauer B, Cranney A, Clinch J, and Tugwell P. Quality of life in patients with rheumatoid arthritis: Which drugs make a difference? Pharmacoeconomics 2003 21: 927-940.
  1. Ward MM. Outcome measurement: health status and quality of life. Curr Opin Rheumatol 2004, 16: 96-101.
  1. WHO. The first ten years of the world health organization. 1958, Geneva: World Health Organization
  1. Miller J. Coping with Chronic Illness, Overcoming Powerlessness. Second edition. Philadelphia PA, FA Davis Company. 1992.
  1. Wolfe F, Cathey MA. The assessment and prediction of functional disability in rheumatoid arthritis. J Rheumatol 1991, 18: 1298-1306.
  1. Callahan LF, Brooks RH, Summey JA, Pincus T. Quantitative pain assessment for routine care of rheumatoid arthritis patients, using a pain scale based on activities of daily living and a visual analog pain scale. Arthritis Rheum 1987, 30: 630-636.
  1. MacKinnon JR, Avison WR, McCain GA. Pain and functional limitations in individuals with rheumatoid arthritis. Int J Rehabil Res 1994, 17: 49-59.
  1. Kazis LE, Meenan RF, Anderson JJ. Pain in the rheumatic diseases. Investigation of a key health status component. Arthritis Rheum 1983 26: 1017-1022.
  1. Nichol MB, Harada AS. Measuring the effects of medication use on health-related quality of life in patients with rheumatoid arthritis. Pharmacoeconomics 1999, 16: 433-448.
  1. Yelin EH. The cumulative impact of a common chronic condition. Arthritis Rheum 1992, 35: 489-497.
  1. Katz PP, Yelin E. Prevalence and correlates of depressive symptoms among persons with rheumatoid arthritis. J Rheumatol 1993, 20: 790-796.
  1. Singh G, Lingala B, Bennett M, Wanke L, Singh A. Epidemiology of fatigue in rheumatoid arthritis: prevalence and clinical correlates. Presented at EULAR 2003, Lisbon, Portugal.
  1. Callahan LF, Cordray DS, Wells G, Pincus T. Formal education and five-year mortality in rheumatoid arthritis: Mediation by helplessness scale scores. Arthritis Care Res 1996, 9: 463-472.
  1. Shmerling RH. Diagnostic tests for rheumatic disease: clinical utility revisited.
    South Med J. 2005, 98: 704-11, 712-3, 728.
  1. American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines. Guidelines for the management of rheumatoid arthritis: 2002 Update.
    Arthritis Rheum. 2002, 46: 328-346.