RHEUMATOID

ARTHRITIS CASE
STUDY
CPT3 2014
Sarah Chai 1104039
Ashley Graham
Jodian Francis
Carla Samuels
Patrice Cobourne
Stephanie Clarke Calvert
Onika Davis

OBJECTIVES
Identify the signs and symptoms of rheumatoid arthritis

(RA) and assess disease severity.

Recommend appropriate nonpharmacologic options for

adjunctive management of RA.

Recommend appropriate disease-modifying drug therapy

for RA and monitor patients effectively to achieve desired

therapeutic outcomes.
Understand the role of analgesic and antiinflammatory

medications in managing RA.

Educate patients and their families about the medications

used to treat RA.

SIGNS AND SYMPTOMS

Joint pains (arthalgias)

Fatigue

Morning stiffness every day for about 2 hours

Swelling and pain in both hands

Decreased range of motion (ROM) in both hands, wrists

and shoulders.

Sixteen(16) tender
(polyarthritis).

and

swollen

joints

bilaterally

LABORATORY VALUES
Decreased hemoglobin levels 10.8 g/dl. (normal for females: 12-14 g/dl).
Increased Erythrocyte sedimentation rateESR, 55mm/hr. (normal for

females: 0 29mm/hr.)
Positive Rheumatoid Factor
A positive result for cyclic citrullinated peptide (anti-CCP) antibodies

indicates a high likelihood of rheumatoid arthritis (RA).

Disease activity Score (DAS 28). - A DAS of 5.1 implies active RA disease

while a DAS of 3.2implies that the RA disease is well controlled.

Hand X-Ray - The X-Ray from the case indicated multiple erosions of MCP

and PIP joints bilaterally with measurable joint space narrowing from
previous X-Ray 3 months ago. Erosion are usually indicative of inflammatory
diseases and normally suggest that there is structural damage.

ADDITIONAL INFORMATION TO
ASSES PATIENT
To assess disease activity the following are
required:
C Reactive Protein
Complete Blood Count
Rheumatoid Factor - antibody present in 70 to
80% of patients with RA
Inflammatory Joint Fluid
Pain Score
Degree of joint tenderness / swollenness

SEVERITY OF RA
The information obtained in the case indicates that the patient
has moderate rheumatoid arthritis.
Characteristics of Moderate Rheumatoid Arthritis
loss of bone density, and perhaps evidence of early bony

erosions due to the destructive inflammation.

These patients may have a couple hours of morning stiffness,

fatigue, evidence of anemia, and a moderately elevated

sedimentation rate (ESR);
all of which may be accompanied by slight weight loss and

significant joint pain and swelling involving at least ten joints.

Patients with moderate rheumatoid arthritis are unable

perform daily activities, including going to work.

GOALS OF PHARMACOTHERAPY
Improve functional status
Improve quality of Life
To decrease disease activity
To control joint pain
To maintain ones ability to function in daily activities and work
To delay disability
To slow the destructive joint changes
To be able to be on medication for RA as well as able to have children
To make the patient feel more energetic and decrease the feeling of being

tired.
To improve muscle strength
To increase range of motion of fingers, wrists and shoulders
To decrease inflammation of joints

DRUG THERAPY PROBLEMS

Methotrexate vs Naproxen

Methotrexate vs Pregnancy
Methotrexate vs Fertility
Methotrexate vs Alcohol
Naproxen vs Alcohol
Indication for therapy- Anemia
Rheumatoid Arthritis vs Alcohol consumption

NONPHARMACOLOGICAL
BENEFITS
Occupational therapy - Self help devices enable patients

with debilitating RA to perform their daily activities.

Physical therapy - Provides patient with skills and

exercises to increase or maintain mobility ie. It helps with

joint function, muscle strength and fitness levels
Rest
Use of assistive devices
Exercise should proceed as tolerable
Weight reduction This alleviates inflamed joint stress
Surgery - Used when RA is severe eg. tendon repair and

joint replacements

PHARMACOLOGICAL
ALTERNATIVES

NON BIOLOGIC DMARDS

Hydroxychloroquine 200mg PO BID
Sulfsalazine 1000mg PO BID
Leflunomide 10- 20mg PO OD
Minocycline 100mg PO BID

Max: 3g QD

BIOLOGIC DMARDS
Adalimumab (Humira) 40 mg SQ every other

week
Etanercept (Enbrel) 50 mg SQ weekly given as
one 50 mg injection or two 25 mg injections in
one day
Infliximab (Remicade) 3mg/kg IV at 0,2 and 6
weeks, then ever 8 weeks
Certolizumab (Cimzia) 400 mg SQ (as 2 SQ
injections of 200 mg) once and then repeat at
weeks 2 and 4

BIOLOGIC DMARDS
Abatacept (Orencia) 750 mg IV over 30 min

repeat doses at 2 and 4 weeks; then every 4

weeks thereafter
Rituximab (Rituxan) 1000 mg IV followed by
1,000 mg IV 2 weeks later
Tocilizumab (Actemra) 4 mg/kg IV infusion over
1 h every 4 weeks; increase to 8 mg/kg based
on clinical response (max 800 mg)
Anakinra (Kineret) 100 mg/day SQ

NONSTEROIDAL
ANTIINFLAMMATORY DRUGS
Aspirin 650mg PO QID
Celecoxib 100- 200mg PO BID
Meloxicam 7.5mg PO OD
Ibuprofen 400mg PO TID

OPTIMAL TREATMENT PLAN

Adalimumab (Humira) 40 mg SQ every other

week x3/12
Prednisone 5mg PO OD x 2/52
Folic Acid 1mg PO OD x3/12

Tramadol 100mg PO q4-6h PRN x2/52

OUTCOME EVALUATION
Signs of improvement with drug therapy includes:
Reduction in joint swelling
Decreased warmth over actively involved joints.
Decreased tenderness to joint palpation
Reduction in joint pain and morning stiffness
Improvement in ability to perform daily
activities.
Longer time to onset of afternoon fatigue.

OUTCOME EVALUATION
Periodic joint radiographs may be useful in assessing

disease progression.
Increasing Hemoglobin and hematocrit to normal levels.
Reduction in ESR levels to less than 30mm/hr.
Reduction in the DAS 28 value to less than 3.2.
Laboratory is of little value to monitoring response to
therapy but is essential in determining and preventing
adverse drug effects.
Patients should be questioned about the presence of
symptoms that may be related to adverse drug effects.

PSYCHOLOGICAL CONSIDERATIONS
Based on the case presented the patient is an

Executive secretary;
married for 3 years;
wants to start a family within the next year, as
such two of the three psychsocial considerations
are evident within this patients life that is her
work and family life.
Being employed positively influences perceived
quality of life; conversely, energy consumed at
work may have negative effects on health status.

PSYCHOLOGICAL
CONSIDERATIONS
Job loss resulting from arthritis is associated

with reduced life satisfaction and greater

depression and pain.
Not only does pain interfere with work, but it
restricts participation in other roles, including
those integral to family life, such as:
being a parent,
managing a household or
maintaining intimate relationships.

ECONOMIC CONSIDERATIONS
The economic considerations of Rheumatoid Arthritis are

numerous and not only affect the patient finances but

also have implication on the productivity of organization
for whom the individual works with.
Focusing on the patient however we see where the cost

of the medications may prove to be of concern depending

on the ones chosen.
Loss of job may be another consideration if the disease

progresses aggressively and result in disabilities or

further complications.

Biologics are very expensive and if chosen for a patient

the doctor must assess if the patient is able to pay for the
drugs

PATIENT EDUCATION

INFORMATION TO ENHANCE
ADHERENCE
Patient Education Educating patients about their disease and

its management can promote an understanding of the risks

and benefits of therapy and encourage adherence
Onset of action for meds used to treat RA- when patients know
how long it takes for drugs to start working they will not
discontinue drugs because they know it takes a while for the
drug to start working
Complication of RA- such as cardiac and pulmonary
involvement
Avoid Triggers of RA such as stress, certain foods, infection
Family and Social Support Network- patients who have persons
to help with their medication regimen tend to be more
adherent.

INFORMATION TO ENSURE
SUCCESSFUL THERAPY
Keep up with follow ups and appointments with

your health care professional.

Before starting other medications be sure to
consult with your pharmacist or physician as
certain drugs may interact with drugs used for
RA and decrease efficacy

INFORMATION TO ENSURE MINIMAL

ADVERSE EFFECTS
Side effect profile of the drugs chosen for the

management of RA should be understood by the

patient.
Take drugs on time and never overdose as this
may increase adverse effects or toxicity of
drugs.
Drug interaction
Have regular lab tests - these medicines are
usually taken for a long time and they can have
serious side-effects. It is usual to have regular
tests such as blood tests done. They look for
some possible side-effects before they become
serious.

INFORMATION TO ENSURE MINIMAL

ADVERSE EFFECTS
Report unusual symptoms to health care
professional. For eg
Sore throat
Fever and other signs of infection
Unexpected bleeding or bruising
Purpura and rashes
Mouth ulcers
Cough or breathlessness
May be signs of myleosupression

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