Medical Management of RA

RA is diagnosed using a combo of…

• Clinical Manifestations

• Labs

• Radiographs/ultrasound

Clinical Manifestations patients typically present with

Peripheral symmetrical joint pain

Morning stiffness >30 mins

S/S for >6 weeks

Synovitis

How is Synovitis assessed?

Palpate each joint

• Tenderness? → subjective

• Synovitis → Objective

What % of patients are negative for antibodies?

25-30%

Does a positive rheumatoid factor always indicate RA?

No.

Other autoimmune diseases have positive rheumatoid factor

What % of patients have a positive RH factor?

up to 90%

What are anticyclic citrullinated peptides (anti CCP) antibodies?

AUTOantibodies that are directed against certain peptides and proteins

what % of patients have positive anti CCP?

more than 80% of clients with RA

What lab is drawn to detect inflammation?

CRP

ESR

Why should info regarding renal & hepatic function be obtained before initiating therapy?

Meds can be toxic to kidney/liver

Why is a baseline CBC taken?

Anti rheumatic meds can cause cytopenia (low blood cells)

What are radiographs used to assess?

Bony erosions

Joint-space narrowing

What does an elevated platelet count indicate?

Inflammation causes elevated platelet count

Why will an x-ray show osteoporosis?

corticosteroid use

What else may appear on x-ray

• Erosion

• Joint space narrowing

• Bony growths

Before the initiation of most biological therapies, what must be preformed?

A TB skin test and hepatitis test

• therapies have potential to reactivate dormant infections

How can patients manage fatigue and joint pain

take rest periods

Initial treatments

Analgesics

NSAIDS

Glucocorticoids

Action of Analgesics/example

Acetaminophen and narcotics

• Pain relief

• DO NOT ALTER DISEASE PROCESS

Action of NSAIDs

• Pain relief

• some reduction in inflammation

  • DO NOT ALTER DISEASE PROCESS

Action of Glucocorticoids/example

Prednisone (PO, IM, IA, IV)

• Supress inflammation

• CAN ALTER DISEASE PROCESS

Corticosteroids considerations

• Not safe at high doses over long periods of time

• Must be tapered (risk of adrenal insufficiency)

• Increased infection risk

• Raises Blood Sugar

• Risk of OSTEOPOROSIS

• may cause fluid retention

Why should corticosteroids be tapered?

Risk of adrenal insufficiency (adrenal crisis)

• Corticosteroids suppress the adrenal glands

• Start to rely on external corticosteroids

• Abruptly stopping → not enough cortisol to maintain normal BP and glucose

How are corticosteroids (prednisone) used in RA?

Low-dose until antirheumatic drug can start to take effect

manage symptoms during acute flare up

Intraarticular injection can decrease pain/inflammation

What do DMARDs do?

ALTER THE IMMUNE SYSTEM

• Alter inflammatory response

• Decrease inflammation

• SLOW DISEASE PROGRESSION

1st line Disease-modifying antirheumatic drug

Methotrexate (Rheumatrex)

Benefit of Methotrexate

Steroid-sparing

Alternate to corticosteroid

Before starting DMARD pts should inform their HCP of a…

hx or exposure to ACTIVE TB

How is Methotrexate taken?

Once weekly

PO, Subq, or IM

Safety with Methotrexate

Monitor for HEPATIC TOXICITY

• Avoid alcohol

Take folic acid - prevent oral ulcers

Avoid live vaccines

Report S/S INFECTION (immunosuppression)

Risk of birth defects: use contraception

Genetically engineered medications made from living organisms and their products, such as proteins

Biologics

MOA of biologics

Interfere with action of the tumor necrosis factor (binds to it)

interrupt immune response

Decrease inflammation

When are Biologics used?

When the patient is unresponsive to non-biologic DMARDS

What can permanent joint deformity lead to?

PERMANENT DISABILITY

Extraarticular complications of RA

Increased INFECTION risk

Increased risk of CANCER

What is scleritis?

Severe OCCULAR inflammation

What may a patient with RAs eyes look like

Sclera (white part) may be RED

What is Sjogren’s Syndrome (S/S)

DRY

• decreased saliva (dry mouth)

• Decreased tears (dry eyes & photosensitivity)

Heart complications of RA

Pericarditis 

Myocarditis

Lung problems in RA

Pleural effusion

Collapsed lung