Case Study 1- Rheumatoid Arthritis

Question 1

What is Rheumatoid arthritis ?

Answer 1

1. Chronic autoimmune and inflammatory disease
   - Immune system attacks healthy cells
   in the body which causes painful
   swelling

Question 2

What symptoms are associated with RA?

Answer 2

1. Symmetrical joint synovitis:

• Pain
• Prolonged stiffness (gets worse at rest,
  following long periods of inactivity)
• Swelling of joints
• Heat in and around joints

Occurs in multiple joints

Question 3

What does autoimmune disease mean?

Answer 3

Immune system attacks healthy cells in the body by mistake which causes painful swelling and inflammation

Question 4

What happens if RA is not managed over time?

Answer 4

Joint deformity and affect different organs such as the heart, lungs, eyes etc

Question 5

What area does RA typically effect?

Answer 5

Small joints within the hands, wrist, knees, feet

Usually affects multiple joints

Question 6

How is RA diagnosed ?

Answer 6

Blood tests that look for Rheumatoid related antibodies such as rheumatoid factor

Question 7

What is the risk factors for RA?

Answer 7

1. Age (often starts in middle age)
2. Women more likely to develop
3. Smoking
4. Obesity

Question 8

What is the 1st list line pharmacological treatment for RA?

Answer 8

DMARDS such as oral MTX, leflunomide, sulfasalazine

Question 9

When should DMARD treatment be started?

Answer 9

ASAP,
Ideally within 3 months of onset of persistent symptoms

Question 10

When should DMARD treatment be started?

Answer 10

ASAP,
Ideally within 3 months of onset of persistent symptoms

Question 11

True or false
DMARDs should be titrated to the min tolerated effective dose ?

Answer 11

True
max tolerated effective dose

Question 11

True or false
DMARDs should be titrated to the min tolerated effective dose ?

Answer 11

True
max tolerated effective dose

Question 12

How long do DMARDs take effect ? What should be considered in conjunction to this and why?

Answer 12

2-3 months
Prescribers should consider offering patient short term bridge treatment with CORTICOSTEROIDS (e.g, oral prednisolone)

Question 13

Why should a short term bridge treatment be given to patients who have just started a DMARD?

Answer 13

Will provide the patient with short term symptomatic relief/control while waiting fro DMARD to take action

Question 14

List 3 side effects that are associated with corticosteroids

Answer 14

• Increased appetite
• Increased risk of infection (increased risk of pneumonia or sepsis)
• Osteoporosis
• Reduced immunity
• Blood glucose is effected

Question 15

What lifestyle advice should you give patient with RA?

Answer 15

1. Smoking offer smoking cessation
2. Weight loss
3. Physiotherapy- enhance flexibility of joint and strengthen muscle
   4.occupational health therapist- access physical ability in day to day life and helps put things in the house to support
4. Relaxation and stress management
5. support is also available online and national support groups

Question 16

What monitoring should be considered?

Answer 16

baseline measurements:
1. FBC- inflammatory markers
2. LFTs
3. Kidney function test
U&Es initially

Repeat every 1-2 weeks until therapy is stable then monitory every 2-3 weeks

Baseline x-ray of hands and feet to show progression of conditon over time

Review patients annually

Question 17

Briefly explain he clinical effectiveness graph of MTX and a corticosteroid (e.g, prednisolone)

Answer 17

Corticosteroid used for rapid symptomatic relief

then slowly ween patient off the prednisolone once the MTX kicks in.

MTX used for disease management
this takes 2-3 months to act therefore no relief will be provided to the patient initially

Question 18

How would you diagnose RA?

Answer 18

Blood test: presence of rheumatoid factor (antibody)

X-rat to see progression

Question 19

What is the mechanism of action of methotrexate?

Answer 19

Folic acid analogue

Binds to and inhibits dihydrofolate reductase (DHR)

Reduces the synthesis of tetrohydrofolate (THF)

Question 20

What should be co-prescribed with methotrexate and why?

Answer 20

Folic acid to reduce methotrexate side effects and promote healthy cells

Question 21

What counselling should you give patients on methotrexate?

Answer 21

1. Folic acid should be taken on a different day to methotrexate
2. Avoid taking with NSAIDs, penicillin, other folate antagonists
3. Patient alert card
4. Take MTX on same day every week

Question 22

What class is infliximab?

Answer 22

Biologic/monoclonal antibody

Question 23

What is the mechanism of action of infliximab?

Answer 23

Prevents TBF alpha binding to its
receptors

Reducing TNF alpha activity

Decreases cytokines driven inflammatory processes

Therefore decreasing synovitis and joint damage in RA

Question 24

What counselling should you offer to patients in infliximab?

Answer 24

Carry the alert card
Prescribe by brand

Question 25

What monitoring should be given to patients in infliximab?

Answer 25

Check for infection Before treatment and 6 months after

Hypersensitivity: 1-2 hours after infusion And delayed hypersensitivity

Non melanoma skin cancer

Signs of bleeding disorders

Worsening of TB

Question 26

Why should folate acid be given on a different day to methotrexate?

Answer 26

They both bind to the same reception there fore giving them on the same day will reduce the absorption/effectiveness of folic acid

Question 27

True or false.
We should stop methotrexate when a patient has an infection ?

Answer 27

True increases risk of infection