Case Study 1- Rheumatoid Arthritis Flashcards
What is Rheumatoid arthritis ?
- Chronic autoimmune and inflammatory disease
- Immune system attacks healthy cells
in the body which causes painful
swelling
What symptoms are associated with RA?
- 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
What does autoimmune disease mean?
Immune system attacks healthy cells in the body by mistake which causes painful swelling and inflammation
What happens if RA is not managed over time?
Joint deformity and affect different organs such as the heart, lungs, eyes etc
What area does RA typically effect?
Small joints within the hands, wrist, knees, feet
Usually affects multiple joints
How is RA diagnosed ?
Blood tests that look for Rheumatoid related antibodies such as rheumatoid factor
What is the risk factors for RA?
- Age (often starts in middle age)
- Women more likely to develop
- Smoking
- Obesity
What is the 1st list line pharmacological treatment for RA?
DMARDS such as oral MTX, leflunomide, sulfasalazine
When should DMARD treatment be started?
ASAP,
Ideally within 3 months of onset of persistent symptoms
When should DMARD treatment be started?
ASAP,
Ideally within 3 months of onset of persistent symptoms
True or false
DMARDs should be titrated to the min tolerated effective dose ?
True
max tolerated effective dose
True or false
DMARDs should be titrated to the min tolerated effective dose ?
True
max tolerated effective dose
How long do DMARDs take effect ? What should be considered in conjunction to this and why?
2-3 months
Prescribers should consider offering patient short term bridge treatment with CORTICOSTEROIDS (e.g, oral prednisolone)
Why should a short term bridge treatment be given to patients who have just started a DMARD?
Will provide the patient with short term symptomatic relief/control while waiting fro DMARD to take action
List 3 side effects that are associated with corticosteroids
- Increased appetite
- Increased risk of infection (increased risk of pneumonia or sepsis)
- Osteoporosis
- Reduced immunity
- Blood glucose is effected
What lifestyle advice should you give patient with RA?
- Smoking offer smoking cessation
- Weight loss
- 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 - Relaxation and stress management
- support is also available online and national support groups
What monitoring should be considered?
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
Briefly explain he clinical effectiveness graph of MTX and a corticosteroid (e.g, prednisolone)
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
How would you diagnose RA?
Blood test: presence of rheumatoid factor (antibody)
X-rat to see progression
What is the mechanism of action of methotrexate?
Folic acid analogue
Binds to and inhibits dihydrofolate reductase (DHR)
Reduces the synthesis of tetrohydrofolate (THF)
What should be co-prescribed with methotrexate and why?
Folic acid to reduce methotrexate side effects and promote healthy cells
What counselling should you give patients on methotrexate?
- Folic acid should be taken on a different day to methotrexate
- Avoid taking with NSAIDs, penicillin, other folate antagonists
- Patient alert card
- Take MTX on same day every week
What class is infliximab?
Biologic/monoclonal antibody
What is the mechanism of action of infliximab?
Prevents TBF alpha binding to its
receptors
Reducing TNF alpha activity
Decreases cytokines driven inflammatory processes
Therefore decreasing synovitis and joint damage in RA
What counselling should you offer to patients in infliximab?
Carry the alert card
Prescribe by brand
What monitoring should be given to patients in infliximab?
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
Why should folate acid be given on a different day to methotrexate?
They both bind to the same reception there fore giving them on the same day will reduce the absorption/effectiveness of folic acid
True or false.
We should stop methotrexate when a patient has an infection ?
True increases risk of infection
