Question

Use this case for questions 1 to 3. Bill is a 62 yo male with a 3 year history of fatigue, joint pain, and prolonged morning stiffness due to RA. He sees his family doctor in Fargo who has treated him with ibuprofen 200 mg four times daily and prednisone 5 mg daily for the past 12 months. However, worsening arthritis symptoms as well as stomach pain have made him seek a second opinion. A physical exam today revealed red, tender and swollen joints over the knuckles and proximal interphalangeal joints of each hand and over the wrists and toes. There are subcutaneous nodules near each elbow. He is 5'9" and weighs 180 lbs. Joint x-rays indicate joint erosion at the MCP and PIP joints. ESR is 69 (normal <30). Other lab tests are normal except hemoglobin is 9.9, hematocrit is 31 and BP is 145/94. Rheumatoid Factor is negative. Disease activity index (DAS28) = 6.97 (severe). Endoscopy reveals a large gastric ulcer. Diagnosis is confirmed as RA, with normocytic anemia and PUD.

1.         Write out an initial pharmaceutical care plan for the patient for ALL medical and pharmaceutical problems that require treatment in the following example format. Include in your plan all recommendations you have to manage his conditions, and how you can monitor disease activity.

Findings (subjective & objective)	Therapeutic Goals	Assessment	Plan and Monitoring	Patient Education
serum K = 3.1 Patient feels week	Normalize K (3.5 to 5.0 mEq/L) Relief of weakness	symptomatic hypokalemia	Give KCl 20 mEq po x 3 today, then 20 mEq daily Monitor serum potassium daily x 2 days, then monthly	Explain nausea may occur

2.         A friend has told Jack that if his rheumatoid factor blood test is negative, he does not have RA. Is this true?

3.         After he has tried your recommended treatment for 3 months, it has not worked well and Jack now has a severe flare of RA symptoms. In addition, he has just been diagnosed with type II diabetes as well. What drug treatment(s) for RA would you recommend now? Why? List your key monitoring parameters for the new treatment.

4.         Mary has been taking methotrexate for about 4 months (along with naproxen as needed). She is currently taking 15mg weekly but her RA is not under control yet and she been feeling really rough the past few days with a sore throat and a cough developing. It’s the weekend and she can’t reach her rheumatologist so she stops at your pharmacy. Should she stop taking MTX?

Answer 1

1,2, No, Rhumatoid factor( RF) autoantibody and to discover Rhumatoid arthritis..Rhumatoid factor is not only the test which reveal the RA..There are many factors Impact RF lab results..Around 20% of RA patients will not have an abnormal RF test( positive) and 5% of people do not have RA will have an abnormal RF test..negative levels do not exclude the disease and positive levels sometime will not confirm the disease..There are other test that should be done when patient suspect for RA like Anticyclic citrullinated peptide, physical examination and imaging..

3, Rhumatoid Arthritis (RA) and diabetes different diseases but it has connection between each other..when patient having ( RA) they more likely to have diabetes..drug treatment can protect you against disease progress..

TNF inhibitors - this drug affect the onset of diabetes..

Hydroxychloroquine can lower the risk.

Abatacept: it lower the inflammation and reduce the risk of diabetes..

Monitoring parameters for the new treatment:

- if patient is overweight they must reduce the weight.

- regular exercise can lower the diabetic risk.

- have a healthy diet at regular intervals

- take medication as prescribed.

- avoid smoking and alcohol and driving.

- if there is any abnormal symptoms than before they should contact the doctor immediately.

- monitor blood glucose level daily in fasting.

4, methotrexate is a folate antagonist and DMARD( disease modifying anti-Rhematoid drug), it treats many cases like cancer, psoriasis, Rhumatoid Arthritis, lupus, vasculitis etc..it is a strong medication,it must be taken as per doctor instructions..we should not over take, or skip the medication it may cause serious side effects including death..There will be possible side effects when they take methotrexate medication like mouth sores, diarrhoea, lymphoma, cough, shortness of breath,hairloss etc..