Question

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Client Profile:

N.M is a 36-year-old overweight female who has Rheumatoid Arthritis (RA).  When her symptoms began to interfere with her daily activities she sought medical help.

Subjective Assessment Data:

• Complains of pain in the morning when waking up
• Has painful, stiff hands and feet
• Feels tired all of the time
• Reports low grade fever
• Takes naproxen (Aleve) 220mg twice daily
• Wears a copper bracelet on the advice of a neighbor

Objective Assessment Data:

• Hands show mild ulnar deformities and puffiness
• Temp: 100 degrees F
• Admitted to the hospital for examination and comprehensive treatment plan
• Medication:  Methotrexate (Rheumatrex) therapy to be initiated.

Discuss and answer the following questions.

1. How does the healthcare provider determine that the client has RA.  What diagnostic studies would the healthcare provider order to assist with the confirmation of the diagnosis of RA?

2. What results may be expected from methotrexate therapy?

Answer 1

Answer:1

Rheumatoid arthritis is a systemic inflammatory condition that affects the joints of the body ( Small more than large joints). It commonly affects the synovial joints. Other organs affected by RA are eyes, lungs, heart

Synovial joints are those joints of the body where the bones are separated from each other by a joint cavity. The components of synovial joints are

1. Fibro-Cartilage - this is a layer of cartilage that covers the articular surfaces ( part of the bone ends facing the joint cavity) of the bones
2. Synovial membrane - the joint cavity is lined by the synovial membrane
3. Synovial fluid - this is the fluid present in the joint cavity.

. Examples of synovial joints are the small joints of the hand and feet, shoulder joint, knee joint

Pathophysiology of RA - There is inflammation of the synovial membrane and there is the destruction of the articular cartilage.

Diagnosis of RA is made on the basis of

1. symptoms,
2. joint x-ray changes
3. serological test ( blood test)

1.Symptoms

1. RA affects women more than men
2. Typically affects patients in their 40s
3. Patients complain of
   1. Pain and morning stiffness of joints
   2. The small joints of the hands and feet are typically affected
   3. The frequency of joint involvement is as follows: Hand > Wrist > elbow > shoulder > knee.
   4. The proximal interphalangeal joint is affected and the distal interphalangeal joint is spared.
   5. Rare involvement is the knee, temporomandibular joint, crico-arytenoid joint.
4. Patients in later stages of the disease have the joint deformity. The deformities seen in RA are
   1. Swan neck deformity of the hands - there is hyperextension of the proximal interphalangeal joint (PIP) and flexion of the distal interphalangeal joints(DIP)
   2. Boutonniere deformity - There is flexion of the PID and extension of the DIP.
   3. Clubbing of the toes
   4. Hallux Valgus - lateral deviation of the first distal phalanx of the foot and medial movement of the metatarsal bone.

2. Joint X-ray

1. Soft tissue swelling and reduction in the joint space.
2. erosion of the margins of the bones forming the joint, not covered by cartilage
3. Ulnar deviation of the metacarpophalangeal joint
4. Subluxation ( partial dislocation of bones forming the joint)

3. Serological test

1. Rheumatoid factor
   1. this an IgM antibody directed against Fc portion of the IgG immunoglobulin
   2. Positive in 75% of RA patients
   3. 20% of normal elderly people may have RA factor positive
   4. Higher levels = poorer/ severe disease
2. Anti-CCP/ anti-cyclic- citrullinated peptide antibody
   1. It is 94% specific to RA

The diagnosis of RA is made on the basis of 2010 American College of Rheumatology/European League Against Rheumatism criteria for RA. The clinical and serological features present in a patient are scored ( given a number each). The total score is calculated and if it is >6 a diagnosis of RA is made

The categories included in the scoring system are

1. Joint involvement (small and large joint)
2. Serology ( RA and Anti-CCP factors)
3. Acute phase reactant (Abnormal CRP or normal ESR)
4. Duration of symptoms ( > 6 weeks)

The health care provider must have considered the diagnosis of RA in this patient based on the presenting clinical features. Features that go in favor of the diagnosis of RA in this patient are

1. Age of the patient
2. Gender
3. morning stiffness of the joints of hands and feet.
4. Joint deformity of the hand (ulnar deviation)

The healthcare worker can confirm his suspicion of RA by doing X-rays of the joints and serological test ( RA factor and Anti-CCP levels.)

Answer 2

Methotrexate (MTX) is a disease-modifying agent used widely in RA. Most of the major guidelines suggest to start MTX early in the disease.

Mechanism of action - it inhibits dihydrofolate reductase - this infers with DNA formation.

Dosage - 7.5mg dose per week (oral) maximum dose allowed 20mg/week

Side effects -

1. Stomatitis, gastric disturbance, hair loss ( folic acid supplementation reduces these effects)
2. Liver function derangement, hepatitis (rare)
3. Pneumonitis ( can cause Interstitial lung disease, rare)
4. Suppression of the bone marrow ( deficiency of folic acid, adversely affects the DNA of developing cells in the bone marrow)
5. Superadded infections

The results to be expected with Methotrexate are

1. Reduction in the signs and symptoms of RA
2. It slows the radiological progression of the disease ( in other words, joint damage is brought under control)
3. It can be given IV and oral as well
4. The side effects are tolerable
5. Can be combined with other drugs like pain killers, other disease-modifying agents (steroids, sulfasalazine, hydroxychloroquine) and newer biological agents (anti-TNF-alpha, anti-B-cell)