Question

PATIENT CASE 1: QUESTIONS 1-5 Name: Christina - Age 48 years • Age of onset of symptoms - 46 years Age of Rheumatoid Arthritis (RA) diagnosis - 47 years RA medication history Past: Methotrexate (MTX) escalated to 20 mg weekly (1 year ago) Current: MTX 20 mg weekly + TNF inhibitor (4 months ago) + Celecoxib 200 mg twice daily Current assessment: Joint count (SJC, TJC): 5 swollen joints; 6 tender joints; DAS28 - 5.3; HAQ-DI - 2.3 ESR: 20 mm/hr. CRP: 1 mg/L Physician Global: 2 (0-10)

Answer 1

1.

The major goals of treating a patient with arthritis and bone inflammation are –

a) Treat the disease through medication – many drugs are used these days to ease the pain of joints and thereby preventing these diseases from getting worse. Some common medications suggested are – anti inflammatory pain relievers such as – aspirin, ibuprofen or naproxen and Corticosteroids such as prednisone. Some other treatment methodologies are – chemotherapy, biologic therapy, narcotic pain reliever etc.

b) Medication – It is followed to relive the pain by changing activities

c) Maintain joint movement , muscle strength and overall function with regular exercise and therapy

d) Reduce the stress level on joints by using braces, splints, or canes.

2.

Health assessment questionnaire disability index (HAQ-DI) comprises of set of questions that are designed to assess the condition and severity of Rheumatoid Arthritis. It is a kind of patient reported outcome (PRO) which is self-administered by the patient. The following categories of body movement or physical work are assessed such as

dressing and grooming, arising, eating, walking, hygiene, grip, reach and common daily activities.

The difficulty level of performing these activities is evaluated on the scale of 0 (no difficulty) to 3 (high difficulty & hence cannot be done).

Based on the self-assessment, treatment options at individual levels are designed keeping the difficulties faced by the patient

3.

Patient suffering from Ra pain are given a set of treatments –

a) Non-drug therapy for pain – In this method, the pain is relieved through the use of splints on the wrist. Impact is given to reduce the stress on knees and hip joints and hence the patient is asked to walk with some support such as walking stick. Better walking essentials such as cushioned-soled shoes and arch-supports can reduce foot pain. These methods just give support to the damaged muscles but do not rebuild the damaged muscles. Some patients are suggested to take hot baths or showers to ease stiff joints while some prefer to apply bag of ice or cold towel to reduce inflammation pain. But all these measures are short lived.

B. Drug therapy for RA pain –

Usual drugs such as

Usual drugs such as

a)         NSAIDs or Non-steroidal anti-inflammatory drugs like naproxen, ibuprofen and diclofenac

b)         DMARDs like hydroxychloroquine, methotrexate or sulfasalazine

c)         Anti-TNF

d) Anti-interleukin 6 therapies, rituximab and abatacept

d)         JAK inhibitors (tofacitinib and baricitinib)

It is not easy to find one drug that releases the pain. Several combination of drugs are taken such as paracetamol,NSAIDS, CORTICOSTEROIDS, OPIOID ANALGESICS and OTHER MEDICATION OPTIONS such as combining an NSAID and an opioid analgesic etc.

4.

Tumor necrosis factor – TNF – It is a medication used to treat inflammatory conditions such as rheumatoid arthritis (RA) and several other forms of arthritis such as psoriatic, juvenile, inflammatory bowel disease, spondylitis, psoriasis etc. This medicine reduces the inflammation only and it can also stop disease from progressing by targeting an inflammation-causing substance i.e TNF. In healthy people, TNF is blocked automatically but in people with rheumatic conditions TNF level gets high and it leads to more inflammation and persistent symptom

Total six different TNF inhibitors are currently being used after approval of U.S. Food and Drug Administration