Question

VS is a 53- year-old woman who has recently been diagnosed with inflammatory arthritis (IA). She is currently complaining of constant swelling, stiffness, and pain, with occasional numbness and tingling in her hands, wrists, and elbows. She reports her pain as 8 (0=no pain; 10- greatest pain) and states that the morning pain is frequently unbearable, rating it as 9 or 10.

Initial Assessment:

B/P: 112/72

Height: 5’6”

Weight: 170 lbs.

BMI: 27.4

Marked edema, warmth, and tenderness is noted in her metacarpal phalangeal joints and digital flexion is decreased due to edema.

History:

History reveals VS first noted symptoms if IA about 6.5 years ago and they coincided with the development of mold in her home’s basement after flooding. She moved from the home shortly after this and she experienced full remission. Two years later, after the loss of a close aunt, VS experienced a return of all symptoms and was prescribed several medications, but could not tolerate the side effects and stopped all medication at this time. VS also had undergone a radical hysterectomy due to severe uterine fibroids when she was 32 years old, at which time hot flashes and insomnia developed. The hot flashes and insomnia continue to this day. Additional symptoms and conditions reported by VS include severe fatigue, IBS with constipation, chronic urinary tract infections (UTIs), and weight gain (over 30 pounds in the past four years). She has taken multiple courses of antibiotics over the years due to the UTIs. She has also had a recent diagnosis of osteoporosis with a T-score of -2.7.

Medication and Supplements:

diclofenac and misoprostol (Arthrotec 75)- one tablet twice daily

alendronate with D₃ (Fosamax Plus D)- 1 tablet weekly

clonidine (Catapres)- 0.1 mg orally twice daily

Note: Hydroxychloroquine (Plaquenil), methotrexate, and prednisone had been discontinued by VS prior to this visit.

Laboratory Data:

VS reported laboratory results from her last rheumatology visit:

antinuclear antibodies (ANA):                   4+ elevation

erythrocyte sedimentation rate (ESR):     53 millimeters per hour

rheumatoid factor (RF):                            negative

Dietary Intake:

VS typically skips breakfast. She drinks 3-4 cups black tea daily. Lunch is frequently cheeseburgers from a fast food restaurant. Since VS does not enjoy cooking, she frequently eats dinner out as well. She reports her previous night’s dinner was Mexican chicken with rice, chips, and salsa. VS also mentions that she craves salty and sweet foods and drinks diet soda daily.

Can you assist her in this case, she is very dedicated and motivate to achieve health by any means??

Write a treatment protocol including dietary and supplement recommendations

Answer 1

Treatment protocol

1. Methotrexate is the drug of first choice.

Side effects includes bone marrow suppression and hepatotoxicity, so the patient complete blood count and blood chemistry should be evaluated

Sulfasalazine and the antimalarial drug hydroxychloroquine may be effective disease modifying antirheumatic drugs (DMARDS) for mild to moderate disease.

Biologic/targeted drug therapies are used to slow disease progrssion in Rheumatoid arthritis. The drugs includes entanercept, adalimumab, anakinra, and abatacept. these druds are use in case of moderate to severe disease who have not responded to DMARDS.

Additional drugs used infrequently for teating RA includes antibiotics, Immunosuppressants( azathioprine, Penicillamine) and gold compounds ( auranofin, gold sodium thiomalate).

corticosteroids therapy can be used to aid in symptom control.

Intra- articular injections may temporarily relieve the pain and inflammation associated with disease flare-ups.

Because VS is old, and at the same time she faced several side effects of medication

Conservative therapies can be implemented to VS such as

1. Provide nutritional and weight management counseling

2. Teach the patient about terapeutic exercise

3. Advice the patient to take rest and joint protection.

4. Educate the patient how to use the assisstive devices.

5. Appilication of heat and cold appilications.

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Nutritional and supplement recommendations

1. Advice the patient to take variety of foods.

2. Provide patient with food containing plenty of grain products, fruits and vegetables.

3. Advice the patient to take low fat, saturated fat and cholesterol.

4. Decrease the intake of sugars.

5. Reduce the intake of alcohol intake.

6.Advice the patient to take real foods, not the processed food.

Supplement recommendations

Patient receiving methorexate may develop folic acid deficiency in addition other rheumatoid arthritis medicines can cause gastric and peptic ulcer. this will make the patient valnurable to certain vitamin and mineral deficiencies because of lack of intake of food.

So the supplements containing folic acid, vitamin C, Vitamin D, Vitamin B12, Vitamin B6, zinc, magnesium, calcium and selenium should be provided.

Fish oil containing omega fatty acids can be given to modulate the inflammatory process.