RHEUMATOID

ARTHRITIS
Andrade, Jhamaica L.
Arciaga, Lara Jayne P.
Junio, Alyssa M.
General Information
• Janet Hobbs

• 58 year old woman

Chief Complaint
“I have pain in all of my joints, a swollen left knee, and
stiffness every morning.”
History of Present Illness
• She presents to her rheumatologist with generalized
arthralgias, a swollen left knee, and morning stiffness that
occurs for the past several weeks.

• She presented with similar symptoms 3 months ago, at

which time her drug regimen was changed from
methotrexate and NSAID therapy to her current regimen.
Patient Medical History
• Rheumatoid arthritis for 6 years

• S/P hysterectomy 4 years ago

• Hypertension for 10 years

Family History
• Father died from complications after a traumatic fall at age 65.
• Mother died of hip fracture and pneumonia at age 78.
• No siblings

Social History
• Housewife; married for 32 years
• She has two grown children with no known medical problems.
• She denies alcohol or tobacco use
• Volunteers in the community extensively, but has been doing less
in the past 2 months.
Medication
• Hydrochlorothiazide 25 mg po Q AM
• Norvasc 10 mg po once daily
• Nabumetone 750 mg, 2 tabs po Q HS
• Prednisone 5 mg, 1/2 tab po Q AM
• Methotrexate 2.5 mg, 6 tabs po once a week
• Hydroxychloroquine 200 mg, 1 tab po BID
• Sulfasalazine EC 500 mg, 1 tab po BID
• Folic acid 1 mg po once daily

Allergy
• Penicillin (rash 25 years ago)
Review of System
• Swelling in left knee
• Decreased range of motion in hands
• Morning stiffness every day for about 3 hours
• Fatigue experienced daily during afternoon hours
• She denies headache, chest pain, shortness of breath, bleeding
episodes, or syncopal attacks; denies nausea, vomiting, diarrhea,
loss of appetite or weight loss
• Reports minor visual changes corrected with stronger prescription
glasses
Physical Examination
General
Pleasant, middle-aged white woman in moderate distress because
of
pain and swelling in left knee

Vital Signs
qWeight - 65.3 kg
qHeight - 5’6”
qBlood Pressure - 138/80 mmHg
qHeart Rate - 82 bpm
qRespiratory Rate - 14 bpm
qTemperature - 37.10C
HEENT (Head Eyes Ears Nose and Throat)
• Atraumatic
• Moon facies
• PERRLA (Pupils equal, round, and reactive to light and
accommodation)
• EOMI (Extraocular Movements or Muscle Intact)
• Atrioventricular nicking visible bilaterally
• Pale conjunctiva bilaterally
• Tympanic membrane intact
• Xerostomia

Neck/Lymph nodes = Supple, no JVD or thyromegaly; no bruits;

palpable lymph nodes
Skin = No rashes; normal turgor; no breakdown or ulcers
Chest = CTA
Breast = No lumps or masses
Genital/Rectal = Deferred
CV (Cardiovascular) = RRR; normal S1, S2; no MRG
Abd (Abdomen) = Soft, nondistended, nontender; (+)
bowel sounds
Neuro (Neurologic) = CN II–XII grossly intact; muscle
strength 5/5 UE, 4/5 LE, DTRs 2/4 biceps and triceps, 1/4
patella
UA (Uric Acid) = Normal
Chest X-ray = No fluid, masses, or infection; no
cardiomegaly
Hand X-Ray = Erosion of MCP and PIP joints bilaterally;
measurable joint space narrowing from previous x-ray 6
months ago
Synovial Fluid = From left knee; white cells 23.0 × 103
/mm3, turbid in appearance
DEXA scan of hip/spine = T-score reported as –2
Ext (Extremities)
Hands: mild RA changes; swelling of the 3rd, 4th, and 5th PIP joints
bilaterally; pain in the 3rd and 4th MCP joints on left; boutonnière
deformity of the 3rd and 4th digits bilaterally; ulnar deviation
bilaterally; decreased grip strength, L > R (patient is
left-handed)
• Wrists: decreased ROM
• Elbows: good ROM; slight permanent contracture on right; fixed
• nodule at pressure point
• Shoulders: decreased ROM (especially abduction) bilaterally
• Hips: decreased ROM on right; atrophy of quadriceps, L > R
• Knees: pain bilaterally; decreased ROM on left; effusion/edema on left
• Feet: no edema; full plantar flexion and dorsiflexion; 3+ pedal pulses
 LAB RESULTS
Patient’s Lab Test Normal Values
Na - 135 mEq/L 35 – 144 mEq/L
K - 4.1 mEq/L 3.5 – 4.8 mEq/L
Cl - 101 mEq/L 97 – 106 mEq/L
CO2 - 22 mEq/L 22 – 32 mEq/L
BUN - 12 mg/dL 7 – 20 mg/dL
SCr - 0.8 mg/dL 0.6 – 1.3 mg/dL
Glu - 103 mg/dL < 140 mg/dL
Hgb -10.0 g/dL 12.1 to 15.1 g/dL
Hct - 31 % 36% to 48%
WBC - 13.0 x 103/mm3 4,500-11,000 WBCs (4.5 to 11.0 x 103/mm3)

Plt - 356 x 103 /mm3 150,000-400,000 Plts per microliter (150 to 400 x
103/mm3)
Ca - 9.1 mg/dL 8.6-10.3 mg/dL
Urate 5.1 mg/dL 2.7-7.3 mg/dL
 AST - 15 IU/L 5 to 40 IU/L

ALT -12 IU/L 19 to 25 IU/L

Alk phos - 56 IU/L 44 - 147 IU/L

T. bili - 0.8 mg/dL 1.2 mg/dL

Alb - 4.2 g/dL 3.4 - 5.4 g/dL

TSH 0.74 mIU/L 0.4 to 4.0 mIU/L

TSH 0.74 mIU/L 0.4 to 4.0 mIU/L

T. chol 219 mg/dL <200 mg/dL

HDL 50 mg/dL >60 mg/dL

LDL 106 mg/dL <100 mg/dL

Trig 150 mg/dL <150mg/dL

Additional Lab Results
qHbsAg (–)
qAnti-HCV (–)
qCK <20 IU/L
qANA negative
qWes ESR 47 mm/h
qRF (+) 1:1,280
qAnti-CCP (+)
qaPTT 31 sec
qINR 1.0
Assessment
58-year-old woman in moderate distress with acute flare of
RA (functional class II). RA not adequately controlled with
current therapy. Patient is adherent with current
medication regimen. HTN is controlled on present therapy.
DEXA scan results suggestive of osteopenia.
Problem Identification
1.a. List the patient’s drug therapy problems.
- INEFFECTIVE DRUG TREATMENT

1.b. What information (signs, symptoms, laboratory values)

indicates the presence and severity of rheumatoid arthritis?
• SIGN AND SYMPTOMS:
qPain or aching in more than one joint.
qSwelling of the left knee
qMorning stiffness
qdecreased ROM in hands
qFatigue or tiredness.
qWeakness
LABORATORY VALUES:
• Wes ESR 47 mm/h
• RF (+) 1:1,280
• Anti-CCP (+)
• ANA negative
• Urate 5.1 mg/dL
1.c. What additional information is needed to assess the patient?
• Number of swollen and tender joints.
• Extent of pain and systemic symptoms such as:
- fatigue and morning stiffness
• Measures of function and health status.
• Patients’ lifestyle
Desired Outcome
2. What are the goals of pharmacotherapy in this case?
• Reduce joint swelling, stiffness, and pain.
• Preserve range of motion and joint function.
• Improve quality of life.
• Prevent systemic complications.
• Slow destructive joint changes.
• Improve day-to-day functioning
Therapeutic Alternatives
3.a. What nonpharmacologic modalities may be
beneficial for this patient?
• Diet
• Exercise
• Occupational and Physical Therapy
• Counseling,
• Stress reduction, and
• Acupuncture
3.b. What pharmacologic alternatives are available for the
treatment of Rheumatoid arthritis?
Nonsteroidal Anti-inflammatory Drugs Ibuprofen (Advil)
(NSAIDs) Naproxen Sodium (Aprelax)
Disease-modifying Antirheumatic Drugs Methotrexate (Pterin)
(DMARDs) Leflunomide (Arava)
Hydroxychloroquine (Plaquenil)
SulfasalazineTofacitinib
(Xeljanz/Xeljanz XR)
Biologic Disease-Modifying Antirheumatic Infliximab (Remicade)
Drugs Adalimumab (Humira)
Etanercept (Enbrel) (Etveza 25)
Golimumab (Simponi)
Tocilizumab (Actemra)
Rituximab (Mabthera)
Certolizumab
Abatacept
Anakinra
Sarilumab
Steroids Prednisone (Aspen Prednisone) (Prolix)
3.c. What economic and psychosocial considerations are
applicable to this patient?
• Cost of Illness
• Interrupted Family Processes
• Impaired Social Interaction
• Anxiety
Optimal Plan
4. What drug, dosage form, dose, schedule, and duration of
therapy
are best for this patient?
Drug Initial Dose Duration of Therapy
Methotrexate (Rasuvo®) Oral 7.5-20 mg every week 6 months

Sulfasalazine (Azulfidine®) Oral 1000 mg twice daily 3 months

Infliximab (Remicade®) IV 3-10 mg/kg every 4-8 weeks ----

Entanercept (Enbrel®) SubQ 50 mg once weekly 3 months

Tofacitinib (Xelanz®) Oral 20 mg daily 2 months

Glucocorticoids (eg. prednisone) 40-60 mg daily ----

Outcome Evaluation
5. What clinical and laboratory parameters are necessary to
evaluate the patient’s drug therapy?

Drug Monitoring/Laboratory Parameters

Methotrexate (Rasuvo®) Oral SCr, CBC with differential, AST, ALT, Hepatitis B and C
screening, Tuberculosis screening
Sulfasalazine (Azulfidine®) Oral CBC with differential, SCr, ALT, AST

Infliximab (Remicade®) IV Tuberculosis screening, hepatitis B screening, CBC with

differential LFTs
Entanercept (Enbrel®) SubQ Tuberculosis screening, hepatitis B screening, CBC with
differential
Tofacitinib (Xelanz®) Oral Tuberculosis screening, hepatitis B screening, CBC with
differential, Hgb, LFTs, FLP, HR, and blood pressure
Glucocorticoids (eg. prednisone) Blood pressure, weight, serum glucose, electrolytes, creatine
kinase, growth in pediatric patients, presence of infection,
bone mineral density, assess HPA axis suppression, Hgb,
occult blood loss, chest x-ray
Patient Education
6. What information should be provided to the patient to enhance
adherence, ensure successful therapy, and minimize adverse
effects?
• Patient education ( which includes dosing, side effects,
infection risk management, symptom self-monitoring)
• Coordinate and schedule follow-up
• Provide patient with written medication changes, time frame
for follow-up, and clinic/emergency contact information.
• Always collaborate with a rheumatologist.