A Pharmacological Look At Rhumatoid Arthritis

E.S. is a 68-year-old Caucasian female who has been diagnosed with rheumatoid arthritis. According to Stedman’s Medical Dictionary for the Health Professions and Nursing, “rheumatoid arthritis (RA) is a systemic disease, that more often occurs in women than in men, which affects connective tissue” (Stedman, 2005, p. 1276). She has had this rheumatic disease for the past 15 years. As would be expected with RA, her symptoms and pain have progressively gotten worse over that period of time. The disease has affected both the joints in her hands and the joints in her knees, but her hands are where the majority of her pain stems from. She is the main person of her household, meaning that she does all of the cleaning, cooking and shopping for her family. Having RA has made it extremely difficult for her to continue her activities of daily living. Management of her symptoms, pain and inflammation, can be done with some success by the medications she has been prescribed. Teaching her home management of these drugs will increase the effectiveness of their actions and greatly increase her activities of daily living.

Pathophysiology

According to Gunta and Rizzo (2007),

“the actual disease process in rheumatoid arthritis is initiated by an autoimmune response in which the cells of the body turn and fight against themselves. The inflammatory response follows, setting into otion a chain of events that perpetuates the condition. As the inflammatory process progresses, the synovial cells and subsynovial tissues undergo reactive hyperplasia. This causes vasodilatation and increased blood flow to the affected joint causing warmth and redness. The result of the increased capillary permeability that accompanies the inflammatory process is the joint swelling that occurs. An extensive network of new blood vessels develop in the synovial membrane which contributes to the advancement of the disease. This vascular tissue is called pannus which is a feature of RA that differentiates it from other forms of inflammatory arthritis” (p. 1026).

The cause of RA is unknown. It is likely that, in genetically predisposed persons, an infective agent or another stimulus binds to toll-like receptors on peripheral dendritic cells and macrophages (Scott & Kingsley 2006). Gunta and Rizzo (2007) state, “The importance of genetic factors in the pathogenesis of RA is supported by the increased frequency of the disease among first-degree relatives and monozygotic twins” (p. 1025). Human leukocyte antigen (HLA is one of a few very important genetic locus that is known to predispose a person to RA (Gunta & Rizzo 2007). HLA can be tested for by a very simple blood test. “The HLA antigens exist on the surface of white blood cells and on the surface of all nucleated cells in other tissues. The presence or absence of these antigens is determined genetically” (K. Pagana; T. Pagana, 2007, p. 544). Another possible way to predict the likelihood of RA is to look for the rheumatoid factor (RF). Once again, a blood test should be ordered to test for the rheumatoid factor. “The tests for RF are directed toward identification of the IgM antibodies. Approximately 80% of patients with rheumatoid arthritis have positive RF titers” (K. Pagana; T. Pagana, 2007, p. 825).

Health Assessment

Client was awake, alert and oriented x3, and her speech was clear and appropriate. Her head was of normal shape and size, and her pupils were 2mm when the penlight was run past her eyes. Her throat was clear with no drainage and membranes were intact. Client’s vital signs were as follows, Temperature-98.4, Pulse-78, Respirations-16, Blood Pressure-128/72, and O2Sat-98% on room air. Her apical heart rate was 76 and regular with no signs of a murmur. Her skin color was pink and her skin temperature was warm, dry and intact with elastic skin turgor. All of her capillary refills were < 3 seconds on all extremities. Her pulses were all palpable and recorded at 2+ for all extremities. Slight edema (1+) was noted in her ankles and knees. She was negative for the Homan’s sign. Client’s respiratory rate was regular, with nonlabored breathing effort, and symmetrical chest expansion on inhalation. Her breath sounds were clear bilaterally, and she reported that she had been coughing up scant white secretions every once in a while. Client’s abdominal contour was round, soft and nontender. Her bowel sounds were normoactive. She stated that her last bowel movement was “soft but not loose”. She can move all extremities but at times she has limited range of motion in her knees, elbows, wrists and fingers of both hands.

Client lives with her husband in a one-story ranch style home. By living in a one- story home she eliminates the difficulty of stairs, which can be trying on the knee joints over time. Her role in the family is head of the household. She does all of the cooking, cleaning, and shopping for her home. Her husband has been ill for about 3 years, so she takes care of him on her own. Depending on the situation, she may need some assistance with her activities of daily living. For instance, she may need help getting out of a chair or opening a can of food to cook. Realistically she will be able to follow the pharmacological regime that has been given to her by her doctor. Her support system includes her family. She lives two miles from her oldest son, daughter in-law, and grandchildren. If she ever needs anything at all, she just calls them and they will come help with whatever needs to be done. She states “my daughter in-law is always there for me when I need to talk about things”. If she were to fall ill and have to be hospitalized it would affect her family greatly. Her ill husband would either have to stay with relatives or someone would have to stay with him at their house until she was well again.

Pharmacologic Interventions

She has been prescribed Celebrex (Celecoxib), Azulfidine (Sulfasalazine), Enbrel (Etanercept), Cozaar (Losartan) and Magnesium Oxide to treat and control her RA, hypertension and hyperacidity.

Celebrex (Celecoxib) is a selective COX-2 inhibitor (coxibs) that was approved for the relief of acute pain and symptoms of chronic inflammatory conditions such as osteoarthritis (OA) and rheumatoid arthritis (RA) (Shi & Klotz 2008). Celebrex is a nonsteroidal anti-inflammatory drug that exhibits anti-inflammatory, and analgesic actions. The client takes one 200mg capsule of Celebrex PO daily. Her dosage is slightly lower than the usual dosage for this medication. The usual dosage of Celebrex for rheumatoid