Unit 5 Case Study: Rheumatoid Arthritis

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Unit 5 Case Study: Rheumatoid Arthritis

Unit 5 Case Study: Rheumatoid Arthritis

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A 50 year old woman has had rheumatoid arthritis for 3 years and has been taking multiple NSAID’s. She has taken corticosteroids a few times during flare ups.

The disease seems to be progressing with stiffness and swelling in her hands and wrists. Examination reveals rheumatoid nodules, synovitis of both wrists and metacarpo-phalangeal joints. This is an indication of an acute exacerbation of rheumatoid arthritis. She is prescribed methotrexate with sulfasalazine and a short course of prednisone.

Assignment Questions

  1. What is the mechanism of action of prednisone?
  2. What is the concern with chronic treatment with glucocorticoids?
  3. What is the mechanism of action of methotrexate and sulfasalazine.
  4. What are the side effects of methotrexate and sulfasalazine

Instructions

  • Prepare and submit a 3-4 page paper [total] in length (not including APA format).
  • Answer all the questions above.
  • Support your position with examples.
  • Please review the rubric to ensure that your assignment meets criteria.
  • Submit the following documents to the Submit Assignments/Assessments area:
    • Case Study: Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic, progressive, and disabling autoimmune disease. It causes inflammation, swelling, and pain in and around the joints and can affect other body organs.

RA usually affects the hands and feet first, but it can occur in any joint. It usually involves the same joints on both sides of the body.

Common symptoms include stiff joints, especially when getting up in the morning or after sitting down for a while. Some people experience  and a general feeling of being unwell.

The  estimates that RA affects up to 1% of the world’s population and over 1.3 million people in the United States.

What is rheumatoid arthritis?
FilippoBacci/Getty Images

RA is an autoimmune disease. It is also a systemic disease, which means it can affect the whole body. It occurs when a person’s immune system mistakes the body’s healthy tissues for foreign invaders.

As the immune system responds,  occurs in the target tissue or organ. In the case of RA, this can be the joints, lungs, eyes, and heart.

Signs and symptoms

Signs and symptoms of RA usually occur in the wrists, hands, or feet and include:

  • pain or achiness in more than one joint
  • stiffness in more than one joint that lasts longer than 30 minutes
  • swelling in more than one joint
  • symmetrical joint involvement
  • a general feeling of being unwell
  • low-grade 
  • appetite loss
  • weight loss
  • weakness
  • joint deformity
  • loss of function and mobility
  • unsteadiness when walking

According to the , people do not typically receive a diagnosis of RA until they are in their 60s. Symptoms may start slowly and often get worse gradually over time.

People with RA usually experience periods when symptoms get worse, known as flares. RA symptoms may flare up due to stress, overactivity, or stopping medications.

Flares are followed by remissions when symptoms go away or are mild. Most people continue to experience flares and remissions throughout their lives.

RA usually affects the same joints on both sides of the body. Pain and stiffness tend to get worse after sleep or periods of inactivity.

Severe RA can lead to other complications throughout the body and cause joint damage that may lead to disability. Treatment can help manage the severity of symptoms and may reduce the likelihood of experiencing complications.

 

Pictures

The images below show how RA can appear in different parts of the body.

VIEW GALLERY5
Treatment

If a person has a diagnosis of RA, the doctor may refer them to a specialist known as a , who will advise on treatment options.

Treatment will aim to:

  • prevent flares and reduce their severity if they occur
  • reduce inflammation to the joints
  • relieve pain
  • minimize any loss of function caused by pain, joint damage, or deformity
  • slow down or prevent damage to the joints and organs

Options include medications, , occupational therapy, counseling, and surgery.

Medications to manage symptoms

Some drugs can help to relieve symptoms and slow disease progression.

 are available over the counter (OTC) from pharmacies. Examples include Motril, . Long-term use and high doses can lead to side effects. These include:

  • bruising
  • gastric ulcers
  • high blood pressure
  • kidney and liver problems

 reduce pain and inflammation and may help slow joint damage, but they cannot cure RA. If NSAIDs do not work, a doctor may inject a steroid into the joint. Relief is usually rapid, but the effect is variable. It can last a few weeks or months, depending on the severity of symptoms.

Corticosteroids can help with acute symptoms or short-term flareups. However, a doctor will limit these injections to no more than three times per year because of their impact on the soft tissue structures in the joints. More frequent injections can potentially damage these structures or cause them to tear off where they attach to the bone.

Disease-modifying antirheumatic drugs (DMARDs)

The  recommends treatment with disease‐modifying antirheumatic drugs (DMARDs), either alone or with other treatments, in people with moderate to severe RA.  (Rheumatrex, Trexall) is an example of a DMARD.

DMARDs affect how the immune system works. They can slow the progression of the RA and prevent permanent damage to the joints and other tissues by interfering with an overactive immune system. A person usually takes a DMARD for life.

These types of medications are most effective if a person uses them in the early stages of RA, but it can take several weeks to a couple of months to fully experience the benefits. Some people may have to try different types of DMARDs before finding the most suitable one.

Side effects can include:

  • liver damage
  • immune-related disorders
  • increased risk of infections
  • , stomach upset, and 
  • abnormal blood counts

Biologic treatments

Biologic treatments, such as tumor necrosis factor-alpha (TNF-alpha) inhibitors, also change how the immune system works. When the human body faces an infection or other threat, it produces , an inflammatory substance. TNF-alpha inhibitors suppress this substance and help prevent inflammation.

TNF-alpha inhibitors can reduce pain, morning stiffness, and swollen or tender joints. People usually notice an improvement 2 weeks after starting treatment.

Examples :

  • certolizumab pegol (Cimzia)
  • golimumab (Simponi

Possible side effects :

  • a higher risk of infection
  • demyelinating diseases, which damage the myelin sheath that normally protects nerve fibers
  • skin reactions

Occupational or physical therapy

An occupational therapist can help a person learn new and effective ways of carrying out daily tasks. This can minimize stress to painful joints. For example, a person with painful fingers might learn to use a specially devised gripping and grabbing tool.

A physical therapist can advise people about using assistive devices, such as a cane, and help individuals develop a suitable exercise plan.

Surgery

In some cases, a doctor may recommend surgery to:

  • repair damaged joints
  • correct deformities
  • reduce pain

The following procedures are possible:

  • arthroscopic surgery, a procedure to remove inflamed joint tissue
  • surgery to release tendons responsible for unusual bending in the fingers
  • carpal tunnel release to relieve nerve compression in the hand and wrist
  • arthroplasty, or total joint replacement
Home remedies

Several strategies can help a person manage RA. Examples include:

  • rest, especially during an RA flare
  • low-impact exercise, such as swimming, to boost overall health and mobility and strengthen the muscles around a joint
  • managing weight, which can prevent additional stress on the joints
  • applying  packs
  • , guided imagery, , or muscle relaxation to relieve stress

A healthcare professional can help a person make a plan that incorporates dietary advice, suggestions for exercise, and other tips.

Diet

A  can help control the inflammation that causes RA symptoms. It also helps a person to manage their weight, which reduces stress on the joints.

A  is a good option for many people with RA. This diet focuses on inflammation-fighting foods, such as:

  • plenty of fresh fruits and vegetables, which are rich in 
  • fatty fish, such as salmon or tuna, which are high in 
  • , which has heart-healthy 
  • nuts, which are also a great source of monounsaturated fats and other nutrients
  • whole grains, which have fiber and antioxidants to help boost heart health
  • legumes, including peas and beans, which are a healthy source of 

People with RA should additionally eat calcium-rich foods to support strong bones, as some RA medications can increase the risk of . Good sources include low fat dairy and dark leafy green vegetables.

Because  can occur during RA flare-ups, causing fatigue, it’s a good idea for a person to incorporate iron-rich foods into their diet, including:

  • lean meats
  • leafy greens
  • fortified breakfast cereals
  • legumes
  • eggs
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Causes

Nobody knows what causes the immune system to malfunction, leading to RA.

Some people appear to have  that make developing RA more likely. One theory is that bacteria or a virus triggers RA in people who have this genetic feature.

In RA, the immune system’s antibodies attack the synovium, the smooth lining of a joint. When this happens, pain and inflammation result.

Inflammation causes the synovium to thicken. Eventually, if left untreated, it can invade and destroy cartilage — the connective tissue that cushions the ends of the bones.

The tendons and ligaments that hold the joint together can also weaken and stretch. The joint eventually loses its shape and configuration. The damage can be severe.

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