Rheumatoid Arthritis

Question 1

What is RA?

Answer 1

• Chronic, systemic disease
• Inflammation of connective tissue in the diarthrodial (synovial) joints.
• Typically with periods of remission and exacerbation.
• Frequently accompanied by extra-articular manifestations.
• It can occur at any time of life, but most people develop RA between the ages of 25 and 50.
• One in 100 Canadians have RA, with women being affected 2 to 3 times more frequently than men.

Question 2

Cause

Answer 2

• Genetic predisposition appears to be important in the development of RA. For example, a higher occurrence of the disease has been noted in identical rather than fraternal twins.
• However, having genes that are conducive to RA does not necessarily mean that you will develop the disease. Something is always needed to light the fire (trigger).
• An autoimmune etiology is currently the most widely accepted

Question 3

Behaviors

Answer 3

Joints

• Specific articular involvement is manifested clinically by pain, stiffness, limitation of motion, and signs of inflammation (e.g., heat, swelling, tenderness)
• Fatigue, weight loss and generalized stiffness may precede the onset of arthritic complaints
• Joint symptoms occur symmetrically
• Frequently affect the small joints of the hands and feet
• Larger peripheral joints such as wrists, elbows, shoulders, knees, hips, ankles, and jaw may also be involved. The cervical spine may be affected, but the axial spine is generally spared
• Most common - a slow onset of joint pain and stiffness starting in one joint and spreading to involve more joints over a period of weeks to months.
• Joint stiffness after periods of inactivity.
• Morning stiffness may last up to several hours or more, depending on disease activity.
• Metacarpophalangeal (MCP) and Proximal interphalangeal (PIP) joints are typically swollen.
• In early disease, the fingers may become spindle shaped from synovial hypertrophy and thickening of the joint capsule.
• Joints become tender, painful, and warm to the touch.
• Joint pain may increase with motion, vary in intensity, and may not be proportional to the degree of inflammation.
• As disease activity progresses, inflammation and fibrosis of the joint capsule and supporting structures may lead to deformity and disability.
• Atrophy of muscles and destruction of tendons around the joint cause one articular surface to slip past the other (subluxation).

Deformity

• Ulnar drift, Boutonniere deformity, Swan neck deformity, Hallux valgus

Extra-articular manifestations

• RA can affect nearly every system in the body
• Three most common are rheumatoid nodules, Sjögren syndrome, and Felty syndrome
• Rheumatoid nodules develop in up to 25% of all clients
• Rheumatoid nodules appear subcutaneously as firm, non-tender, granuloma-type masses and are usually over the extensor surfaces of joints such as fingers and elbows
• Nodules develop insidiously and can persist or regress spontaneously
• RA - Complications
• Flexion contractures and hand deformities cause diminished grasp strength and affect the client’s ability to perform self-care tasks.
• Nodular myositis and muscle fibre degeneration can lead to pain similar to that of vascular insufficiency.
• Cataract development and loss of vision can result from scleral nodules.
• On the skin, nodules can ulcerate, similar to pressure sores.
• Nodules on the vocal cords lead to progressive hoarseness.
• Nodules in the vertebral bodies can cause bone destruction.
• Carpal tunnel syndrome

Question 4

Diagnositcs Studies

Answer 4

• Positive Rheumatoid Factor (approx. 80% of clients)
• Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) - general indicators of active inflammation
• Synovial fluid analysis in early disease often shows a straw-coloured fluid with many fibrin flecks
• White blood cell (WBC) count of synovial fluid is elevated (greater than 2.0 × 109/L)
• Anti-CCP (anti-cyclic citrullinated peptide) antibody – specific marker
• X-rays are not specifically diagnostic of RA, bone scans more useful

Question 5

Disease-Modifying Anti-Rheumatic Drugs (DMARDs)

Answer 5

Therapeutic effect: DMARDs suppress inflammation and help to prevent damage to the joint - slows the disease process by modifying the immune system.

• Prescribing DMARDs early on is important to prevent long-term damage.
• Starts to work in approx. 6-8 weeks; however, some may take longer - up to 3-4 months.
• While waiting for DMARDs to take effect, an additional medication such as a steroid or an NSAID may be prescribed to help control the symptoms.

Question 6

Methotrexate

Answer 6

• Inhibits DNA, RNA, protein synthesis
• Usually the first drug of choice
• Rapid anti-inflammatory effect - may be seen as early as 3 to 6 weeks
• Given either as tablets or injection (once a week)
• Side effects include bone marrow suppression and hepatotoxicity
• Requires frequent laboratory monitoring, including CBC, hepatic and renal function

Question 7

Hydroxychloroquine (Plaquenil)

Sulfasalazine (Salazopyrin)

Answer 7

Hydroxychloroquine (Plaquenil)

• originally used to treat malaria
• Suppresses formation of antigens
• Given as a tablet, once or twice a day
• Risk of ocular toxicity or ototoxicity

Sulfasalazine (Salazopyrin)

• Blocks prostaglandin synthesis
• Given as tablets, usually twice a day
• May cause orange-yellow discoloration of urine or skin
• Contraindicated for those allergic to sulfa

Question 8

Gold Salds

Answer 8

• Anti-inflammatory action and may decrease phagocytosis and lysosomal activity
• Usually given in a weekly injection for five months, then biweekly or monthly to sustain the clinical effects.
• Most common side effects are skin rashes, mouth ulcers, GI problems, particularly diarrhea, and renal toxicity
• Parenteral - Myochrysine (gold sodium thiomalate)
• Oral - Ridaura (Auranofin)

Question 9

Biologics

Answer 9

• Prevent/suppress inflammation that damages joints.
• Biologics target molecules on cells of the immune system, joint, and the products that are secreted in the joint, all of which can cause inflammation and joint destruction.
• Therapeutic effects may be quick (days to weeks) or may take 3-6 months.
• There are several types of biologics, each of which targets a specific type of molecule involved in this process (tumor necrosis factor, interleukin-1, and cell surface molecules on T and B lymphocytes).
• Patients who have had an unsatisfactory response to DMARDs, either alone or in combination with other arthritis medications, are usually good candidates for biologics.

Question 10

TFN and Non TFN biologics

Answer 10

TNF biologics

• Block the action of TNF (tumor necrosis factor)
• Decreases inflammatory & immune response
• Administered either by injection or by intravenous infusion.
• Possible risks: injection site reaction, infusion reaction, infection
• Etanercept (Enbrel), Infliximab (Remicade), Adalimumab (Humira)

Non-TNF biologics

• Work via different mechanisms
• Decreases inflammatory & immune response
• Administered either by injection or by intravenous infusion.
• Possible risks: injection site reaction, infusion reaction, infection
• Anakinra (Kineret), Abatacept (Orencia), Rituximab (Rituxan)