rheumatoid arthritis

Rheumatoid Arthritis

By : Hammad

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History of Rheumatoid Arthritis (RA)

• 123 AD first text describes symptoms very similar to RA

• 1800 first recognised description of RA by French physician Dr A J Landré-Beauvais (1772-1840)

• 1859 name “rheumatoid arthritis" itself was coined by British Dr A B Garrod.

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What is it?

• Chronic, progressive, autoimmune disease

• Causes inflammation in joints (especially hands, wrists, feet)

• Systemic condition

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What is inflammation?

• Normal body defence mechanism

• Increased blood flow

• Blood cells produce chemical messengers to continue the process

• Heat, swelling, redness, pain, loss of function

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Who does it affect?

• 0.8% of UK population

• 3x more common in women

• Onset usually between ages 40 - 60

• Approx 580,000 patients in UK

• 12,000 under age 16

• 26,000 new diagnoses/year

• NHS costs: £560 million/year

• Economy: £1.8 billion/year

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What causes RA?

• Genetics

• Environment

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Genetics

• 1st degree relative: 2-7 fold risk

• Identical twin: 16% chance of RA

• Need an environmental trigger as well

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Environment

• Geography

• Hormones

• Infection

• Smoking

• Diet

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Symptoms

• Joint pain

• Joint swelling

• Morning stiffness

• Fatigue

• Weight loss

• Flu-like symptoms

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What else does RA do?

• Eyes: dryness, inflammation

• Lungs: fluid, inflammation, nodules

• Skin: nodules, ulcers

• Heart: fluid, inflammation, ischaemic heart disease

• Blood: anaemia, low counts

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How is RA treated?

General Principles:

• Patient education/self-management

• Multi-professional team care

• Medication

• Surgery

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Symptomatic Treatments

• Education/support

• Rest/relaxation

• Joint protection

• Physiotherapy

• Painkillers

• Anti-inflammatory drugs

• Steroids

• Joint injections

• Pain Management Clinics

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Reduction of Joint Damage

Disease-modifying Anti-Rheumatic Drugs (DMARDS)

•Methotrexate

•Sulfasalazine

•Leflunomide

•Hydroxychloroquine

•Azathioprine

•Ciclosporin

•Gold

•Penicillamine

Biologic drugs

• Anti-TNF therapy:

Infliximab

Etanercept

Adalimumab

Certolizumab

Golimumab

• Rituximab

• Abatacept

• Tocilizumab

Drug Therapy

• Drugs remain cornerstone of treatment

• DMARDs (Disease-modifying antirheumatic drug) can lessen permanent effects of RA

• Choice of drug is based on

– Disease activity

– Patient’s level of function

– Lifestyle considerations

Drug Therapy

• Many of the drugs used to treat RA are expensive

• Methotrexate (Rheumatrex) is drug of choice – Rapid antiinflammatory effect decreases clinical

symptoms in days to weeks

– Inexpensive

– Lower toxicity compared to other drugs

Drug Therapy

• Effective DMARDs for mild to moderate disease

– Sulfasalazine (Azulfidine)

– Antimalarial drug hydroxychloroquine

• Leflunomide (Arava) is a newer synthetic DMARD that blocks immune cell overproduction

Drug Therapy

• Use of combination therapy can slow symptoms and joint damage while improving function

• Drug combinations are individualized and often include – A DMARD

– An NSAID

– A corticosteroid

Drug Therapy

• Biologic/targeted drug therapies can also slow disease progression in RA

• Can be used in patients with moderate to severe disease who have not responded to DMARDs or in combination therapy with an established DMARD

Drug Therapy

• Corticosteroid therapy can aid in symptom control – Intraarticular injections may relieve pain and

inflammation associated with flare-ups • Long-term use should not be a mainstay

– Risk osteoporosis, avascular necrosis

– Low-dose prednisone for a limited time to decrease disease activity until DMARD effect is seen

Drug Therapy

• Various NSAIDs and salicylates to treat arthritis pain and inflammation

• Aspirin is often used in high dosages of 4 to 6 g/day (10 to 18 tablets)

• NSAIDs have antiinflammatory, analgesic, and antipyretic properties

Drug Therapy

• NSAIDs

– Do not alter natural history of RA

– Full effectiveness may take 2 to 3 weeks

• Some relief may be noted within days

– May be used when patient cannot tolerate high doses of aspirin

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Goals of Therapy

• To relieve pain, stiffness, swelling, fatigue

• To prevent joint damage/disability

• To improve quality of life

• ? To achieve disease remission

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Principles of Treatment

• Early diagnosis

• Early initiation of treatment

• Regular assessment (Disease Activity Scores)

• “Treat to Target”

• Annual review

Nursing Implementation Acute Intervention

• Usually treated on an outpatient basis

• Hospitalization may be necessary for patients with extraarticular complications or advancing disease – Reconstructive surgery for disabling deformities

• Nursing intervention begins with a careful physical assessment

Nursing Management Assessment

• Nurse must also

– Evaluate psychosocial needs and environmental concerns

– After problem identification, coordinate a carefully planned program for rehabilitation and education for interdisciplinary health care team

Nursing Management Problems

• Chronic pain

• Impaired physical mobility

• Activity intolerance

• Self-care deficit

• Ineffective therapeutic regimen management

• Disturbed body image

Nursing Management Planning

• Overall goals – Satisfactory pain relief

– Minimal loss of functional ability of affected joints

– Perform self-care

– Participate in planning and carrying out therapeutic regimen

– Maintain a positive self-image

Nursing Management Planning

• Primary goals in managing RA

– Decrease inflammation

– Manage pain

– Maintain joint function

– Prevent or correct joint deformity

Nursing Management Interventions

• Goals may be met through a comprehensive program

– Drug therapy – pain control, antiinflammatory

– Rest

– Joint protection

– Heat and cold applications – pain control

– Exercise

– Patient and family teaching


• Suppression of inflammation

– NSAIDs

– DMARDs

– Biologic therapies

• Careful attention to timing is critical to

– Sustain a therapeutic drug level

– Decrease early morning stiffness


• Discuss with patient – Action and side effects of each prescribed drug

– Importance of laboratory monitoring

• Many RA patients take several different drugs so the nurse must make the drug regimen as understandable as possible


• Nonpharmacologic relief of pain – Therapeutic heat and cold

– Rest

– Relaxation techniques

– Joint protection

– Biofeedback

– Transcutaneous electrical stimulation

– Hypnosis


• Lightweight splints may be prescribed to rest an inflamed joint and prevent deformity – Should be removed regularly to perform skin care

and ROM exercises

– Should be reapplied as prescribed

– Occupational therapist may help identify additional self-help devices to assist in activities of daily living


• Morning care and procedures should be planned around morning stiffness

• To relieve joint stiffness and increase comfort

– Sitting or standing in a warm shower

– Sitting a tub with warm towels around shoulders

– Simply soaking hands in a basin of warm water

rheumatoid arthritis

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