Rheumatoid Arthritis Catherine Brooks and Courtney Marsh Rheumatoid

Rheumatoid Arthritis Catherine Brooks and Courtney Marsh

Rheumatoid Arthritis Case Study Joy G. is a 48 -year old married mother of 3 active boys. She loves her part-time job as a hairdresser at a popular salon. Seven months ago, Joy began noticing stiffness in both hands in the morning that lasted longer and longer. Stiffness now lasted more than 1 hour every morning and included hands, wrists and ankles. She also had increasing difficulty standing for long periods at work or at home due to foot and ankle pain. She began taking ibuprofen 800 mg 3 times daily and found it helped her get through her day with less pain and stiffness. Three months ago, Joy noticed pain in her right and left shoulders when she would cut or blow dry her client’s hair. She also began feeling extremely tired and short tempered. She had no energy to do her usual activities. Ibuprofen was no longer very effective for her pain or stiffness. What signs and symptoms of RA does she have? Next step: blood test. For what? rheumatoid factor, CCP antibodies, elevated ESR and C-reactive protein. (Duclon, 2020)

Introduction Rheumatoid arthritis is an autoimmune disorder known for causing joint pain, but it affects many other areas of the body, as well. It can affect the skin, eyes, heart, lungs, and blood vessels (Scott, Wolfe, & Huizinga, 2010). Uncontrolled active rheumatoid arthritis causes joint damage, disability, decreased quality of life, and other comorbidities. Video introduction: https: //newsnetwork. mayoclinic. org/discussio n/mayo-clinic-minute-what-is-rheumatoidarthritis/ (Mayo Clinic, 2020)

Pathology ● Environmental and/or genetic factors lead to the production of inflammatory, destructive synovial fluid. The affected synovium breaks down collagen, which causes edema (Hinkle & Cheever, 2018). ● The synovial membrane proliferates, resulting in pannus-- an abnormal amount of tissue within the joints. The presence of pannus erodes the surrounding bone and cartilage, leading to a loss of articular surface and range of motion (Alam et al. , 2017). ● Muscle fibers also degenerate. Contractile force and elasticity of tendons and ligaments decline (Hinkle & Cheever, 2018). (Alam et al. , 2017)

Incidence/Prevalence Rheumatoid arthritis is the most commonly diagnosed systemic inflammatory arthritis (Wasserman, 2011). Incidence: ● In industrialized countries, there are 5 -50 new cases annually, per 100, 000 people (Scott, Wolfe, & Huizinga, 2010). Prevalence: ● In industrialized countries, rheumatoid arthritis affects 0. 5%-1. 0% of adults (Scott, Wolfe, & Huizinga, 2010). Rheumatoid arthritis is most typical in women and elderly people (Scott, Wolfe, & Huizinga, 2010). (Flynn, 2017)

Etiology ● Although researchers have not yet determined the exact mechanism of action for the etiology of rheumatoid arthritis, it is known to be autoimmune in origin. ● Many believe that it involves T lymphocyte activation, the release of inflammatory cytokines, and antibody formation in synovial tissue and other organs. ● Some research has isolated tumor necrosis factor-alpha and interleukin-1 as the two key cytokines involved in rheumatoid arthritis (Frandsen & Pennington, 2018). (Towns and Bathon, 2020)

Signs and Symptoms of Rheumatoid Arthritis -Low positive or high positive rheumatoid factor (RF) or anti-citrullinated peptide antibody (ACPA) -Abnormal erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) -Symmetric joint pain -Cardinal signs of inflammation: ● edema, warmth, erythema, loss of function -Spongy tissue on palpation -Guarding & immobilization of joints -Systemic signs of inflammation: ● fever, weight loss, fatigue, anemia, enlarged lymph nodes -Deformities of the hands and feet: ● ulnar deviation, swan neck deformities -Raynaud’s phenomenon: ● cold or stress-induced vasospasm causing episodes of digital blanching or cyanosis -Rheumatoid nodules: ● nontender, movable nodules in the subcutaneous tissue, usually over bony prominences -Other extra-articular abnormalities: ● arteritis, neuropathy, pericarditis, splenomegaly, and Sjögren’s syndrome (Hinkle & Cheever, 2018)

Comparing osteoarthritis and rheumatoid arthritis (Flynn, 2017)

Progression ● Progression of RA at the joint: ○ ● Synovitis→ pannus formation→ fibrous ankylosis→ bony ankylosis As RA progresses, it also begins to affect other organs and body systems. For example: ○ ○ RA may contribute to atherosclerosis by interfering with HDL production. Synovial inflammation can compress surrounding nerves and cause neuropathies or paresthesias. ● This may also lead to axonal degeneration and neuronal demyelination. U. S. National Library of Medicine. (2020).

Risk Factors ● 50% of the risk for development of rheumatoid arthritis is attributable to genetic factors. ● Smoking is the main environmental risk (Scott, Wolfe, & Huizinga, 2010). ● Bacterial and viral illnesses also may also place individuals at risk (Hinkle & Cheever, 2018). Genes Smoking Bacteria & Viruses

Prevention, Intervention, and Treatment Disease-modifying antirheumatic drugs (DMARDs), the key therapeutic agents, reduce synovitis and systemic inflammation and improve function. ●The leading DMARD is methotrexate, which can be combined with other drugs of this type (Scott, Wolfe, & Huizinga, 2010). Therapeutic success depends on the timing of intervention, with earlier treatment typically resulting in better outcomes (Smolen, Aletaha, & Mc. Innes, 2016). The goals of treatment include minimization of joint pain and swelling, prevention of radiographic damage and visible deformity, and continuation of work and personal activities. ●Joint replacement is indicated for patients with severe joint damage whose symptoms are poorly controlled by medical management (Wasserman, 2011).

Novel, Experimental Therapies Biological agents are used when arthritis is uncontrolled or toxic effects arise with DMARDs. ● Tumor necrosis factor inhibitors were the first biological agents, followed by abatacept, rituximab, and tocilizumab. ● Response depends on treatment history and disease duration (Smolen & Aletaha, 2015). ● Infections and high costs restrict prescription of biological agents. The ultimate goal is long-term remission induced by intensive, short-term treatment selected by biomarker profiles (Scott, Wolfe, & Huizinga, 2010). Video on RA treatment (Mayo Clinic, 2014): https: //www. mayoclinic. org/diseasesconditions/rheumatoid-arthritis/multimedia/rethinking-rheumatoid-arthritis/vid-20109650

Living with Rheumatoid Arthritis ● According to Gail Sexton (personal communication, February 24, 2020) -○ ○ ○ Diagnosed with RA through a blood test when she was in her late 40 s after experiencing joint pain/tenderness in her hands, weight loss, and difficulty with walking and balance Sought treatment out of town since none of the doctors in her rural hometown specialized in rheumatology Developed non-Hodgkin’s lymphoma after 3 years of RA treatment-- a major risk associated with many DMARDs Forced to terminate her RA medication, adalimumab (Humira), during chemotherapy Resumed RA treatment with a different drug, rituximab (Rituxan), after she went into remission Currently receives 2 IV infusions of Rituxan (within 2 weeks of each other) every 6 months; each infusion takes 3 -4 hours

Summary Rheumatoid arthritis is an autoimmune disorder that results from the chronic destruction and repair of joint tissue. This leads to joint pain and swelling, joint deformity, and local and systemic inflammation. Rheumatoid arthritis is more common in women. It is believed to be inherited, though smoking is a noteworthy environmental risk factor. (Arthritis National Research Foundation, 2019) Treatment has traditionally involved pain management and DMARDs, but biologic therapies are arising as a novel alternative.

References Alam, J. , Jantan, I. , & Bukhari, S. N. (2017). Rheumatoid arthritis: Recent advances on its etiology, role of cytokines and pharmacotherapy. Biomedicine & Pharmacotherapy, 92(1), 615 -633. Retrieved from: https: //www-sciencedirect-com. citadel. idm. oclc. org/ science/article/pii/S 0753332217311319. Arthritis National Research Foundation. (2019). A Brief History of Rheumatoid Arthritis. Retrieved from the Arthritis National Research Foundation website: https: //curearthritis. org/arthritis-archives-rheumatoid-arthritis/ Balzer, D. (2018). Mayo Clinic Minute: What is rheumatoid arthritis? Retrieved from the Mayo Clinic News Network website: https: //newsnetwork. mayoclinic. org/discussion/mayo-clinic-minute-what-is-rheumatoid-arthritis/ Duclon, K. (2020). Rheumatoid Arthritis Case Study. American College of Rheumatology. Retrieved from: https: //www. rheumatology. org/Portals/0/Files/Rheumatoid-Arthritis-Case-Study. pdf Flynn, J. (2017). Is Your Joint Pain Osteoarthritis of Rheumatoid Arthritis? University of California, Berkeley, School of Public Health. Retrieved from: https: //www. healthcentral. com/article/dont-ignore-buckling-knees. Frandsen, G. , & Pennington, S. S. (2018). Abrams’ clinical drug therapy: Rationales for nursing practice (11 th ed. ). Wolters Kluwer. Hinkle, J. L. , & Cheever, K. H. (2018). Brunner & Suddarth’s textbook of medical-surgical nursing (14 th ed. ). Wolters Kluwer. Mayo Clinic. (2020). Rheumatoid Arthritis. Retrieved from the Mayo Clinic website: https: //www. mayoclinic. org/diseases-conditions/rheumatoidarthritis/symptoms-causes/syc-20353648 Scott, D. L. , Wolfe, F. , & Huizinga, T. W. (2010). Rheumatoid arthritis. Lancet, 376(9746), 1094 -108. doi: 10. 1016/S 0140 -6736(10)60826 -4

References, continued Smolen, J. S. & Aletaha, D. (2015). Rheumatoid arthritis therapy reappraisal: strategies, opportunities and challenges. Nature Reviews Rheumatology, 11(5): 276 -89. doi: 10. 1038/nrrheum. 2015. 8 Smolen, J. S. , Aletaha, D. , & Mc. Innes, I. B. (2016). Rheumatoid Arthritis. The Lancet 388(10055): 2023 -2038. doi: 10. 1016/S 0140 -6736(16)30173 -8 Towns, M. , & Bathon, J. (2020). Inhibition of Interleukin-1 as a Strategy for the Treatment of Rheumatoid Arthritis. Johns Hopkins Arthritis Center. Retrieved from the Johns Hopkins Arthritis Center website: https: //www. hopkinsarthritis. org/arthritis-info/rheumatoid-arthritis/ra-treatment/interleukin-1 -inhibition/ U. S. National Library of Medicine. (2020). Rheumatoid arthritis. Retrieved from: https: //ghr. nlm. nih. gov/condition/ rheumatoid-arthritis#diagnosis. Wasserman, A. M. (2011). Diagnosis and management of rheumatoid arthritis. American Family Physician, 84(11), 1245 -52. Retrieved from: https: //www. ncbi. nlm. nih. gov/pubmed/22150658 Williams, V. (2014). Rethinking Rheumatoid Arthritis. Retrieved from the Mayo Clinic News Network website: https: //www. mayoclinic. org/diseases-conditions/rheumatoid-arthritis/multimedia/rethinking-rheumatoid-arthritis/vid 20109650