Rheumatoid Arthritis: A Chronic Inflammation

By Catherine A. Olubummo, RN, MS, MSN, FNPNursing made Incredibly Easy! November/December 20092.3 ANCC contact hoursOnline: www.nursingcenter.com

© 2009 by Lippincott Williams & Wilkins. All world rights reserved.

Definition

An autoimmune disorder characterized by chronic symmetric inflammation of the synovial joints

Often affects the wrist and finger joints closest to the hand, usually progressing from peripheral to more proximal joints

A systemic disease with multiple extra-articular features, the most common of which are fever, weight loss, fatigue, anemia, lymph node enlargement, and Raynaud’s phenomenon

When a chronic fluctuating course of the disease is experienced, it may result in joint destruction, deformity, disability, and premature death

Prevalence

RA is seen in all racial and ethnic groups

Two to three times more likely to occur in women than men (70% of those diagnosed with RA are women)

Although RA may affect any age group, peak onset of the disease is between ages 30 and 55

Patients with RA are said to be three times more likely to have been hospitalized for an acute heart attack; a recent study found that arthritis affects 57% of adults with heart disease

Three Stages of RA

Phagocytosis produces enzymes within the joint, which break down collagen, causing edema, proliferation of the synovial membrane, and pannus (inflammatory exudate) formation

Pannus causes the synovium to thicken

Cartilage is destroyed and bone erodes, leading to loss of articular surfaces and joint motion

Pathophysiology

Causes The etiology of RA remains unknown; however,

most investigators believe that genetics, environment, and hormonal and reproductive factors are relevant

Researchers have shown that people with the HLA genetic marker have a fivefold greater probability of developing RA

Other more recently identified genes with a connection to RA include STAT4, TRAF1 and C5, and PTPN22

Other causes may include infectious agents such as bacteria and viruses and the body’s response to stressful events

Signs and Symptoms

Patients usually experience bilateral and symmetrical small joint involvement in the proximal interphalangeal and metacarpo-phalangeal joints

Initial symptoms include:• tender, warm, swollen joints• morning stiffness, lasting more than 1 hour• weakness• malaise• fatigue• persistent low-grade fever• anorexia and weight loss

Signs and Symptoms

Chronic inflammation may lead to destruction of cartilage, bone, and ligaments, causing deformity of the joints

Spontaneous remission is rare, although women with RA often experience remission when pregnant

RA typically progresses to a chronic state associated with significant morbidity and functional disability

The Effects of RA on Certain Joints

Diagnostics

There’s no single test for the disease

Symptoms may differ in severity and can mimic those of other types of arthritis and joint conditions

The presence of extra-articular features, such as weight loss, fever, anemia, serositis (inflammation of the serous tissues), carpal tunnel syndrome, and rheumatoid vasculitis, favors the diagnosis of RA

Diagnosis will rely on a thorough medical history and physical exam, X-rays to show joint spacing and erosion, and lab tests

Diagnostics

Possible lab tests include:• complete blood cell count with differential• erythrocyte sedimentation rate and C-reactive protein• rheumatoid factor (present in 70% to 80% of patients with RA)• blood urea nitrogen and creatinine levels• hepatic panel (alanine aminotransferase, aspartate aminotransferase, and albumin)• synovial fluid analysis• hemolytic complement• antinuclear antibody titers

The American Rheumatism Association Classification of RA

Treatment Goals

Overall treatment goals for RA are to control signs and symptoms, restore physical function, and prevent development of joint damage and disability

If damage already exists, the goal is to halt the progression of the disease

With advanced, unremitting disease, subsidiary goals are to relieve pain, improve joint motion, limit functional losses, incur a minimum of adverse reactions, and improve the patient’s sense of well-being and ability to function

Nonpharmacologic Management

Instruction in joint protection, conservation of energy, joint range of motion (ROM), and strengthening exercises is important

Regular participation in exercise conditioning programs can greatly improve joint mobility, muscle strength, aerobic fitness, function, and psychological well-being, without increasing fatigue or joint symptoms

Pharmacologic Management

Primary goals of pharmacologic therapy for RA are relief of pain, reduction of inflammation, preservation of functional status, prevention of complications such as joint damage, and remission of the pathogenic process

Pharmacologic therapy often consists of a combination of nonsteroidal anti-inflammatory drugs (NSAIDs), disease-modifying antirheumatic drugs (DMARDs), and glucocorticoids

Biologic response modifiers, such as anti-tumor necrosis factor (TNF) alpha therapy and interleukin-1 receptor antagonist (IL-1RA) therapy, are also options

NSAIDs

Initial medical treatment of RA usually involves the use of NSAIDs such as aspirin or a selective cyclo-oxygenase-2 inhibitor (also known as a COX-2 inhibitor), to reduce joint inflammation and pain

Patients taking anticoagulants or corticosteroids must avoid the use of NSAIDs due to an increased risk of bleeding

Alternatively, simple analgesics may be considered in place of NSAIDs and DMARDs

DMARDs

All patients with RA are candidates for DMARD therapy

The initiation of DMARD therapy shouldn’t be delayed beyond 3 months for any patient with an established diagnosis who, despite adequate treatment with NSAIDs, has ongoing joint pain; significant morning stiffness, fatigue, and active synovitis; persistent elevation of erythrocyte sedimentation rate and C-reactive protein levels; or radiographic joint damage

For any untreated patient with persistent synovitis and joint damage, DMARD treatment should be started promptly to prevent or slow further damage

DMARDs

Common adverse reactions may include nausea, headaches, diarrhea, alopecia, leucopenia, and thrombocytopenia

Patients receiving DMARD therapy must have routine kidney and liver function tests and urinalysis

Patients must also be told to restrict alcohol intake

Continuous monitoring of the number of swollen joints, duration of morning stiffness, and overall function will determine the drug’s efficacy

Glucocorticoids

Short-term, low-dose oral glucocorticoids are highly effective in relieving symptoms in active RA; patients will require close monitoring for adverse reactions

Articular injections of a glucocorticoid are often used for persistent, erosive RA in single large joints

Anti-TNF Alpha Therapy

Administered by infusion, anti-TNF alpha drugs alter the natural progression of RA by inhibiting structural joint damage, such as bone erosion and joint space narrowing

Monitor the patient’s pulse and BP every 30 minutes for early detection of potential infusion reactions and prompt intervention

Patients with hypersensitivity to murine proteins or those who have moderate to severe heart failure shouldn’t receive anti-TNF alpha therapy

Caution should be exercised in immunosuppressed patients and those with current infections; serious infections have occurred in patients treated with anti-TNF agents

IL-IRA Therapy

Anakinra subcutane has recently been approved by the FDA for treatment of RA

It’s indicated to reduce signs and symptoms and slow the progression of structural damage for moderately to severely active RA in patients age 18 or older who haven’t received adequate relief with one or more DMARDs

It can be used alone or in combination with DMARDs; this drug shouldn’t be used in combination with TNF antagonists because it increases the risk of infection

IL-IRA Therapy

Routine complete blood cell and platelet counts are recommended because neutropenia and thrombocytopenia have occurred in a small number of patients

Headache, GI upset, and injection site reactions have been reported

Live viruses shouldn’t be administered concurrently

Patients with acute and chronic infections shouldn’t receive this drug

Surgical Treatment

Surgical treatments should be considered in patients who have untreatable pain, loss of ROM, or limitation in function due to joint damage

Surgical procedures include tendon reconstruction, carpal tunnel release, synovectomy, resection of metatarsal heads, total joint arthroplasty, and joint fusion

Patient Teaching

Teach your patient about: • lifestyle modification, such as increased bed rest during flare-ups• use of adaptive aids to facilitate activities of daily living (such as raised toilet seats, special eating utensils, zipper pullers, and long-handled shoe horns)• prioritizing and planning activities to accommodate fatigue• use of splints for painful and swollen wrists and hands• the benefit of warm showers in the morning and frequent position changes to alleviate stiffness

Patient Teaching

Teach your patient about medication use, restrictions, and adverse reactions to report

Warn her not to stop certain medications without notifying her healthcare provider

Instructions should be given about dietary restrictions or recommendations as they relate to prescribed medications

Advise her to discuss the use of any complementary or alternative therapies with her healthcare provider

Patient Teaching

During periods of remission, encourage your patient to exercise regularly

Education concerning a regular aerobic and muscle strengthening exercise program is essential to help reduce stiffness, avoid joint contractures, and prevent osteoporosis

The goal of exercise is to maintain ROM, strength, endurance, and mobility; improve general health; and promote well-being

Patient Teaching Referral to a rheumatologist for diagnosis and

treatment of RA is strongly recommended

Referral to an orthopedic surgeon specialized in joint replacement should be considered for end-stage joint disease

Physical and occupational therapists should be consulted for exercise programs and adaptive devices

Referral to a clinical psychologist or social worker may be beneficial

Self-management programs, educational information, and exercise programs are available to patients at http://www.arthritis.org