Pathophysiology week 09

My Knees

Rheumatoid arthritis (RA) is a chronic, progressive, autoimmune disease that causes inflammation in the joints, inflaming and thickening the synovial membranes surrounding the joints. Women are 2-3 times more likely than men to develop this disease. Onset usually occurs between 30-50 years of age; nevertheless, manifestation can occur at any age. Laboratory testing and imaging may help confirm diagnosis and track progression of this disease; however, rheumatoid arthritis diagnosis is primarily clinical, involving no single diagnostic test . In the following scenario, Sandy finds out she has rheumatoid arthritis after several visits to her physician and series of lab tests.
Sandy is a 45 y.o. women who works transporting patients at the local hospital. She has noticed stiffness in her hands when she wakes up for several months. Recently Sandy has been feeling depressed, fatigued, and nauseated at times. One morning she wakes up an both knees are swollen, red, and warm to the touch. She decides it is time to go to the doctor.
The doctor takes Sandy’s history, examines her knees and hands, and runs some test.
CBC: RBC (red blood cell) 3.9 million/mcL (norm. 4.2-5.9)
WBC (white blood cell) 7,000/mcL (norm. 4,500-10,500)
Platelets 375,000/mcL (norm. 150,000-350,000)
ESR (erythrocyte sedimentation rate): 23mm/hr (norm. female 1-20mm/hr / male 1-13mm/hr)
CRP (C-reactive protein ): normal
RF (rheumatoid factor ): seropositive
ANA (antinuclear antibodies): negative
Unlike other arthritis, rheumatoid arthritis symptoms usually occur in the morning or after periods of inactivity. There are usually three or more tender and swollen joints involved. Symptoms come (exacerbation) and go ( remission) depending on degree of tissue inflammation. Rheumatoid arthritis symptoms develop over a period of time. Development of symptoms occur from circulating immune factors which can include fatigue, depression, malaise, lack of appetite (anorexia), and low grade fever along with muscle aches and stiffness. During the active phase (exacerbation/flares), joints become red,swollen, painful, and tender. The tissue lining (synovium) around the joint becomes inflamed causing increase production of synovial fluid. Eventually the synovium becomes thicken by the inflammation process (synovitis), increasing the swelling, painfulness, and immobility of the joints. Initially the disease progression may be subtle and mild and may only affect the wrist and hands. Rheumatoid arthritis affects joints symmetrically (equally on both sides of the body) which may increase difficulty in doing daily tasks as the disease progresses. Over time, chronic inflammation weakens bone integrity by erosion of the cartilage, ligaments and muscles. Progression of the disease eventually affects other organs. (Gould, B. E., pg. 590, 2011) (aafp, 2012) (nlm.nih.gov, 2012) (rheumatology.org, 2012)
The rheumatoid arthritis is also a systemic disease and other organs and parts of the body may become affected as well. Glands of the eyes and mouth can become inflamed decreasing tear and saliva production causing dryness in the eyes and mouth area called Sjogren’s syndrome, a secondary condition due to rheumatoid arthritis. SOB or chest pain can develop when the lining of the lungs become inflamed (pleuritis) or pericarditis when there is inflammation of the tissue surrounding the heart (pericardium. Rheumatoid arthritis can cause a reduction of RBCs resulting in chronic anemia. Anemia develops when the inflammation process releases a small protein that effects how the body uses iron and produces a hormone erythropoietin that controls production of RBCs. (anemia.org, 2012)
There is no known cause that triggers the immune system to attack the ‘self cells’ in rheumatoid arthritis. Genes (family history), environment (infections, smoking, consumption of > 3 cups of coffee, high intake of vit. D) and hormones (pregnancy and oral contraceptives < occurrence) all are suspected but not proven. In Sandy's case, her only past history was that she experienced stiffness in her hands when she first woke up for several months. It was only shortly prior to visiting her physician that she experienced upon awaking, both of her knees were sore, swollen, red, and warm to the touch. It took multiple doctor visits and lab tests in order to diagnose Sandy with rheumatoid arthritis. (aafp, 2012)
Laboratory indicators for initial evaluation for rheumatoid arthritis per American College of Rheumatology on Subcommittee of Rheumatoid Arthritis (ACRSRA) are the following: Hemoglobin/ hematocrit /anemia/ slightly decreased; WBC may be increased; platelets increased; Liver function: normal or slightly elevated alkaline phosphatase; ESR increased over 30mm/hr/ monitors the disease coarse); RF positive ( approx, 70%+ have RA however can indicate other inflammation disease); CRP may or may not be increased in rheumatoid arthritis. An increase CRP indicates the amount of inflammation present only/ use to monitor disease coarse; ANA results has a limited value. Sandy's marked lab values are the following: RBCs: slight increased. Platelets: slight increased. ESR: slight increase/ 23mm/hr. RF: seropositive. (arthritis.org, 2012)
Joint destruction begins a few weeks after symptoms appear. This is why it is imperative to start early treatment (within three months) after confirmed diagnosis to decrease the disease progression According to ACRSRA. Initial treatment should include non-steroidal anti-inflammatory drug (NSAID) for control of pain, with low dose of glucocorticoids, and disease modifying ant-rheumatic drugs (DMARDs). Treatment goals are centering around preservation of function and quality of life, minimizing pain and inflammation, joint protection, and control systemic complications. (aafp, 2012)
Sandy's physician most likely prescribed for just pain control would be acetaminophen (Tylenol, Tempra) or analgesic and non-steroidal anti-inflammatory control (NSAID) such as ibuprofen (Motrin, Advil) or piroxicam (Feldene). Celebrex may or may not be suggested. Celebrex is a newer NSAID or Cox-2 medication that has been quite successful in controlling pain because of its inhibiting factors on prostaglandins during inflammation. The incidence of increase risks for stroke and heart attacks associated with use has come under further investigation. Medication prescribed will depend on hypersensitivity or GI disorders or other risks and effectiveness in controlling Sandy's pain. Sandy's doctors would most likely monitor and weigh potential beneficial affects against side effects and discuss thoroughly with Sandy the pros and cons of each medication. (Gould, B. E., pg. 590, 2011) (aafp, 2012)
Sandy is also given a low dose of a anti-inflammatory glucocorticoid to be taken every other day (qod). Steroids at low dosage (such as less than 10mg of Predisone)) can be most effective in relieving rheumatoid arthritis symptoms and slow joint damage. Minimal dosage is encourage to minimized potential side effects such osteoporosis, cataracts, and abnormal blood glucose level. Glucocorticoids are usually administer during exacerbation periods, under shortest possible periods and is always withdrawn slowly, never abruptly discontinued. If Sandy was also started on a DMARD medication (Methrotrexate), glucocortcoids are sometimes administer in conjunction with a DMARD medication until the DMARD's beneficial effects takes hold. (Gould, B. E. , pg 590-591, 2011) (aafp, 2012)
The ultimate goals in treating Sandy will be to prevent and minimize joint damage, minimize functional loss, minimize pain, and promote quality of life. Undue stress on the affected joints should be minimized and adequate rest and additional support, when needed, should be be provided to facilitate movement. Sandy should have pathways to a variety of health care professionals, including her primary physician, rheumatologist, pharmacist, psychiatrist, physical therapy (PT), occupational therapy (OT), nursing specialist, podiatrist, dietitian and a social worker. A broad-spectrum approached for treatment for rheumatoid arthritis can be very beneficial to Sandy's well being. Sandy should be encourage to use dynamic-aerobic activities that are compatible with her abilities in order to maintain strength and physical functioning such as swimming or tai chi. Ambulatory aids such as a cane or walker could be helpful if needed. Physiotherapy and message therapy reduce spasm in adjacent muscles and reduce pain. Orthotic inserts in shoes could be beneficial to reduce risk of deformity and improve function. OT can provide assistive devices such as joint splints and educating Sandy alternative practices that can reduce joint pain and stiffness. (Gould, B. E., pg.590, 2011) ( racgp.org.au, 2012)(aafp.org, 2012)

References

Anonymous. (2012). Motor RACGP RA Guideline
Retrieved March 3, 2012, from RACGP website
http://www.racgp.org.au/Content/NavigationMenu/ClinicalResources/RACGPGuidelines/Earlyrheumatoidarthritis/RACGP_RA_guideline.pdf
Rindfleisch, R.A. (2012). Diagnosis and Management of Rheumatoid Arthritis
Retrieved March 3, 2012, from aafp website
http://www.aafp.org/afp/2005/0915/p1037.html

Anonymous. (2012). Guide Lab Tests
Retrieved March 3, 2012, from Arthritis website
http://www.arthritis.org/guide-lab-tests.php

Anonymous. (2012). Arthritis
Retrieved March 3, 2012, from NLM NIH website
http://www.nlm.nih.gov/medlineplus/arthritis.html#cat5

Anonymous. (2012). Rheumatoidarthritis
Retrieved March 3, 2012, from NLM NIH website
http://www.nlm.nih.gov/medlineplus/rheumatoidarthritis.html

Anonymous. (2012). Monitoring Inflammation and Iron Deficiency Anemia in Rheumatoid Arthritis
Retrieved March 3, 2012, from Anemia website
http://www.anemia.org/patients/feature-articles/content.php?contentid=000359&sectionid=00015

Anonymous. (2012). Criteria for Rheumatic Diseases
Retrieved March 3, 2012, from Rheumatology website
http://www.rheumatology.org/practice/clinical/classification/index.asp

Gould, B. E. (2011) Chapter 24
(pp. 590-592), Pathophysiology for the Health Professions, 4th Edition. Saunders Learning, printed in United States.

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