Download Anti-TNF Alpha Therapy

Rheumatoid Arthritis:
A Chronic Inflammation
By Catherine A. Olubummo,
RN, MS, MSN, FNP
Nursing made Incredibly Easy!
November/December 2009
2.3 ANCC contact hours
Online: www.nursingcenter.com
© 2009 by Lippincott Williams & Wilkins. All world rights reserved.
Definition
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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
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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
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Phagocytosis produces enzymes within the joint,
which break down collagen, causing edema,
proliferation of the synovial membrane, and
pannus (inflammatory exudate) formation
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Pannus causes the synovium to thicken
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Cartilage is destroyed and bone erodes, leading
to loss of articular surfaces and joint motion
Pathophysiology
Causes
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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
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Patients usually experience bilateral and
symmetrical small joint involvement in the
proximal interphalangeal and metacarpophalangeal 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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Routine complete blood cell and platelet counts
are recommended because neutropenia and
thrombocytopenia have occurred in a small
number of patients
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Headache, GI upset, and injection site reactions
have been reported
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Live viruses shouldn’t be administered
concurrently
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Patients with acute and chronic infections
shouldn’t receive this drug
Surgical Treatment
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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
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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
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Teach your patient about medication use,
restrictions, and adverse reactions to report
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Warn her not to stop certain medications without
notifying her healthcare provider
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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
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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
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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 endstage 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