Pharmacological Management of Rheumatoid Arthritis and Nursing Implications
Rheumatoid arthritis (RA) is a chronic complication that affects the joints. Just like other chronic systemic diseases, RA lacks definite cure. Therefore, the management of the complication can only improve the condition of the disease in patients. The pharmacological treatment is crucial in the management of the rheumatoid arthritis. A number of medications including NSAIDs, various DMARDs, and glucocorticoids can help in the management of the condition. NSAIDs are commonly employed as the first-line medication of the complication. They relieve the pain and reduce the severity of the inflammation. However, the increase in severity of arthritic condition calls for the administration of other drugs alongside NSAIDs. The inflammation of joints can be controlled by administration of glucocorticoids. DMARDs are often administered to halt or slow down the progression of RA. This class of drugs is beneficial but has a long onset period before the patients can experience the first changes. Consequently, it is often administered in conjunction with medications that control the severity of the compilation. The major challenge associated with the use of this medication is its toxicity. Their adverse toxic effects usually make some patients discontinue taking them. This research paper discusses the pharmacological management of this chronic disease. It also explores the nursing implication for the effective management of the complication.
Keywords: medication, nurses, patients, rheumatoid arthritis
Rheumatoid arthritis (RA) is defined as a progressive inflammatory complication that affects the joints (“Management of rheumatoid arthritis,” 2014). RA is a pathologic condition that affects various tissues in the body and usually causes synovitis and articular tissue destruction. The complication is associated with the stiffness, pain, and inflammation of the large joints in the knee and small synovial joints in the feet and hands. Although RA is often marked by periods of remission and exacerbation, the complication is usually progressive in nature. As a rule, the disease worsens over time if the inflammation is not slowed down or stopped. The advanced stages of RA cause severe joint destruction, as well as bone erosion (Ciconne, 2007). RA affects approximately 0.5% to 1.0% of the world’s population. The severe pain and suffering that the complication causes devastates patients, their family, as well as social and economic life. Regrettably, just like other chronic systemic diseases, rheumatoid arthritis lacks definite cure. The nonexistence of the cure is largely associated with the lack of proper knowledge on the causative agents of the complication (S. Crouch, M. Crouch, & Chapelhow, 2008; Ciconne, 2007). Since there are some effective medications for pharmacological management of the rheumatoid arthritis, pharmacological management plays a very crucial role in the treatment of the disease.
Pharmacological Treatment of the Rheumatoid Arthritis
There are various types of RA medications that play different roles. The main types include DMARDs (disease-modifying anti-rheumatic drugs), type of DMARD known as biologic-response modifiers, glucocorticoids, NSAIDs (non-steroidal anti-inflammatory medications), and analgesics or painkillers (Ciconne, 2007). The available medications can be regarded as either slow-acting anti-rheumatic or symptomatic ones. The slow-acting anti-rheumatic medications are also known as second line or disease modifying ones. The symptomatic medications are not designed to influence the underlying disease process. Rather, they are intended to reduce the severity of inflammation and pain experienced by the patient. The symptomatic drugs include NSAIDs and analgesics.
Although these therapies are helpful, Newman, Fitzpatrick, Revenson, Skevington, and Williams (1995) notes that most of the RA pharmacological medications are often very toxic to the body. Therefore, toxicity and cost of the drugs often create the basis of settling on the medication of choice for most patients (Newman, 1995). The main objectives of the RA therapy include the reduction of symptoms such as inflammation, stiffness, and pain; it also maintenance the joint function. Medication further helps in the reduction of systemic involvement and delay of the disease progression (Lehne, 2013). Essentially, the nurses ought to understand the principles behind the inflammatory process and how the RA therapy affects the process. Having an understanding of these principles enables nurses to take proper care of the RA patients (S. Crouch, M. Crouch, & Chapelhow, 2008).
Of note, it is more effective to initiate treatment soon after diagnosis. Efficient care for patients with rheumatoid arthritis combines medications with other approaches. Nevertheless, an individual can still take rheumatoid arthritis medications without considering other approaches (“Management of rheumatoid arthritis,” 2014).
Late diagnosis of the rheumatoid arthritis significantly intensifies the risk of the erosive joint damage. Therefore, the patients suspected of having RA ought to be referred to a rheumatologist with the immediate effect. The quick response would enable the timely administration of the disease-modifying agents before the condition aggravates. The disease-modifying drugs can only prevent the damage of joints if administered in the first few months. Conversely, an early diagnosis and effective treatment of RA with proper drugs is vital in reducing the destruction and disability of joints. However, once the mechanical damage has transpired due to the delay in the RA diagnosis, it might be difficult to reverse the condition. The severe pain and joint deformity usually call for aids and appliances and, ultimately surgery (“Management of rheumatoid arthritis,” 2014).
Non-steroidal Anti-inflammatory Drugs (NSAIDs)
In terms of the treatment of RA, NSAID is often regarded as the first-line of defense. They are commonly employed as the first drugs in the treatment of RA. Instead of or in addition to the painkillers, the doctor might prescribe NSAID to the RA patients. The doctor might pick up the traditional NSAID or an alternative type known as the COX-2 inhibitor. Diclofenac, naproxen ibuprofen, and aspirin are the examples of traditional NSAIDs while examples of COX-2 inhibitor include celecoxib and etoricoxib (NHS, 2014). In reducing inflammation, NSAIDs are not as effective as glucocorticoids are. Nonetheless, they are preferred as they possess an added advantage of analgesia and have fewer side effects. Just like the analgesics, NSAID medications do not reduce the progression of the rheumatoid arthritis. Rather, the medications help in the reduction of pain and inflammation in the patient’s joints. In some patients, though, NSAIDs can control RA for a short period when used solely (Ciconne, 2007).
Most NSAIDs primarily exerts their anti-inflammatory, as well as analgesic, effects by deterring the production of prostaglandins. It is believed that certain prostaglandins such as PGE2 are involved in the inflammatory response. They exert chemotactic effect on the leucocytes, increase the vascular permeability, and intensify the local blood flow. NSAIDs inhibit prostaglandins’ production by preventing COX enzyme synthesis. The latter commonly initiates the synthesis of prostaglandins.
Although NSAIDs are more expensive compared to other drugs, newer samples have commendable anti-inflammatory and analgesic effects. In addition, some of the new drugs cause less gastrointestinal discomfort. For instance, the COX-2 (cyclooxygenase-2) selective medications might be predominantly favorable to the RA patients with a history of peptic ulcers among the other gastrointestinal complications. The COX-2 drugs such as celecoxib inhibit the secretion of the COX-2 enzyme that stimulates the synthesis of prostaglandins that causes pain and inflammation. However, the celecoxib spares the secretion of productive prostaglandins synthesized by COX-1 in the platelets, kidney, and stomach. Therefore, selective COX-2 drugs such as celecoxib might be especially helpful during the prolonged use in patients with RA since they are less toxic to the stomach and other body tissues.
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The doctor will always discuss with the patient the NSAID type that suits him or her after considering the associated benefits and risks. The selection of a suitable NSAID might necessitate considerable trial and contain error. Although rarely, taking an NSAID tablet can lead to the increased risk of severe stomach problems. Such risks can include internal bleeding; the medications disrupt the stomach lining that protects it from being damaged by the stomach acids. As a rule, it is not prudent to take simultaneously two different NSAIDs as it often results in a huge increase of the side effects with no considerable increase in the therapeutic benefits (Ciconne, 2007).
The gastric ulceration and hemorrhage can be resolved somewhat by using aspirin in an enteric-coated form. The coating delays the release until aspirin reaches the small intestine. It is also possible to alleviate the adverse side effects by other medication alongside the NSAID tablets to lower the amount of the stomach acid. Proton pump inhibitor (PPI) is a typical example of the medication that can be administered in order to reduce the amount of acid. The additional medication greatly reduces the risk of damage of the patient’s stomach lining (NHS, 2014).
Essentially, prostaglandins play an imperative role in the control of the blood flow in the kidneys. The secretion also plays a significant role in the maintenance of the glomerular filtration. Therefore, the use of NSAIDs that inhibit the secretion of prostaglandins can impair the renal function in some RA patients. The impaired renal function might cause salt retention, increased blood pressure, and edema. The patients with compromised kidney function or fluid imbalances have the highest risk when put on the NSAID medication (Johns Hopkins Center, 2014). The prolonged use of NSAID can also impair renal function more frequently in the debilitated or old patients. Although aspirin and NSAID have side effects, the patients continue to use these drugs extensively for prolonged periods with no serious effects. The prolonged use is possible especially when the selection of drugs is done through an informative trial and error method (Ciconne, 2007).
It is essential for nurses to identify whether the NSAID prescribed to a patient is an inhibitor of COX-2 or both COX-1 and COX-2. Nurses should also learn the patient’s drug history including the drug reactions or allergies, as well as previous over-the-counter medications. The side effects that the nurses should observe include black stools, bleeding gums, ecchymosis, and petechiae. Administration of NSAIDs should be discontinued one week prior to elective surgery due to the possibility of prolonged bleeding. The nurses should also advise patients to take NSAIDs with meals so as to prevent gastrointestinal upsets (Zychowicz, 2003).
Apart from the medications employed to control the progression of RA, it might be necessary to put a patient on medication particularly to relieve the pain. Principally, the painkillers should be offered to individuals suffering from RA whose pain control is inadequate. The painkillers do not help in the treatment of the underlying inflammation of the patient’s joints; rather, they aid in relieving the pain. For instance, the painkillers might be recommended for DMARDs to exert their effects. In addition, the patient might be put on painkillers during the periods of the extreme RA symptoms; flare-ups (“Management of rheumatoid arthritis,” 2014).
There are different medicines that can be administered to reduce the pain. In certain cases, the patients are advised to take analgesics like paracetamol or co-codamol to relieve the pain associated with RA. The administration of analgesics can lessen the necessity of prolonged treatment with NSAIDs or the COX-2 (cyclooxygenase-2) inhibitors (“Management of rheumatoid arthritis,” 2014).
Corticosteroids are the effective medications that can help lessen pain, inflammation, and stiffness. They exhibit both immunoregulatory and anti-inflammatory effects. The drugs can be used as a tablet such as prednisolone or injected directly into the affected joint. The injection can also be done into the muscle in order to help several joints. Corticosteroids provide the short-term pain relief while the patient is awaiting for DMARDs to begin their anti-inflammatory activities or during a flare-up (NHS, 2014). The drugs are also beneficial as a chronic adjunctive therapy for rheumatic arthritis patients with a serious complication that does not respond well to NSAIDs and DMARDs.
Since corticosteroids have the potential to affect the entire body system, the nurse must always be alert for the side effects. Essentially, a high dosage and long-term use of corticosteroids is not preferred as they cause serious side effects. In addition, corticosteroids interact with a wide range of medications; therefore, a nurse should obtain the drug history of the patient (Zychowicz, 2003). The side effects of corticosteroids comprise muscle weakness, thinning of the skin, and weight gain (NHS, 2014).
The nurse should always oversee cardiovascular complications including the cognitive heart failure, thromboembolism, hypertension, and arrhythmias in patients taking corticosteroids. Other side effects of corticosteroids might comprise higher risk of cataracts, elevated blood sugar protein wasting, as well as increased serum triglycerides and lipids. The use of steroids is also associated with osteoporosis, the thinning of bones. Osteoporosis would occur even when prednisone is administered at low doses. Consequently, the patients without and with osteoporosis risk factors should undergo densitometry even when they are on low dose prednisone. The scan is essential to assess the fracture risk. Vitamin D and calcium supplementation, in addition to bisphosphonates, are recommended for the prevention and treatment of osteoporosis (Johns Hopkins Center, 2014).
As a rule, it is inessential to administer higher prednisone doses except in cases of the life-threatening complications of RA. If administered for a long period, the drug might cause severe steroid toxicity. Administering the prednisone dose once a day is associated with fewer side effects as compared to taking an equivalent dose of the medication twice or three times daily. Steroids are commonly administered in the morning, when the patient wakes up, so as to mimic the body’s steroid surge (Johns Hopkins Center, 2014).
Corticosteroids might also react adversely with the central nervous system. This reaction may result in seizures, paresthesias, emotional liability, nervousness, and insomnia.
Disease-Modifying Anti-rheumatic Drugs (DMARDs)
A wide range of DMARDs is currently available for the treatment of RA. Once diagnosed, a combination of DMARD tablets is administered to the patient as a part of the initial treatment. These medications are especially effective in reducing the development of the symptoms of the condition thereby slowing down the progression of the disease. The medicine functions by blocking the harmful effects of the chemicals produced during the attack of the joints by the immune system. If left uncontrolled, the chemicals can cause extensive damage to the nearby tendons, bones, cartilage, and ligaments (NHS, 2014).
There are various DMARDs available for the treatment of RA. The available drugs include methotrexate, sulfasalazine, hydroxychloroquine, and leflunomide. Methotrexate is the most frequently administered DMARD to patients with rheumatoid arthritis. The drug exhibits a rapid onset of action and is the most effective in this class of drugs. Methotrexate is commonly the first DMARD employed in the medication of RA in both children and adults (NHS, 2014).
According to Smeltzer, Bare, Hinkle, and Cheever (2010), methotrexate primarily works by slowing down the effects of RA. Its use results in the decreased synovitis, less narrowing of the joint space, and decreased bone erosion. The medication inhibits folic acid synthesis, thereby inhibiting the proliferation of lymphocytes among other cells, eliciting autoimmune reactions in RA. Other inhibitory effects exerted by methotrexate include stimulation of adenosine release and inhibition of inflammatory cytokines. The suppression of adenosine release ensures the increased quantities of endogenous adenosine. The latter normally acts by inhibiting various mechanisms of the patient’s immune system (Ciconne, 2007).
The nurses should administer DMARD alongside a short-course of corticosteroids as a pain reliever due to the prolonged onset of action. The medication can also be combined with the biological treatments for the better results. Methotrexate is somewhat a toxic medicine, and certain side effects might occur that the nurses need to monitor. The principle problems associated with the drug involve the gastrointestinal tract. The effects include nausea, loss of appetite, sore mouth, diarrhea, and intra-gastrointestinal hemorrhage, among the other gastrointestinal distress. The prolonged use of methotrexate in the RA patients has also been associated with the hematologic disorders, pulmonary problems, hair loss, and liver dysfunction., The regular blood tests are essential to monitor its effects during the period of drug administration due to the effect of methotrexate on blood count (Ciconne, 2007).
Occasionally, methotrexate can have negative effects on the lungs. Therefore, having a chest X-ray during administration of the drug is essential. The tests will enable the comparison if the patient develops persistent dry cough or experience shortness of breath while taking methotrexate (NHS, 2014). These adverse side effects often constrain the use of methotrexate in the treatment of RA. Most RA patients who discontinue the use of this methotrexate do so due to the adverse side effects. Rarely do patients stop taking the drug due to the loss of effectiveness. Nevertheless, most people tolerate the drug well. It offers an encouraging benefit-to-risk ratio in numerous rheumatoid arthritis patients in comparison to other DMARD medications (Ciconne, 2007).
The nurses should monitor patients receiving infliximab or abatacept for hypersensitivity reactions that might occur during and after IV fusion. Manifestations of lymphoma in patients on DMARDs should also be supervised. The nurses should as well put liver function and blood for patients on DMARDs, especially infliximab, under close supervision (Broyles, Reiss, & Evans, 2012).
Characteristically, it might last for a few months before the patient notices that a DMARD is working. Therefore, it is imperative for the patient to continue with the dose even if he/she does not notice methotrexate working at first (NHS, 2014). A patient might also need to try two or three types of DMARD before settling on the most suitable one. Once the patient and the doctor settle on the most suitable DMARD, the doctor will always advise the patient to take the medicine for a prolonged period (NHS, 2014).
Treatment during Pregnancy
Rheumatoid arthritis medication during pregnancy is often complex since none of the above-discussed drugs have been proven to be safe if administered to the pregnant women. Therefore, the medication decisions demand thoughtful consideration of the benefits and risks to both the fetus and the mother. It is prudent to stop all DMARD medication in pregnant and lactating women, and even in women planning to conceive. Either there exist evidence of the risks that DMARDs pose to the fetus or possibility of their existence cannot be ignored. Hyrdoxychloroquine is perhaps the safest DMARD for administration during pregnancy. There is evidence of potential teratogenicity of methotrexate; the administration of the drug should be discontinued in both mothers and women planning conception. Leflunomide is teratogenic: therefore, women who have been on the drug and have been planning conception should undertake the washout of its chemicals (Johns Hopkins Center, 2014).
Though the safety of NSAIDs and prednisone are yet to be demonstrated, there is no evidence that these drugs pose threats to the fetus when administered in the first two trimesters. The joint symptoms control is best done with the lowest possible prednisone dose. Possible prednisone complications in pregnant women comprise hypertension, progression of maternal gestational diabetes, and retardation of intrauterine growth. The expecting patients ought to avoid NSAIDs in the third trimester due to the possibility of early closure of the ductus arteriosus, peripartum hemorrhage, and prolonged labor. Despite the excretion of NSAIDs and prednisone in the breast milk, the American Academy of Pediatrics considers both compatible with the breast-feeding (Johns Hopkins Center, 2014).
Rheumatoid arthritis is a joint disease that can generate overwhelming effects on the functioning, as well as structure, of the synovial joints. Fortuitously, the management of the complication can be improved considerably following the advancements of the drug therapy. Pharmacological treatment of the rheumatoid arthritis can be achieved through the administration of NSAIDs, various DMARDs, and glucocorticoids. NSAIDs represent the primary form of medication in the initial stages of RA. As the severity of the arthritic condition increases, the drugs are commonly administered in the conjunction with other drugs. Glucocorticoids are largely effective in the reduction of the joint inflammation, a condition typical of RA. Nonetheless, the administration of DMARDs is limited due to their toxic effects. DMARDs are often administered to halt or slow down the progression of RA. It acts by suppressing the immune response, a typical occurrence in RA. Although these medications are important, the pharmacological management of RA, in the long-term, is scarcely favorable. As a rule, the potential long-term benefit of these treatments is limited by the removal or withdrawal of patients from their prescribed course of treatment due to the adverse side effects. Nonetheless, combining pharmacological treatment with other modes of therapy such as physical exercise might prove more effective.