Question

Kate, age 57 years, is experiencing severe rheumatoid arthritis in her wrists, fingers, and knees. The joints are quite inflamed, red, and swollen. She is sitting rigidly in a chair and refuses to put on a sweater, even though she is shivering, or let anyone touch her arms. She has been prescribed an analgesic and an anti-inflammatory drug, but her dose is not due for another hour. She is feeling nauseated, so she has not eaten for the past 8 hours.

Discuss the potential treatment strategies and medications involved to relieve the pain being experienced by the patient. Explain the complications of continued use of over the counter non-steroidal anti-inflammatory (NSAIDs) medications. What other medications are appropriate for this patient, and why?

Answer 1

RHEUMATOID ARTHRITIS

Rheumatoid arthritis is a condition that can cause pain, swelling and stiffness in joints.It is what is known as an auto-immune condition. This means that the immune system, which is the body’s natural self-defence system, gets confused and starts to attack your body’s healthy tissues. In rheumatoid arthritis, the main way it does this is with inflammation in your joints. Rheumatoid arthritis affects around 400,000 adults aged 16 and over in the UK. It can affect anyone of any age. It can get worse quickly, so early diagnosis and intensive treatment are important. The sooner you start treatment, the more effective it’s likely to be.

There are a variety of treatments available for rheumatoid arthritis. The earlier that intensive treatment is started, the more likely it is to work. There are three main ways to treat rheumatoid arthritis:

• drugs
• physical therapies
• surgery

Drugs

There are four main groups of drugs that are used to treat rheumatoid arthritis. These are:

• painkillers
• non-steroidal anti-inflammatory drugs (NSAIDs)
• disease-modifying anti-rheumatic drugs (DMARDs)
• steroids (also known as corticosteroids).

Non Steroidal Anti Inflammatory drugs

NSAIDs reduce pain in two ways. First, they alter the sensation of pain by blocking certain enzymes that participate in the pain response. Second, they work to reduce swelling that is often associated with certain types of pain. Some NSAIDs, however, are only effective at reducing swelling when taken at higher doses.

When NSAIDs are used regularly over an extended period of time, as is often the case with chronic pain, the potential for side effects increases. Evidence suggests that the potential for NSAID-associated complications increases as you get older. Some more common side effects include:

• Stomach irritation and ulcers
• Gastrointestinal (GI) bleeding
• Increased potential for bruising
• Exacerbation of asthma symptoms
• Increased risk of stroke, heart attack, and blood clots

If you plan to be on NSAIDs for chronic pain long-term, your doctor may alter the dosage. He or she may also provide you with other prescription medication that offsets the potential for developing any of the above conditions. The potential for NSAID complications may be increased if you:

• Smoke
• Drink alcohol regularly
• Are a senior
• Have a history of heart disease
• Have high blood pressure
• Have ever had any GI problems
• Have kidney or liver disease

Disease Modifying Anti-Rheumatic Drugs (DMARDS)

Disease-modifying anti-rheumatic drugs (DMARDs) act by altering the underlying disease rather than treating symptoms. They're not painkillers, but they'll reduce pain, swelling and stiffness over a period of weeks or months by slowing down the disease and its effects on the joints. There are two types: conventional DMARDs and biological therapies.

Conventional DMARDs

This group of drugs are slow-acting and can take several weeks to work, so it's important to keep taking them even if they don't seem to have any effect at first. If you don't respond well to one of these drugs, or if you develop any side-effects, then your doctor may try one of the others.

Conventional DMARDs:

• ciclosporin
• cyclophosphamide
• hydroxychloroquine
• leflunomide
• methotrexate
• mycophenolate
• sulfasalazine.

Biological therapies

Biological therapies are newer drugs that have been developed in recent years. They target individual molecules and tend to work more quickly than conventional DMARDs.

Some biological therapies are called anti-TNF drugs. They target a protein called tumour necrosis factor, which increases inflammation when excess amounts are present in the blood or joints. Other biological therapies target different proteins.

Biological therapies are only given to people who have already tried other treatments appropriate to their condition and not responded well to them. Biological therapies are often given in combination with a conventional DMARD such as methotrexate.