Question

Use this case for questions 1 to 3. Bill is a 62 yo male with a 3 year history of fatigue, joint pain, and prolonged morning stiffness due to RA. He sees his family doctor in Fargo who has treated him with ibuprofen 200 mg four times daily and prednisone 5 mg daily for the past 12 months. However, worsening arthritis symptoms as well as stomach pain have made him seek a second opinion. A physical exam today revealed red, tender and swollen joints over the knuckles and proximal interphalangeal joints of each hand and over the wrists and toes. There are subcutaneous nodules near each elbow. He is 5'9" and weighs 180 lbs. Joint x-rays indicate joint erosion at the MCP and PIP joints. ESR is 69 (normal <30). Other lab tests are normal except hemoglobin is 9.9, hematocrit is 31 and BP is 145/94. Rheumatoid Factor is negative. Disease activity index (DAS28) = 6.97 (severe). Endoscopy reveals a large gastric ulcer. Diagnosis is confirmed as RA, with normocytic anemia and PUD.

1.         Write out an initial pharmaceutical care plan for the patient for ALL medical and pharmaceutical problems that require treatment in the following example format. Include in your plan all recommendations you have to manage his conditions, and how you can monitor disease activity.

Findings (subjective & objective)	Therapeutic Goals	Assessment	Plan and Monitoring	Patient Education
serum K = 3.1 Patient feels week	Normalize K (3.5 to 5.0 mEq/L) Relief of weakness	symptomatic hypokalemia	Give KCl 20 mEq po x 3 today, then 20 mEq daily Monitor serum potassium daily x 2 days, then monthly	Explain nausea may occur

2.         A friend has told Jack that if his rheumatoid factor blood test is negative, he does not have RA. Is this true?

3.   After he has tried your recommended treatment for 3 months, it has not worked well and Jack now has a severe flare of RA symptoms. In addition, he has just been diagnosed with type II diabetes as well. What drug treatment(s) for RA would you recommend now? Why? List your key monitoring parameters for the new treatment.

Answer 1

In the present scenario, Bill is 62 years old diagnosed with Rheumatoid arthritis and endoscopy reveals a large gastric ulcer with normocytic anemia, with worsening arthritis symptoms and stomach pain.

1. The pharmaceutical care plan includes:

Findings (Subjective and Objective	Therapeutic Goals	Assessment	Plan and monitoring	Patient Education
ESR level of the patient is 69. and having severe pain	Normalize the ESR/maintain the ESR level <30	The assessment shows red, tender and swollen joints over the knuckles and proximal interphalangeal joints of each hand and over the wrists and toes. There are subcutaneous nodules near each elbow.	Methylprednisolone acetate 20-mg to 40 mg. *Monitor the ESR level to know the status of the inflammatory process	Explain regarding the common side effects of corticosteroids

Findings (Subjective and objective)	Therapeutic goals	Assessment	Plan and Monitoring	Patient Education
The disease activity index is 6.97 and having swelling and tenderness of joints	The DSA 28 level should maintain <6	Swollen joints over the knuckles and proximal interphalangeal joints of each hand and over the wrists and toes	Give Xelijanz XR:11mgPO q day *Assess for the patient relief *Assess for the hemoglobin level and should maintain more than 9	Explain regarding the GI disturbances

Findings (subjective and objective	Therapeutic goals	Assessment	Plan and Monitoring	Patient Education
The patient is having tender joints	Relief from pain and tenderness	Inflammation of joints	Give methotrexate *Assess the patient relief from pain 8.Regular monitoring of full blood count and liver function test	Explain regarding the side effects like mouth ulcer and nausea

2. The present statement is not true, why because when RF is negative, but a person has symptoms similar to those of rheumatoid arthritis seronegative arthritis can be diagnosed.

3. In the present scenario, Mr. Jack had tried for a recommended treatment for 3 months and not worked well. I think because of the use of high dose steroids he developed type II diabetes.

I think the basic DMARD (Disease-Modifying antirheumatic drug) is not well working for him and because of the side-effects of corticosteroids, he developed type II diabetes.

I think the better treatment for him is biologic DMRD's.

The biologics are proteins that have been synthesized by genetically engineered cells that interact with a molecule that is important in the pathogenesis of tissue inflammation and destruction.

But the not like other traditional DMARD's it may take time to work improve the patient from Rheumatoid arthritis symptoms.

The main drug of choices are :

*TNF inhibitors

Other biologics that may be used for the treatment of RA are:

*IL-1Ra inhibitors (Human Interleukin-1 receptor antagonist)

*Costimulatory (CD28-CD80/86)receptor inhibitor

*CD 20 antibody

*IL-6 receptor antibody