3   Why has the patient been prescribed ibuprofen?

4   What advice would you give the patient about their ibuprofen?

5   What is the reasoning behind adding methotrexate to the drug regimen?

6   What side-effects might this patient anticipate as a result of taking methotrexate?

7   How would using a steroid help in controlling the symptoms of this disease?

8   What side-effects would you be monitoring for in a patient taking oral prednisolone?

1 Why does this patient have pain and tenderness in her joints?

A

•   Pain is received via specialist receptors called nociceptors, which are free nerve endings that lie in the tissues.

•   Nociceptors are stimulated by mechanical, thermal and chemical means. They can become sensitive to a variety of chemicals which are present after local tissue injury (Barrett et al. 2009).

•   This patient has a condition that has caused her tissue cells to have become injured and release a number of chemicals that initiate the inflammatory response. Examples of these are kinins, prostaglandin and histamine. These chemicals work collectively to cause increased vasodilation (widening of blood capillaries) and permeability of the capillaries (Tortora and Derrickson 2009). This leads to increased blood flow to the injured site.

•   These substances also act as chemical messengers that attract some of the body’s natural defence cells – a mechanism known as chemotaxis.

•   Although highly beneficial to the body’s defence strategies, some chemicals such as bradykinin and prostaglandins also increase the sensitivity of the pain fibres in the area so that it becomes painful and tender (Pocock and Richards 2006).

2 Why have the doctors carried out the blood tests that are described above?

A LATEX TEST

The latex test for rheumatoid factor is used to help diagnose rheumatoid arthritis and to distinguish it from other forms of arthritis and other conditions that cause similar symptoms of joint pain, inflammation and stiffness.

In patients with symptoms and clinical signs of rheumatoid arthritis the presence of significant concentrations of rheumatoid factor indicates that it is likely that they do have the condition – 70–90% of patients with rheumatoid arthritis have a positive rheumatoid factor test. A negative rheumatoid factor test does not exclude rheumatoid arthritis. About 20% of patients with rheumatoid arthritis will be persistently negative or have low levels of rheumatoid factor (Sihvonen et al. 2005).

CRP

CRP is a member of the class of acute-phase reactants, as its levels rise dramatically during inflammatory processes occurring in the body. This increment is due to a rise in the plasma concentration of interleukin-6 and other cytokines that trigger the synthesis of CRP and fibrinogen by the liver. Interleukin-6 is produced predominantly by macrophages that are increased during the inflammatory process. CRP is thought to assist in complement binding to foreign and damaged cells and enhances phagocytosis by macrophages (NICE 2009).

FULL BLOOD COUNT

Although a full blood count cannot in itself diagnose rheumatoid arthritis the results can help to support the diagnosis. Platelets – cells used for clotting – are often increased. The white cell count, which reflects immune system response, may be increased. In addition, haemoglobin levels may be low. About 80% of people who develop rheumatoid arthritis have associated anaemia.

3 Why has the patient been prescribed ibuprofen?

A Ibuprofen is a common medicine prescribed for rheumatoid arthritis. It and other NSAIDs are thought to work by inhibiting the action of certain hormones that cause inflammation and pain in the body. These hormones are called prostaglandins. By blocking the effects of prostaglandins, ibuprofen can help reduce the pain and joint swelling associated with rheumatoid arthritis (Rang et al. 2011).

4 What advice would you give the patient about their ibuprofen?

A

•   You should first ascertain if the patient has an allergy to ibuprofen or similar products. Hypersensitivity or allergic responses are possible with almost any drug. Individuals with asthma are more likely to experience allergic reactions to ibuprofen and other NSAIDs.

•   Ibuprofen may cause ulceration of the stomach or intestine, and the ulcers may bleed. Sometimes, ulceration can occur without abdominal pain, and black, tarry stools, weakness and dizziness upon standing (postural hypotension), due to bleeding, may be the only signs of an ulcer. Therefore the person should be advised to be aware of these symptoms (Downie et al. 2007).

•   Ibuprofen reduces the flow of blood to the kidneys and impairs their function. This impairment is most likely to occur in patients who already have impaired function of the kidney or congestive heart failure, and the use of ibuprofen in these patients should be cautious (BNF 2012).

•   The most common side-effects from ibuprofen are rash, ringing in the ears, headaches, dizziness, drowsiness, abdominal pain, nausea, diarrhoea, constipation and heartburn. Therefore the patient should be advised about these potential problems and encouraged to read the information contained in the packaging (Barber and Robertson 2012).

•   The drug does have suspected interactions. If taken with lithium (a mood stabilizer) it may lead to increased levels of lithium due to its influence on lithium excretion by the kidneys. Ibuprofen has a similar effect on an antibiotic known as gentamycin. Gentamycin levels may rise, thus increasing the risk of side-effects. Ibuprofen should also be avoided during pregnancy as no adequate studies have been completed on its safety during this period.

A Methotrexate belongs to a group of drugs that go under the umbrella term of DMARDs. The DMARD group includes a variety of drugs with differing chemical structures and, therefore, modes of action, such as sulfasalazine, gold compounds, penicillamine, chloroquine, metho-trexate and leflunomide. The anti-rheumatoid actions of the drugs in this category were discovered mostly by accident: we know that they work but have no conclusive evidence to suggest why (NICE 2009).

DMARDs improve patients’ lives by reducing the swelling and tenderness in the joints, and while some years ago this class of drugs was usually used as a last resort it is now usual to start a DMARD as soon as possible after the diagnosis has been made, in order to limit the disease as much as possible.

Methotrexate works on DNA, the genetic material within the nucleus of a cell. As with most drugs in this classification, it is not known how exactly methotrexate works in relation to rheumatoid arthritis, however, empirically, it has been shown to reduce the amount of inflammation and slow the progression of the disease process. It is usually the drug of choice as a first-line treatment following diagnosis. The drug has fewer side-effects than others in this group and, because of its favourable results, patients are more likely to be concordant.

Studies have suggested that when methotrexate is given alongside another DMARD, for example leflunomide, disease and, therefore, symptom progression is much less marked than when giving one drug only. Combination therapy may also allow for lower doses of individual drugs to be given.

6 What side-effects might this patient anticipate as a result of taking methotrexate?

A Side-effects include:

•   nausea;

•   stomatitis;

•   diarrhoea;

•   fatigue;

•   mild inflammation of the liver.

As the drug affects the body’s ability to fight infection, the patient should be educated to report signs and symptoms, such as sore throat, shortness of breath and frequency of micturition to a health professional. Low blood cell counts are less likely with this drug than others in this group. Rare side-effects such as liver damage and lung damage may occur (BNF 2012).

7 How would using a steroid help in controlling the symptoms of this disease?

A The important role of glucocorticoids is concerned with their powerful anti-inflammatory and immunosuppressive effects. They not only stop initial redness, pain, heat and swelling but also affect the healing and repair process. They have the ability to stop all types of inflammatory response whether caused by physical stimuli or inappropriate immune responses in the body.

Whatever the reason for their production, glucocorticoids can be harnessed to help treat conditions where hypersensitivity or unwanted inflammatory processes present. This group of drugs can, therefore, be used in a range of conditions, from autoimmune disease and organ rejection following transplantation to hay fever and skin conditions. However, their ability to suppress the normal inflammatory response has consequences due to masking of infections and decreasing the potential healing properties of all tissue.

8 What side-effects would you be monitoring for in a patient taking oral prednisolone?

A Side-effects are a very important issue; however, they are more likely when these drugs are given systemically rather than locally or when they are prescribed in high doses over an extended period of time. Side-effects are not normally seen when these drugs are given as replacement therapy.

•   Patients on long continued treatment with glucocorticoids are obviously at risk of developing serious side-effects. As the body’s blood sugar is constantly elevated, the body develops a secondary diabetic condition. Also, as sodium is retained by the body, so is water, thereby increasing blood volume and leading to a hypertensive state.

•   Glucocorticoid actions of lowering the calcium plasma level lead to the body homeostatically replacing this from the bones. This in turn leads to osteoporosis and potential occurrence of fractures. The Royal College of Physicians (2002) recommends that those aged 65 or over and those with a prior fragility fracture commence bone protective therapy at the time of starting glucocorticoids.

•   Glucose being formed by proteins leads to muscular weakness and, in children, can affect growth. However, this is unlikely unless the treatment is extended to six months or beyond.

•   As the person’s ability to fight infection is compromised, infection can go undetected. Any infection must be treated early with antibiotics and an increased dose of steroids to compensate for the body’s natural response.

•   A particularly problematic side-effect is the inability of wounds to heal. This can lead to extensive long-term therapies being instigated to treat traumatic injuries.

•   The patient must also be educated regarding the risks of suddenly stopping their medication. If the body has stopped stimulating the adrenal cortex, it will lose its ability to make its own corticosteroids. Therefore, any sudden withdrawal will lead to a gross insufficiency and the patient may well enter what is called a steroidal crisis. Patients should be phased off their medication slowly to allow the body to recover its natural abilities. This normally takes about two months, although it may take much longer.

•   All patients receiving long-term therapy are advised to carry a card stating that they are receiving steroid treatment, which must not be stopped abruptly. They should also inform their dentist of their treatment (Brunner et al. 2009).