RA is commonly used as the prototype for inﬂammatory arthritis. The incidence rate is approximately 3%, with a two to three times greater incidence in women (Ruddy et al., 2001). In RA, the autoimmune reaction (Fig. 54-3) primarily occurs in the synovial tissue. Phagocytosis produces enzymes within the joint. The enzymes break down collagen, causing edema, proliferation of the synovial membrane, and ultimately pannus formation. Pannus destroys cartilage and erodes the bone. The consequence is loss of articular surfaces and joint motion. Muscle ﬁbers undergo degenerative changes. Tendon and ligament elasticity and contractile power are lost.
Clinical manifestations of RA vary, usually reﬂecting the stage and severity of the disease. Joint pain, swelling, warmth, erythema, and lack of function are classic. Palpation of the joints reveals spongy or boggy tissue. Often ﬂuid can be aspirated from the inﬂamed joint. Characteristically, the pattern of joint involvement begins with the small joints in the hands, wrists, and feet. As the disease progresses, the knees, shoulders, hips, elbows, ankles, cervical spine, and temporo mandibular joints are involved. The onset of symptoms is usually acute. Symptoms are usually bilateral and symmetric. In addition to joint pain and swelling, another classic sign of RA is joint stiffness, especially in the morning, lasting for more than 30 minutes (Klippel, 2001).
In the early stages of disease, even before bony changes occur, limitation in function can occur when there is active inﬂammation in the joints. Joints that are hot, swollen, and painful are not easily moved. The patient tends to guard or protect these joints through immobilization. Immobilization for extended periods can lead to contractures, creating soft tissue deformity.
Deformities of the hands and feet are common in RA (Fig. 54-4). The deformity may be caused by misalignment resulting from swelling, progressive joint destruction, or the subluxation (partial dislocation) that occurs when a bone slips over another and eliminates the joint space.
RA is a systemic disease with multiple extra-articular features. Most common are fever, weight loss, fatigue, anemia, lymph node enlargement, and Raynaud’s phenomenon (cold- and stress-induced vasospasm causing episodes of digital blanching or cyanosis). Rheumatoid nodules may be noted in patients with more advanced RA and develop at some time in up to half of patients (Klippel, 2001). These nodules are usually nontender and movable in the subcutaneous tissue. They usually appear over bony prominences such as the elbow, are varied in size, and can disappear spontaneously. Nodules occur only in individuals who have rheumatoid factor. The nodules often are associated with rapidly progressive and destructive disease. Other extra-articular features include arteritis, neuropathy, scleritis, pericarditis, splenomegaly, and Sjögren’s syndrome (dry eyes and dry mucous membranes).
|Rheumatoid arthritis. (A) Early|
|Rheumatoid arthritis. (B) Advanced.|
Assessment and Diagnostic Findings
Several factors can contribute to a diagnosis of RA: rheumatoid nodules, joint inﬂammation detected on palpation, and certain laboratory ﬁndings. The history and physical examination address manifestations such as bilateral and symmetric stiffness, tenderness, swelling, and temperature changes in the joints. The patient is also assessed for extra-articular changes; these often include weight loss, sensory changes, lymph node enlargement, and fatigue. Rheumatoid factor is present in more than 80% of patients with RA, but its presence alone is not diagnostic of RA. The erythrocyte sedimentation rate (ESR) is signiﬁcantly elevated with RA. The red blood cell count and C4 complement component are decreased. C-reactive protein and antinuclear antibody test results may also be positive. Arthrocentesis shows synovial ﬂuid that is cloudy, milky, or dark yellow and contains numerous inﬂammatory components, such as leukocytes and complement.
In patients with early RA, treatment begins with education, a balance of rest and exercise, and referral to community agencies for support. Medical management begins with therapeutic doses of salicylates or NSAIDs. When used in full therapeutic dosages, these medications provide both anti-inﬂammatory and analgesic effects. Taking medications as prescribed to maintain a consistent blood level is necessary to optimize the effectiveness of the anti inﬂammatory medication.
Several COX-2 inhibitors, another class of NSAIDs, have been approved for treatment of RA. COX (cyclo-oxygenase) is an enzyme involved in the inﬂammatory process. COX-2 inhibitors block the enzyme involved in inﬂammation while leaving intact the enzyme involved in protecting the stomach lining. As a result, COX-2 inhibitors are less likely to cause gastric irritation and ulceration than other NSAIDs (Bombardier et al., 2000).
The trend in management is toward a more aggressive pharmacologic approach earlier in the disease. A window of opportunity for symptom control and improved disease management occurs within the ﬁrst 2 years of disease onset. Therefore, the disease modifying antirheumatic agents (antimalarials, gold, penicillamine, or sulfasalazine) are initiated early in treatment. If symptoms appear to be aggressive (ie, early bony erosions as seen on x-rays), methotrexate may be considered. Methotrexate is currently the gold standard in the treatment of RA because of its success in improving disease parameters (ie, pain, tender and swollen joints, quality of life). The goals are to control symptoms and prevent destruction of the joints (Koopman, 2001).
An alternative treatment approach for RA has emerged in the area of biologic therapies. Biologic response modiﬁers are a group of agents that consist of molecules produced by cells of the immune system or by cells that participate in the inﬂammatory reactions (Koopman, 2001). Recent studies (Moreland et al., 1999; Weinblatt et al., 1999) using tumor necrosis factor-alpha inhibitors, both alone and in combination with other medications, have shown that patients demonstrate signiﬁcant improvement based on American College of Rheumatology criteria (Felson et al., 1995). Two examples of biologic response modiﬁers that are currently available are enatercept (Enbrel) and inﬂiximab (Remicade). These agents inhibit the function of tumor necrosis factor-alpha, a key cytokine known to play a role in the disease process in RA (Miller, 2001). Research in this area is ongoing
Additional analgesia may be prescribed for periods of extreme pain. Opioid analgesics are avoided because of the potential for continuing need for pain relief. Nonpharmacologic pain management techniques (eg, relaxation techniques, heat and cold applications) are taught.
MODERATE, EROSIVE RA
For moderate, erosive RA, a formal program with occupational and physical therapy is prescribed to educate the patient about principles of joint protection, pacing activities, work simpliﬁcation, range of motion, and muscle-strengthening exercises. The patient is encouraged to participate actively in the management program. The medication program is reevaluated periodically, and appropriate changes are made if indicated. Cyclosporine, an immunomodulator, may be added to enhance the disease modifying effect of methotrexate.
PERSISTENT, EROSIVE RA
For persistent, erosive RA, reconstructive surgery and corticosteroids are often used. Reconstructive surgery is indicated when pain cannot be relieved by conservative measures. Surgical procedures include synovectomy (excision of the synovial membrane), tenorrhaphy (suturing a tendon), arthrodesis (surgical fusion of the joint), and arthroplasty (surgical repair and replacement of the joint). Surgery is not performed during disease ﬂares.
Systemic corticosteroids are used when the patient has unremitting inﬂammation and pain or needs a “bridging” medication while waiting for the slower disease-modifying antirheumatic agent (eg, methotrexate) to begin working. Low-dose corticosteroid therapy is prescribed for the shortest time necessary to minimize side effects. Joints that are severely inﬂamed and fail to respond promptly to the measures outlined previously may be treated by local injection of a corticosteroid (Ruddy et al., 2001)
ADVANCED, UNREMITTING RA
For advanced, unremitting RA, immunosuppressive agents are prescribed because of their ability to affect the production of antibodies at the cellular level. These include high-dose methotrexate (Rheumatrex), cyclophosphamide (Cytoxan), and azathioprine (Imuran). These medications, however, are highly toxic and can produce bone marrow suppression, anemia, gastrointestinal disturbances, and rashes.
Through all stages of RA, depression and sleep deprivation may require the short-term use of low-dose antidepressant medications, such as amitriptyline (Elavil), paroxetine (Paxil), or sertraline (Zoloft), to reestablish an adequate sleep pattern and to manage chronic pain better.
The FDA has approved a medical device for use in treating patients with more severe and longstanding cases of RA who have failed to respond to or are intolerant of disease-modifying antirheumatic drugs. The device, a protein A Immunoadsorption column (Prosorba), is used in 12 weekly 2-hour apheresis treatments to bind IgG (ie, circulating immune complex). In this unique population of patients, a signiﬁcant improvement using the American College of Rheumatology Criteria for Improvement has been demonstrated in several studies using the Prosorba column (Felson et al., 1999; Gendreau, 2001).
Patients with RA frequently experience anorexia, weight loss, and anemia. A dietary history identiﬁes usual eating habits and food preferences. Food selection should include the daily requirements from the basic food groups, with emphasis on foods high in vitamins, protein, and iron for tissue building and repair. For the extremely anorexic patient, small, frequent feedings with increased protein supplements may be prescribed. Some medications (ie, oral corticosteroids) used in RA treatment stimulate the appetite and, when combined with decreased activity, may lead to weight gain. Therefore, patients may need to be counseled about eating a healthy, calorie-restricted diet.
Because of repeated contact with the patient, the nurse has the opportunity to assess and intervene in patient concerns and issues that occur with the diagnosis of a chronic illness such as RA. Because the disease commonly affects young women, major concerns may be related to the effects of the disease on childbearing potential, caring for family, or work responsibilities. The patient with a chronic illness may seek a “cure” or have questions about alternative therapies. Frequently, however, patients are hesitant to share their concerns with health care professionals (American College of Rheumatology, 1998).
REFERENCES AND SELECTED READINGS
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