Rheumatoid Arthritis

Chief Complaint
“Lately I am very achy, I feel exhausted, and I am having a hard time getting going in the
morning.”

HPI
Analise Schaefer is a 54-year-old African-American woman who presents to rheumatology
clinic with complaints of generalized arthralgias, fatigue, and morning stiffness. She has a 13-
year history of RA currently treated with methotrexate. She reports worsening in her
symptoms over the past 6 months.

PMH
RA × 13 years

Heart failure with reduced ejection fraction (currently NYHA class III)

FH
Father is alive and being treated for hypertension and osteoarthritis. Mother is alive and
being treated for severe RA. Two siblings with no major health concerns.

SH
Tax accountant; married for 25 years; heterosexual, sexually active, monogamous. Denies
tobacco or illicit drug use. Drinks one to two glasses of wine per week.

Meds
Methotrexate 2.5 mg, six tablets (15 mg) PO once a week

Folic acid 1 mg PO once daily

Lisinopril 40 mg PO once daily

Metoprolol succinate 100 mg PO once daily

Spironolactone 25 mg PO once daily

Furosemide 40 mg PO once daily

Patient receives medications at a local community pharmacy. Medication profile indicates

that she refills her medications on time on the first of each month.

All
Sulfonamides (hives)

ROS
Complains of swelling and pain in both hands; reports decreased ROM in hands and wrists;
has morning stiffness every day for about 2 hours and fatigue daily during the afternoon
hours; denies HA, chest pain, bleeding episodes, or syncope; no nausea, vomiting, diarrhea,
loss of appetite, or weight loss.

PE
Gen
African–American woman in moderate distress because of pain, swelling, and fatigue related
to arthritis

VS
BP 118/76 mm Hg, P 62 bpm, RR 14, T 37.1°C; Wt 65 kg, Ht 5′6″

Skin
No rashes; normal turgor; no breakdown or ulcers; no subcutaneous nodules

HEENT
Normocephalic, atraumatic; moist mucous membranes; PERRLA; EOMI; pale conjunctiva
bilaterally; TMs intact; no oral mucositis

Neck/Lymph Nodes
Neck supple, no JVD or thyromegaly; no thyroid bruit; no lymphadenopathy
Chest
CTA

Breasts
Deferred

CV
RRR; normal S1, S2; no MRG

Abd
Soft, NT/ND; (+) BS

Genit/Rect
Deferred

MS/Ext
Total of 16 tender and 16 swollen joints bilaterally

Hands: swelling and tenderness on palpation of second, third, fourth, and fifth PIP and MTP
joints bilaterally; decreased grip strength, L > R (patient is left-handed)

Wrists: decreased ROM

Elbows: good ROM

Shoulders: decreased ROM (especially abduction) bilaterally

Hips: good ROM

Knees: good ROM, no pain bilaterally

Feet: no obvious swelling of MTP joints; full plantar flexion; reduced dorsiflexion; 2+ pedal
pulses

Neuro
CN II–XII intact; muscle strength 4/5 UE, 4/5 LE, DTRs 2+ throughout
Labs
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Na 135 mEq/L Hgb 10.8 g/dL AST 15 IU/L CK <20 IU/L

K 4.1 mEq/L Hct 31% ALT 12 IU/L ANA negative

Cl 101 mEq/L WBC 6.2 × 103/mm3 Alk phos 56 IU/L Wes ESR 60 mm/hr

CO2 22 mEq/L Plt 356 × 103/mm3 T. bili 0.8 mg/dL RF (+) 50 U/mL

BUN 12 mg/dL Ca 9.1 mg/dL Alb 4.2 g/dL Anti-CCP 70 EU

SCr 0.8 mg/dL Urate 5.1 mg/dL HbsAg (–) aPTT 31 seconds

Glu 103 mg/dL TSH 0.74 mIU/L Anti-HCV (–) INR 1.0
UA
Normal

Chest X-Ray
No fluid, masses, or infection; no cardiomegaly

Hand X-Ray
Multiple erosions of MCP and PIP joints bilaterally; measurable joint space narrowing from
previous x-ray 1 year ago

DAS 28
6.2 today; 3.0 one year ago

Assessment
1. RA
2. Heart failure
Collect Information
1.a.
What subjective and objective information indicates the presence of rheumatoid arthritis?

Assess the Information

2.a.
Assess the severity of rheumatoid arthritis based on the subjective and objective information
available.

2.b.
Create a list of the patient’s drug therapy problems and prioritize them. Include assessment
of medication appropriateness, effectiveness, safety, and patient adherence.
Develop a Care Plan
3.a.
What are the goals of pharmacotherapy in this case?

3.b.
What nondrug therapies for rheumatoid arthritis might be useful for this patient?
3.d.
Create an individualized, patient-centered, team-based care plan to optimize medication
therapy for this patient’s rheumatoid arthritis and other drug therapy problems. Include
specific drugs, dosage forms, doses, schedules, and durations of therapy.
3.e.
What alternatives would be appropriate if the initial therapy for rheumatoid arthritis fails or
cannot be used?

Follow-up: Monitor and Evaluate

5.a.
What clinical and laboratory parameters should be used to evaluate the therapy for
achievement of the desired therapeutic outcome and to detect or prevent adverse effects?

Efficacy:

Safety:
5.b.
Develop a plan for follow-up that includes appropriate time frames to assess progress toward
achievement of the goals of therapy.

Bonus Assignments question

1.
Create a list of clinically significant drug interactions for NSAIDs and DMARDs,
including methotrexate.