DMARDs in the Management of Rheumatoid Arthritis

TRADITIONAL DMARDs

Introduction

DMARDs are important in the prevention of joint deformities and injuries that can occur in RA. In general, DMARDs disrupt the immune system signaling cascade (Benjamin, 2018). According to Smolen et al. (2014), therapy with DMARDs should be started as soon as diagnosis of RA is made. DMARDs can be administered orally or intravenously (Benjamin, 2018). While there are several different types of DMARDs that can be utilized, Hydroxychloroquine (HCQ) and Methotrexate (MTX) a few of the most commonly used drugs (Singh et al., 2012).

Mechanisms of Action

HCQ increases pH in cells, which alters protein degradation and assembles macromolecules in the cell, which results in down-regulation of the immune system.

MTX is an immunomodulatory compound. It interferes with DNA synthesis via various mechanisms such as reducing neutrophil adhesion and pyrimidine supply in dividing cells. In addition, MTX inhibits gene expression and cell-mediated immunity in the body (Benjamin, 2018).

Adverse Effects

Common adverse effects of all DMARDs include headache, nausea, and vomiting. More specifically, HCQ can induce visual disturbances, abdominal cramps, and peripheral neuritis. MTX can cause arachnoiditis, stomatitis, and nephropathy. Traditional DMARDs also pose an increased risk of cardiovascular issues and bDMARDs should be used in patients with a preexisting cardiovascular condition (Solomon et al., 2013).

PT Implications

The PT should be aware of seizures, skin irritations, gastrointestinal (GI) symptoms, and blood pressure issues when treating a patient receiving DMARDs. In addition, assessing pulmonary function and back pain is of utmost importance as they can be indications that the patient may be in danger of drug toxicity. If the patient presents with any abnormalities in vitals or metabolic outcome measures these adverse signs and symptoms should be appropriately noted and relayed to the primary physician (Ciccone, 2013).