DMARDs in the Management of Rheumatoid Arthritis
TRADITIONAL DMARDs[edit | edit source]
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).
HCQ
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 interferes with DNA synthesis and reduces the pyrimidine supply in dividing cells. It is an immunomodulatory and anti-inflammatory agent, but the exact mechanism is unknown.
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The half-lives of these drugs range from 3 hours for low doses of MTX to 14-28 days for LEF. The elimination and removal processes for MTX and SSZ occurs in the kidneys, while HCQ is partially metabolized and unchanged by the liver. The clearance mechanisms for LEF remain unknown.
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. LMTX 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).
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).
