Pharmacological Management of Rheumatoid Arthritis: Difference between revisions

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<div class="editorbox"> '''Original Editor '''- [[User:Doris Molina-Henry|Doris Molina-Henry]] '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>
<div class="editorbox"> '''Original Editor '''- [[User:Doris Molina-Henry|Doris Molina-Henry]] '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>
== Introduction ==
== Introduction ==
[[Rheumatoid Arthritis|Rheumatoid arthritis]] (RA) is a chronic, [[Autoimmune Disorders|autoimmune disease]] marked by systemic inflammation of both articular [[Joint Classification|joints]] and extra-articular areas (e.g. cardiopulmonary systems).  
[[Rheumatoid Arthritis|Rheumatoid arthritis]] (RA) is a chronic, [[Autoimmune Disorders|autoimmune disease]] marked by systemic [[Inflammation Acute and Chronic|inflammation]] of both articular [[Joint Classification|joints]] and extra-articular areas (e.g. cardiopulmonary systems). See links for more information on RA
[[File:RA joint damage.png|right|frameless|400x400px]]
[[File:Rheumatoid_arthritis_joint.gif|right|466x466px]]
* RA is a progressive disease
Physical therapy plays a significant role in managing Rheumatoid arthritis (RA). Physical therapists (PTs) should have a good understanding of the disease's pathophysiology and the implications of therapeutic interventions used to prevent or slow down its progression. This knowledge is crucial to provide proper care to patients.
* Onset can occur at any age but peaks around 30 to 60 years old.
* Females are three times as likely to be diagnosed with RA compared to males
* Children can also be affected, as seen in [[Juvenile Rheumatoid Arthritis|juvenile idiopathic arthritis]].<ref name=":0">Goodman CC, Fuller KS. Rheumatoid Arthritis. In: Pathology: Implications for the Physical Therapist. 4th ed. St. Louis, MO: Elsevier; 2015:1317-1328.</ref>
In total, about 1-2% of people in the United States have RA, with 80% of them testing positive for rheumatoid factors ie autoantibodies produced by the immune system that is responsible for the autoimmune component of the disease.<ref>Bukhari M, Lunt M, Harrison BJ, Scott DG, Symmons DP, Silman AJ. Rheumatoid factor is the major predictor of increasing severity of radiographic erosions in rheumatoid arthritis: results from the Norfolk Arthritis Register Study, a large inception cohort. Arthritis & Rheumatology. 2002;46(4):906-912. doi:0.1002/art.10167.</ref><ref>Harris ED. Rheumatoid arthritis: pathophysiology and implications for therapy. N Engl J Med. 1990;322(18):1277-1289.</ref>


Physical therapy plays a large role in the management of RA and physical therapists (PT) should be aware of the pathophysiology of the disease and the implications of therapeutic interventions used to delay or arrest the progression to provide proper patient care.


== Mechanism of Action ==
RA is marked by periods of exacerbation and remission. During the exacerbation period, it is theorized that certain cells, such as cytokines and tumor-necrosis-factor-alpha (TNF-⍺), cause the inflammatory and destructive process that occurs in the disease. In joint capsules, these inflammatory factors are found in the pannus, an abnormal layer of granulation tissue, and prevents the synovium from providing the necessary nutrients and lubrication to the joint. As the pannus proliferates, the space within the joint diminishes, consequently leading to the disintegration of the collagen, cartilage, and other surrounding tissues found here. Synovial hyperplasia occurs, causing local swelling and joint pain.<ref name=":0" /> These synovial changes result in irreversible bone and joint deformity, instability, and fusion, which will further affect the proper functioning of the body.<ref>Elliot JM, Grainger AJ, Grigorian MA, Szechinksi JW, Harry KG. Rheumatoid arthritis: a guide to imaging studies. J Muscoskel Med. 1999;16(9):507-514.</ref> Extra-articular systems are similarly affected due to the inflammatory components coursing through the circulation.<ref name=":0" />


== Signs and Symptoms ==
RA begins insidiously; it starts with cartilage degradation, then moves to ligamentous laxity, followed by synovial expansion and erosion. The joints of the hand are affected early on but any joint can be affected, including the knee and temporomandibular joint. Morning stiffness is an iconic symptom of RA, along with fatigue, diffuse musculoskeletal pain, and even depression.<ref name=":0" /> As the disease progresses, joint deformities and subluxation can occur, particularly in the cervical spine (Kim, 2005).<ref>Kim DH. Rheumatoid arthritis in the cervical spine. J Am Acad Orthop Surg. 2005;13(7):463-474.</ref> Extra-articular signs include vasculitis, anemia, [[myelopathy]], nodulosis, scleritis, and many others.<ref>Davis JM, Matteson EL. My treatment approach to rheumatoid arthritis. Mayo Clinic Proceedings. 2012;87(7):659-673.</ref>


== Types of Drug Therapies ==
== Types of Drug Therapies ==
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There are two primary sub-classifications of drugs used in the treatment of RA;  
There are two primary sub-classifications of drugs used in the treatment of RA;  
# Drugs that provide disease-modifying therapy (DMARDs)  DMARDs are medications taken regularly for longer periods of time independent of acute symptoms. DMARDs consist of Traditional DMARDs (DMARDs) and Biological DMARDs (bDMARDs).  
# Drugs that provide disease-modifying therapy (DMARDs)  DMARDs are medications taken regularly for longer periods independent of acute symptoms. DMARDs consist of Traditional DMARDs (DMARDs) and Biological DMARDs (bDMARDs).
# Drugs for symptomatic treatment. DMARDs are medications taken regularly for longer periods of time independent of acute symptoms. Symptomatic therapy is used to relieve acute pain and inflammation associated with the disease process. Non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and corticosteroids are the primary drugs of choice for symptomatic therapy.<ref>Singh JA, Saag KG, Bridges SL, et al. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Care Res. 2016;68(1):1-25. doi:10.1002/acr.22783.</ref>
# Drugs for symptomatic treatment. DMARDs are medications taken regularly for longer periods independent of acute symptoms. Symptomatic therapy is used to relieve acute pain and [[Inflammation Acute and Chronic|inflammation]] associated with the disease process. Non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and corticosteroids are the primary drugs of choice for symptomatic therapy.<ref>Singh JA, Saag KG, Bridges SL, et al. [https://acrjournals.onlinelibrary.wiley.com/doi/epdf/10.1002/art.39480 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis]. Arthritis & Rheumatology 2016;68(1):1-26. </ref>
Drug Classes


== Drug Classes ==
* [[DMARDs in the Management of Rheumatoid Arthritis|DMARDs]]
[[DMARDs in the Management of Rheumatoid Arthritis|DMARDs]]
* [[BDMARDs in the Management of Rheumatoid Arthritis|bDMARDs]]
 
* [[Corticosteroids in the Management of Rheumatoid Arthritis|Corticosteroids]]
[[BDMARDs in the Management of Rheumatoid Arthritis|bDMARDs]]
* [[NSAIDs in the Management of Rheumatoid Arthritis|NSAIDs]]
 
[[Corticosteroids in the Management of Rheumatoid Arthritis|Corticosteroids]]
 
[[NSAIDs in the Management of Rheumatoid Arthritis|NSAIDs]]


== Summary ==
== Summary ==
Rheumatoid [[Arthritis]] is a complex and ever-changing disease with treatment options that are just as intricate. Treatment regimen is based on disease severity, location of injury, comorbidities or contraindications, cost of drug, and the need for monotherapy or a combination of drugs.<ref>Benjamin O, Lappin SL. Disease Modifying Anti-Rheumatic Drugs (DMARD) [Updated 2018 Oct 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018. Available from: <nowiki>https://www.ncbi.nlm.nih.gov/books/NBK507863/</nowiki></ref> The PT must be aware of the effects of each drug category in order to monitor for injurious signs and symptoms the patient may present.
[[Rheumatoid Arthritis]] is a complex and constantly evolving disease that requires intricate treatment options. The treatment plan depends on various factors such as the severity of the disease, the location of the injury, comorbidities or contraindications, the cost of the drug, and the need for monotherapy or a combination of drugs.<ref name=":0" /> The physical therapist should monitor patients for signs of injury based on their drug categories.


NSAIDs and corticosteroids are recommended for use in the initial stages of RA for short-term and symptomatic pain relief. There are minimal side effects of NSAIDs, but signs and symptoms that may present include GI bleeding, cardiovascular issues, and dizziness.<ref>U.S. Food and Drug Administration. Motrin® Ibuprofen Tablets, USP. https://www.accessdata.fda.gov/drugsatfda_docs/label/2007/017463s105lbl.pdf. Last Modified January 20, 2007. Accessed November 21, 2018.</ref><ref>U.S. Food and Drug Administration. Voltaren® (diclofenac sodium enteric-coated tablets). https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/019201s046lbl.pdf. Last Modified January 20, 2007. Accessed November 21, 2018.</ref><ref>U.S. Food and Drug Administration. Celebrex® celecoxib capsules. https://www.accessdata.fda.gov/drugsatfda_docs/label/2008/020998s026lbl.pdf. Last Modified January 20, 2007. Accessed November 21, 2018.</ref> Corticosteroids are also used in the initial stage as a means of reducing disease activity in patients who are awaiting a response to DMARD therapy.<ref name=":1">Kumar P, Banik S. Pharmacotherapy options in rheumatoid arthritis. Clin Med Insights Arthritis Musculoskelet Disord. 2013;6:35-43. doi:10.4137/CMAMD.S5558</ref> Typical adverse effects of Corticosteroids include immunosuppression, which oftentimes leads to infection, the development of [[osteoporosis]], and other [[Metabolic/Endocrine Disorders|metabolic]] conditions.<ref>Bingham, C. John Hopkins University. Rheumatoid arthritis treatment. https://www.hopkinsarthritis.org/arthritis-info/rheumatoid-arthritis/ra-treatment/. Accessed October 3, 2018.</ref>  
In the initial stages of [[Rheumatoid Arthritis]] (RA), NSAIDs and corticosteroids are recommended for short-term and symptomatic pain relief. While NSAIDs have minimal side effects, they may cause gastrointestinal bleeding, cardiovascular problems, and dizziness. It is important to monitor any signs or symptoms that may present while taking these medications.<ref name=":0">McNeil. FDA:Motrin (ibuprofen suspension, oral drops, chewable tablets, caplets) prescribing information. Physicians’ desk Ref [Internet]. 2007;56:2002–5. Available from:https://www.accessdata.fda.gov/drugsatfda_docs/label/2007/017463s105lbl.pdf</ref><ref>Novartis. ( diclofenac sodium enteric-coated tablets ) WARNING : RISK OF SERIOUS CARDIOVASCULAR AND GASTROINTESTINAL. 2016; Available from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/019201s046lbl.pdf</ref><ref>U.S. Food and Drug Administration. CELEBREX ® celecoxib capsules Cardiovascular Risk • C. 2016;1–31. Available from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2008/020998s026lbl.pdf</ref> Corticosteroids are also used in the initial stage as a means of reducing disease activity in patients who are awaiting a response to DMARD therapy.<ref name=":1">Kumar P, Banik S. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3747998/pdf/cmamd-6-2013-035.pdf Pharmacotherapy Options in Rheumatoid Arthritis.] Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders. 2013 Jan;6:CMAMD.S5558. </ref> Typical adverse effects of corticosteroids include immunosuppression, which often leads to infection, the development of [[osteoporosis]], and other metabolic conditions.<ref>Bingham, C. John Hopkins University. Rheumatoid arthritis treatment. Available from: https://www.hopkinsarthritis.org/arthritis-info/rheumatoid-arthritis/ra-treatment/. Accessed October 3, 2018.</ref>  


DMARDs and bDMARDs are similar in that they can adversely affect the GI system, pulmonary function, blood pressure, and cause skin irritation.<ref name=":1" />
DMARDs and bDMARDs are similar in that they can adversely affect the GI system, pulmonary function, and [[Blood Pressure|blood pressure]], and cause [[skin]] irritation.<ref name=":1" />


Although these effects may be seemingly minor in comparison to more malignant conditions, the PT should monitor and report these symptoms as appropriate. Many of these medications may cause the patient to become frail in stature, so the PT must exercise caution during the therapy session. In addition, [[Patient education in Pain Management|patient education]] is a significant component of care and the clinician is responsible for providing relevant treatment while remaining within the physical therapy scope of practice.
Although these effects may be seemingly minor in comparison to more malignant conditions, the PT should monitor and report these symptoms as appropriate. Many of these medications may cause the patient to become [[Introduction to Frailty|frail]] in stature, so the PT must exercise caution during the therapy session. In addition, [[Patient education in Pain Management|patient education]] is a significant component of care and the clinician is responsible for providing relevant treatment while remaining within the physical therapy scope of practice.


== References ==
== References ==

Latest revision as of 23:46, 29 October 2023

Original Editor - Doris Molina-Henry Top Contributors - Kirenga Bamurange Liliane, Kristie Nguyen, Lucinda hampton, Kim Jackson, Pacifique Dusabeyezu, Carmen Reichle, Doris Molina-Henry and Amanda Kersey

Introduction[edit | edit source]

Rheumatoid arthritis (RA) is a chronic, autoimmune disease marked by systemic inflammation of both articular joints and extra-articular areas (e.g. cardiopulmonary systems). See links for more information on RA

Rheumatoid arthritis joint.gif

Physical therapy plays a significant role in managing Rheumatoid arthritis (RA). Physical therapists (PTs) should have a good understanding of the disease's pathophysiology and the implications of therapeutic interventions used to prevent or slow down its progression. This knowledge is crucial to provide proper care to patients.



Types of Drug Therapies[edit | edit source]

Recently, there have been incredible expansions in the management of RA due to an increasing number of available drug options This brief video gives an overview of drug options

[1]

There are two primary sub-classifications of drugs used in the treatment of RA;

  1. Drugs that provide disease-modifying therapy (DMARDs) DMARDs are medications taken regularly for longer periods independent of acute symptoms. DMARDs consist of Traditional DMARDs (DMARDs) and Biological DMARDs (bDMARDs).
  2. Drugs for symptomatic treatment. DMARDs are medications taken regularly for longer periods independent of acute symptoms. Symptomatic therapy is used to relieve acute pain and inflammation associated with the disease process. Non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and corticosteroids are the primary drugs of choice for symptomatic therapy.[2]

Drug Classes

Summary[edit | edit source]

Rheumatoid Arthritis is a complex and constantly evolving disease that requires intricate treatment options. The treatment plan depends on various factors such as the severity of the disease, the location of the injury, comorbidities or contraindications, the cost of the drug, and the need for monotherapy or a combination of drugs.[3] The physical therapist should monitor patients for signs of injury based on their drug categories.

In the initial stages of Rheumatoid Arthritis (RA), NSAIDs and corticosteroids are recommended for short-term and symptomatic pain relief. While NSAIDs have minimal side effects, they may cause gastrointestinal bleeding, cardiovascular problems, and dizziness. It is important to monitor any signs or symptoms that may present while taking these medications.[3][4][5] Corticosteroids are also used in the initial stage as a means of reducing disease activity in patients who are awaiting a response to DMARD therapy.[6] Typical adverse effects of corticosteroids include immunosuppression, which often leads to infection, the development of osteoporosis, and other metabolic conditions.[7]

DMARDs and bDMARDs are similar in that they can adversely affect the GI system, pulmonary function, and blood pressure, and cause skin irritation.[6]

Although these effects may be seemingly minor in comparison to more malignant conditions, the PT should monitor and report these symptoms as appropriate. Many of these medications may cause the patient to become frail in stature, so the PT must exercise caution during the therapy session. In addition, patient education is a significant component of care and the clinician is responsible for providing relevant treatment while remaining within the physical therapy scope of practice.

References[edit | edit source]

  1. ↑ Mayo Clinic Drugs for RA Available from: https://www.youtube.com/watch?v=8vu6aNmAano&feature=youtu.be (last accessed 29.12.2019)
  2. ↑ Singh JA, Saag KG, Bridges SL, et al. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis & Rheumatology 2016;68(1):1-26.
  3. ↑ 3.0 3.1 McNeil. FDA:Motrin (ibuprofen suspension, oral drops, chewable tablets, caplets) prescribing information. Physicians’ desk Ref [Internet]. 2007;56:2002–5. Available from:https://www.accessdata.fda.gov/drugsatfda_docs/label/2007/017463s105lbl.pdf
  4. ↑ Novartis. ( diclofenac sodium enteric-coated tablets ) WARNING : RISK OF SERIOUS CARDIOVASCULAR AND GASTROINTESTINAL. 2016; Available from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/019201s046lbl.pdf
  5. ↑ U.S. Food and Drug Administration. CELEBREX ® celecoxib capsules Cardiovascular Risk • C. 2016;1–31. Available from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2008/020998s026lbl.pdf
  6. ↑ 6.0 6.1 Kumar P, Banik S. Pharmacotherapy Options in Rheumatoid Arthritis. Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders. 2013 Jan;6:CMAMD.S5558.
  7. ↑ Bingham, C. John Hopkins University. Rheumatoid arthritis treatment. Available from: https://www.hopkinsarthritis.org/arthritis-info/rheumatoid-arthritis/ra-treatment/. Accessed October 3, 2018.
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