Rheumatoid Arthritis: Not

Responding to Therapy Level

II
November 25, 2023
Prepared and Discussed by:

Sadjail, Melissa Grace O.

BS-Pharmacy IV
University of Southern Philippines Foundation
MEDICATION LIST
MEDICATION INDICATION DRUG CLASS MOA
Methotrexate 50 mg/2 mL, -indicated for severe active antineoplastic agent -inhibition of enzymes
1.0 mL (25 mg) rheumatoid arthritis, responsible for
polyarticular juvenile nucleotide synthesis
subcutaneously once a
idiopathic arthritis and including dihydrofolate
week severe, recalcitrant, reductase, thymidylate
disabling psoriasis synthase,
-indicated to treat aminoimidazole
gestational caboxamide
choriocarcinoma, ribonucleotide
chorioadenoma destruens, transformylase
hydatiform mole, breast (AICART), and amido
cancer, epidermoid cancer phosphoribosyltransfer
of the head and neck, ase
advanced mycosis
fungoides, lung cancer, and
advanced non-Hodgkin's
lymphoma.
haematinics stimulates the
production of red blood
cells, white blood cells,
and platelets in persons
suffering from certain
megaloblastic anemias
Folic acid 1 mg PO once
MEDICATION LIST
MEDICATION INDICATION DRUG CLASS MOA
Folic acid 1mg PO once -indicated for the treatment of vitamins -it is biochemically
daily folic acid deficiency, inactive, is converted to
megaloblastic anemia, and in tetrahydrofolic acid and
anemias of nutritional origins, methyltetrahydrofolate
pregnancy, infancy, or by dihydrofolate
childhood reductase (DHFR).
These folic acid
congeners are
transported across cells
by receptor-mediated
endocytosis where they
are needed to maintain
normal erythropoiesis,
synthesize purine and
thymidylate nucleic
acids, interconvert
amino acids, methylate
tRNA, and generate
and use formate.
ALLERGIES

NKDA
PE

Gen

Women in distress because of pain, swelling, and fatigue related to arthritis

VS
BP 110/72 mm Hg, P 61 bpm, RR 15, 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
PE

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
PE

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 left­handed)
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
PE

Neuro
CN II–XII intact; muscle strength 4/5 UE, 4/5 LE, DTRs 2+ throughout

Labs
Na 136 mEq/L Hgb 11.4 g/dL AST 18 IU/L CK <20 IU/L

K 4.1 mEq/L Hct 33% ALT 14 IU/L ANA negative

Cl 102 mEq/L WBC 5.2 × Alk phos 56 IU/L Wes ESR 60 mm/hr
103/mm3
CO2 Plt 372 × 103/mm3 T. bili 0.8 mg/dL RF (+) 50 U/mL
21 mEq/L
BUN 14 mg/dL Ca 9.1 mg/dL Alb 4.2 g/dL Anti­CCP 70 EU

SCr 0.8 mg/dL Urate 5.1 mg/dL HbsAb (+) aPTT 31 seconds

Glu 92 mg/dL TSH 0.74 mIU/L HbsAg (–) INR 1.0

HepB core Ab (–)

Anti­HCV (–)
PE
UA
Normal

Chest X­Ray
No fluid, masses, or infection; no cardiomegaly

Hand X­Ray
Multiple erosions of MCP and PIP joints bilaterally; measurable joint space
narrowing from previous X­ray 1 year ago

DAS 28
6.2 today; 3.0 one year ago
LABS
LAB VALUES NORMAL VALUES INTERPRETATION POSSIBLE CAUSES

Na 135 mEq/L Na 135/147 mEq/L Normal N/A

K 4.1 mEq/L K 3.7 - 5.2 mEq/L Normal N/A
Cl 101 mEq/L Cl 96 - 106 mEq/L Normal N/A
CO2 22 mEq/L CO2 23 - 29 mEq/L Low
BUN 12 mg/dL BUN 6 - 21 mg/dL Normal N/A
SCr 0.8 mg/dL SCr 0.59-1.04 mg/dL Normal N/A
Glu 103 mg/dL Glucose 70-110 mg/dL Normal N/A
Hgb 10.8 g/dL Hgb Female- 12-16 Low -including anemia of
mg/dL chronic inflammation and
iron deficiency anemia.

Hct 31% Hct 38.8 to 50% Low -Anemia.

-Bleeding.
-Bone marrow being unable
to produce new red blood
cells
LABS
LAB VALUES NORMAL VALUES INTERPRETATION POSSIBLE CAUSES
WBC 6.2 × 103/mm3 WBC 4.5 - 11 x Normal N/A
103/mm3
PIt 356 x 103/mm3 Plt 150 - 450 X Normal N/A
103/mm3
Ca 9.1 mg/dL Ca 8.5 – 10.5 mg/dL Normal N/A
Urate 5.1 mg/dL 3.5 to 7.2 milligrams Normal N/A
per deciliter (mg/dL)
TSH 0.74 mlU/L 0.5 to 5 microunits per Normal N/A
milliliter
AST 15 IU/L AST 10 to 40 IU/L Normal N/A
ALT 12 IU/L ALT 7 to 56 IU/L Normal N/A
Alk phos 56 IU/L Alk Phos 44 to 147 Normal N/A
international units per
liter (IU/L)
T. bili 0.8 mg/dL T.bili 1.2 milligrams per Normal N/A
deciliter (mg/dL)
LABS
LAB VALUES NORMAL VALUES INTERPRETATION POSSIBLE CAUSES
Alb 4.2 g/dL Albumin (Alb) 3.4 to Normal N/A
5.4 g/dL
HBsAg (-) HBsAg (Hepatitis B Negative for Hepatitis N/A
surface antigen) B
Anti-HCV (-) Hepatitis C virus test Negative for Hepatitis N/A
C
CK <20 IU/L CK Females is 30 - low -alcoholic liver disease
145 U/L or rheumatoid arthritis

ANA negative antinuclear antibodies Negative for N/A

(ANA) in your blood antinuclear antibodies
Wes ESR 60 mm/hour Women under 50 High -Bone infections.
years old: less than 20 -Infection of the heart or
mm/hr heart valves.
-Rheumatic fever.
-Severe skin infections,
such as erysipelas.
-Tuberculosis.
LABS

LAB VALUES NORMAL VALUES INTERPRETATION POSSIBLE CAUSES

Anti-CCP 70 EU Anti-CPP Less than 20 positive -usually a sign of
EU/ml rheumatoid arthritis.
- inflammatory arthritis,
such as systemic lupus
erythematosus
aPTT 31 sec Aptt normal range is normal N/A
around 25 to 35
seconds
INR 1.0 INR 1.0 to 1.5 Normal N/A
PROBLEM DRUG IDENTIFICATION
DRUG A DRUG B INTERACTION TYPE OF EFFECT LEVEL OF RISK
(Y/N) INTERACTION
Naproxen Folic Acid N Type A N/A Unknown
Naproxen may increase the
Naproxen Methotrexate Y Type D blood levels and side effects of
Major
methotrexate. You may be
more likely to experience this
interaction if you have kidney
disease or are receiving a high
dose of methotrexate. The risk
may be less if you are using
methotrexate once a week to
treat certain forms of arthritis.

Folic Acid Methotrexate Y Type B Folic acid helps protect Moderate

the healthy cells in your
body and reduces some
of the side effects of
methotrexate. It can
make you less likely to
be sick (vomit) or get
diarrhoea.
Category Type A- There is no drug-drug interaction. Information has shown no pharmacokinetic or
pharmacodynamics interactions between selected drugs and therefore no measurement is required for the drug
therapy.
Category Type B- There is minor significance of the drug to drug interactions and therefore no measurement
is required for the therapy.
Category Type C- There is drug to drug interaction that requires monitoring of patient therapy.
Category Type D- There is drug to drug interaction that requires modification of the medication therapy.
Category Type X- There is drug to drug interaction that is contraindicated therefore combination must be
avoided.
Antagonism- Drug interactions wherein the action of one drug causes a lessened or diminished effect of the
other.
Additivity- Drug interactions wherein the actions used in combination produce a sum of the expected
individual responses.
Potentiation- Drug interactions wherein an exposure to one drug results in the other drug producing an effect
greater than given alone.
ASSESSMENT

ASSESSMENT RATIONALE

Rheumatoid Arthritis Patient has arthralgia and morning stiffness based

on past medical history , RA joint space narrowing
from previous x-ray
Anemia due to RA -low Hematocrit and hemoglobin in laboratory results
Rheumatoid arthritis causes inflammation in the body. This
inflammation impedes the body's ability to create enough
new blood cells and can lead to anemia
DEFINITION OF THE DISEASE

Rheumatoid Arthritis - is an autoimmune and inflammatory disease, which

means that your immune system attacks healthy cells in your body by
mistake, causing inflammation (painful swelling) in the affected parts of the
body. RA mainly attacks the joints, usually many joints at once.
PATHOPHYSIOLOGY
RISK FACTORS OF THE DISEASE LIST DOWN THE RISK FACTORS
THE PATIENT HAS
• Sex/Gender (Women)
• Age ● Gender (Woman)
• Family history ● Family History (Mother)
• Smoking ● Age
• Excess weight ● Morning stiffness
• Genetics
CLINICAL PRESENTATION THE PATIENT HAS
● Pain or aching in more than one joint.
● Stiffness in more than one joint.
● Tenderness and swelling in more than one joint.
● The same symptoms on both sides of the body (such as in both hands or both knees)
GOALS OF TREATMENT

• • symptom relief including pain control,

• • slowing or prevention of joint damage,
• • preserving and improving functional ability,
• • achieving and maintaining disease remission.
Principles of Treatment - Pharmacologic Approach, Drug Alternatives and drugs to be
avoided

Pharmacologic Approach
● NSAIDs
● DMARDs
● Corticosteroids

Drug Alternatives
• Supplements
• a combination of vitamins A, C, and E
• Herbs
• Zyflamend are sufficient to reduce the recommended doses of NSAIDs or corticosteroids

drugs to be avoided
• Alcohol
• Sulfa drugs
NON-PHARMACOLOGICAL APPROACH
• Exercise
• Diet
• Complementary Therapies ( relaxation, meditation, massage, homeopathy, magnet therapy, music
therapy, imagery, and therapeutic touch)
• Adequate rest, weight reduction if obese, occupational therapy, physical therapy, and use of assistive
devices may improve symptoms and help maintain joint function.
• Patients with severe disease may benefit from surgical procedures such as
tenosynovectomy, tendon repair, and joint replacements.
• Patient education about the disease and the benefits and limitations of drug therapy is
important.
EVALUATION OF OUTCOMES

• Clinical and laboratory parameters that should be monitored to assess

the efficacy of the pharmacotherapeutic plan and to prevent adverse
effects
CURRENT LIST OF MEDS THE PATIENT IS PRESCRIBED WITH ACTION PLAN
DRUG ACTION PLAN INDICATION/PURPOSE MONITORING
PARAMETERS
Naproxen Continue Naproxen is a nonsteroidal anti- monitored periodically for signs
inflammatory drug (NSAID) used to of blood loss, renal
relieve symptoms of arthritis (eg, dysfunction, and hepatic
osteoarthritis, rheumatoid arthritis, or dysfunction.
juvenile arthritis) such as inflammation,
swelling, stiffness, and joint pain.
Continue Methotrexate is also used to treat severe Initial monitoring test
Methotrexate psoriasis and rheumatoid arthritis in adults. Baseline: AST, ALT, ALK-P,
It is also used to treat active polyarticular- albumin, total bilirubin, hepatitis
course juvenile rheumatoid arthritis in B and C studies, CBC with
children. platelets, Scr

Maintenance monitoring test

CBC with platelets, AST,
albumin every 1–2 months

Continue As a medication, folic acid is used to treat A folic acid test is used to
Folic Acid folic acid deficiency and certain types of measure the amount of folic
anemia (lack of red blood cells) caused by acid in your bloodstream.A folic
folic acid deficiency. acid test can help determine
whether you may benefit from a
folic acid supplement.
CURRENT LIST OF MEDS THE PATIENT IS PRESCRIBED WITH ACTION PLAN
DRUG ACTION PLAN INDICATION/ MONITORING
PURPOSE PARAMETERS
PROBLEM LIST
PROBLEM INTERPRETATION ASSESSMENT RATIONALE
immune system attacks PE checking on swelling Caused by the immune
Rheumatoid Arthritis healthy cells in your body joints system attacking
by mistake, causing healthy body tissues.
inflammation (painful
swelling) in the affected
parts of the body
People who have RA Hgb lab test Anemia is a condition
Hgb sometimes develop other that causes a low red
conditions, such as blood cell count and
anemia. Anemia is a insufficient levels of
condition that causes a hemoglobin
low red blood cell count
and insufficient levels of
hemoglobin,
Hct Low hemoglobin and Hct lab test Chronic inflammation
hematocrit results can lower the
(anemia) can be production of red blood
associated with cells in your bone
rheumatoid arthritis. marrow. This can lead
to the release of certain
TREATMENT CARE PLAN/HEALTHCARE NEED
HEALTHCA PHARMACOTHERAP RECOMME MONITORING DESIRED FREQUENCY
RE NEED EUTIC GOAL NDATION PARAMETERS ENDPOINT OF
FOR MONITORING
THERAPY
Rheumatoid To reduce the DMARDs D Improving Close
Arthritis symptoms, slow NSAIDs isease activity score patients quality monitoring of
(DAS),
progression and slow Vectra DA,
of life the full blood
the amount of joint E count and liver
deformation. rythrocyte sedimenta function test is
tion rate necessary
(ESR or sed rate) or initially and then
C-reactive protein
(CRP) levels. monthly
intervals for at
least the first
three months of
treatment
Hgb end-stage RA include Iron Blood test For the hgb to Once a month
pain relief, slowing or supplements back to normal
prevention of
additional joint
damage, maintaining
current levels of
TREATMENT CARE PLAN/HEALTHCARE NEED
HEALTHCARE PHARMACOTH RECOMMEND MONITORING DESIRED FREQUENCY
NEED ERAPEUTIC ATION FOR PARAMETERS ENDPOINT OF
GOAL THERAPY MONITORING
Hct Higher Iron Hct laboratory The Hct be Once a month
production of supplements test back to normal
RBC in bone
marrow
FINDINGS NEEDED FOR THE PATIENT IS STABLE AND SAFE TO BE DISCHARGED

• Normal Lab result

• Alleviate Symptoms
Infographics - how patient can know he/she is at risk for developing the disease
Infographics - easily understandable for patients to know about the disease (S&S, should the patient get
tested, what to do if you think you have it?)
Infographics
- treatments ( pharma and nonpharma)
Infographics - What to do if you are given a prescription? (Proper storage, how to stay compliant, avoid the
following, med schedules, follow-up visit, side-effects, go to ER if)
Infographics - monitor yourself at home (BP, blood glucose levels, Inhaler Techniques,etc) whichever is
applicable
Recommended GO TO REFERENCES and explain why it's a good reference - how did it help you for this
case

These are the following links are our references in this case. All necessary information needed are found
here. The following links below are very useful since it is very informative.
https://www.cdc.gov/arthritis/basics/rheumatoid-arthritis.html#:~:text=Rheumatoid%20arthritis%2C%20or%
20RA%2C%20is,usually%20many%20joints%20at%20once
.

https://www.cdc.gov/arthritis/basics/rheumatoid-arthritis.html

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4546043/

https://pubmed.ncbi.nlm.nih.gov/22073934/

https://www.galapagoshealth.com/en/therapy-areas/rheumatoid-arthritis/clinical-outcomes.html