Case #13

1. Case #13 Ellen Marie de los Reyes March 15, 2007

2. Patient History -60 yr old female Chief Complaint: knee, ankle, shoulder pain History: -20 yrs ago>right shoulder joint pain Diagnosed as bursitis responded well to steroid injections -10 yrs ago>developed knee pain synovial fluid aspiration steroid injection on the area

3. -developed pain in ankles, shoulders and right hip -pain without swelling in wrists, metacarpophalangeal and proximal interphalangeal joints -morning stiffness for 6 hrs -no back pains Treatment: Prednisone for 7 weeks -it helped but she stopped taking it because she is afraid of the side effects

4. Laboratory Examinations and Procedures • Good History and Physical Examination • X-ray: note characteristic changes in the joint • Laboratory tests: 1. increased erythrocyte sedimentation rate 2. anemia 3. presence of rhematoid factor

5. Diagnoses • Rheumatoid arthritis: • Pt has stiffness in the morning • Inflammation in 3 or more joints • Arthritis in the hand, wrist, or finger joints Differential Diagnoses -Bursitis -Gout -osteoarthritis

6. Rheumatoid Arthritis: develops in his or her 20s or 30s many joints are involved and the lining of the joints (the synovium) is inflamed, damaging all tissues in the joint joints are painful and stiff and appear warm, tender, and swollen with fluid. Blood tests confirming rheumatoid arthritis show widespread inflammation that affects the body in general, often causing anemia, weight loss, and fatigue X-ray images in rheumatoid arthritis show bones that are thin and eroded Osteoarthritis develops much later in life only one or a few joints are typically involved and inflammation is rare and lasts for only a short while. joint does not feel hot or tender and does not look red. x-ray images show extra bony growth such as bony spurs and extra calcium deposits. Rheumatoid arthritis vs Osteoarthritis

7. Rheumatoid Arthritis • autoimmune disease that causes chronic inflammation of the joints. • cause inflammation of the tissue around the joints, as well as other organs in the body • chronic illness that cause joint destruction and functional disability.

8. Plan Management The goal of treatment in rheumatoid arthritis is to reduce joint inflammation and pain, maximize joint function, and prevent joint destruction and deformity. 2 Classes of Medications: 1. fast-acting "first-line drugs" 2. slow-acting "second-line drugs"

9. First line drugs • Not intended for long term treatment • NSAIDs • Corticosteroirds

10. Second line Drugs • In general, however, patients improve function and minimize disability and joint destruction when treated earlier with second-line drugs • DMARDs (Disease Modifing Antirheumatoid drugs • methotrexate

11. Other treatments • Early medical intervention has been shown to be important in improving outcomes • Aggressive management can improve function, stop damage to joints as seen on x-rays, and prevent work disability. • Optimal treatment for the disease involves a combination of medications, rest, joint strengthening exercises, joint protection, and patient (and family) education. • Treatment is customized according to many factors such as disease activity, types of joints involved, general health, age, and patient occupation. • Treatment is most successful when there is close cooperation between the doctor, patient, and family members. • Surgery: patients with severe joint deformity

12. Prednisone -glucocorticoid -used as a replacement theray -Mgt: 10mg/kg/day -Taper thereafter by decreasing 1mg/kg/day every 2-3 wks

13. Pharmakinetics • Administered orally, topical and parentenal • MOA: drugs are bound to corticosteroid-binding globulin (CBG) in the blood and enter the cell by diffusion

14. Unwanted Side effects • Usually seen in prolonged systemic use -suppression of response to injection -supression of endogenous glucocorticoid snthesis -metabolic actions -osteoporosis -Cushing’s syndrome -weight gain, facial puffiness, thinning of the skin and bone, easy bruising, cataracts, risk of infection, muscle wasting, and destruction of large joints, such as the hips