NU 307 Pharmacology: Rheumatoid Arthritis

• The musculoskeletal system will be discussed with reference to the conditions rheumatoid arthritis and osteoporosis, as well as gabapentin.
• The musculoskeletal system is being covered in NU 307 Pharmacology at Endicott College.

Rheumatoid Arthritis

• Rheumatoid Arthritis (RA) is an inflammatory, systemic, autoimmune disease.
• RA primarily affects the synovial joints, but can occur anywhere connective tissue is widespread.
• RA causes joint stiffness, pain, swelling, and deformities.
• RA impacts mostly young to middle-aged women.
• RA is caused by environmental and genetic factors.
• The goal of drug therapy for RA is to decrease joint pain and inflammation.
• Symptoms of RA include pain and stiffness in more than one joint, morning joint stiffness, joint tenderness and swelling, decreased range of motion, fatigue/malaise, and low-grade fever.

Drug Therapy for RA

• Main drug categories for RA treatment include NSAIDs, glucocorticoids, and disease-modifying antirheumatic drugs (DMARDs).
• DMARDs are divided into two categories: nonbiologic (traditional) and biologic.

Nonbiologic DMARDs

• Nonbiologic DMARDs have an immunosuppressive effect by interfering with normal B and T lymphocytes activity.
• The common nonbiologic DMARD methotrexate (Rheumatrexate} is a folate antagonist with an antineoplastic therapeutic class.
• Nonbiologic DMARDs decrease joint inflammation and subsequent joint damage, and cause an immunosuppressive effect.
• Nonbiologic DMARDs can suppress bone marrow, making the patient more susceptible to infection.
• Monitor labs (RBC, WBC, platelets) for bone marrow suppression.
• A lot of ADR are caused by Nonbiologic DMARDs, like infection, liver damage, Gl ulcers, pulmonary fibrosis, and dizziness.
• Nursing interventions for nonbiologic DMARDs include monitoring for low platelets, RBC, and WBC; monitoring for signs and symptoms of infection; monitoring LFTs and observing for jaundice; monitoring for GI bleeding; monitoring for respiratory distress and decreased oxygen; and monitoring for abdominal pain and N/V/D.
• Nonbiologic DMARDs are administered orally, SC, or IM, once a week.
• Folic acid may also be taken to decrease toxicity.
• Instructions to give clients taking Nonbiologic DMARD include reporting abnormal bleeding, reporting signs/symptoms of infection immediately, avoiding alcohol, reporting jaundice/signs/symptoms of liver damage, reporting SOB or difficulty breathing, and drinking at least 2L per day for help.
• Contraindications for nonbiologic DMARDs: Pregnancy, renal insufficiency, and liver insufficiency or hepatitis.
• Precautions for Nonbiologic DMARDs include: peptic ulcers/ulcerative colitis, active infections, can affect digoxin, caffeine may reduce effectiveness, alcohol use will increase hepatotoxicity and risk for bleeding, and using with warfarin.

Biologic DMARDs

• Biologic DMARDs bind to tumor necrosis factor, which prevents attachment to the cells of joint tissue, preventing inflammation.
• The common biologic DMARD etanercept (Enbrel) is a TNF blocker (tumor necrosis factor) with an immunosuppressant therapeutic class.
• Biologic DMARDs are still for treat and decrease joint inflammation and cause immunosuppressive effects.
• Biologic DMARDs increases patient susceptibility to infection.
• Biologic DMARDs may cause reactivation of latent TB.
• A TB test should be administered prior to starting therapy.
• Patients should avoid live vaccines.
• Biologic DMARDs are typically given as a weekly injection.
• Nursing interventions for Biologic DMARDs (etanercept (Enbrel)) include assessing for infection before injection, monitoring for s/s during therapy, monitoring for skin reactions, monitoring for redness, warmth, and itching at the injection site, and monitoring for s/s of heart failure - cough, SOB, pink sputum, and high HR and BP.
• Biologic DMARDs are administered via SC injection.
• The injection site of Biologic DMARDs must be monitored after for redness, pain, and swelling.
• Instructions to give clients taking Biologic DMARD include reporting signs/symptoms of infection immediately, avoiding immunizations and live vaccines, reporting skin rashes ASAP, and reporting signs/symptoms of heart failure.
• Contraindications for Biologic DMARDs include active infections, hematologic disease, and malignancy.
• Precautions for Biologic DMARDs include autoimmune disorders, live vaccines, and heart failure.
• Interactions with Biologic DMARDs include chemotherapeutic drugs and live vaccines.

Goal of RA Therapy

• There is no cure for RA.
• The goals of RA therapy are to control disease activity, stop/slow further damage, and improve quality of life.
• Quality of life relates to pain, inflammation, stiffness, and complications.
• Only 66% of patients with rheumatoid arthritis are adherent to DMARDs.
• Nonadherence is associated with disease flares, increased disability, and health care costs in rheumatoid arthritis.
• Modifiable factors associated with adherence in rheumatoid arthritis are the patient-physician relationship, patients' beliefs about medications, knowledge about their disease, and self-efficacy.

Osteoporosis

• Osteoporosis is a progressive disease resulting in reduced bone mass (through absorption), decreased bone density, and increased risk for fractures.
• Causes of osteoporosis include aging, menopause, overuse of alcohol, caffeine and tobacco, and long-term glucocorticoid therapy.
• The goal of drug therapy is to increase bone strength and decrease risk for fractures.
• There are four main drug categories to prevent or treat osteoporosis: Selective Estrogen Receptor Modulators (SERMs), Bisphosphonates, Calcitonin, and Calcium Supplements.
• Selective Estrogen Receptor Modulators (SERMs) activate estrogen receptors in tissue needed to decrease bone loss and increase bone density.
• Bisphosphonates inhibit osteoclasts and decrease bone resorption.
• Calcitonin decreases bone resorption by inhibiting osteoclasts.
• Calcium Supplements are a non-dietary source of calcium to promote bone growth.

Calcium Review

• Normal range for calcium is 9-11 mg/dL.
• Hypocalcemia is below 9 mg/dL.
• Hypercalcemia is above 11 mg/dL.

Selective Estrogen Receptor Modulators (SERMs)

• Common Drug: raloxifene (Evista)
• SERMs are used for the prevention or treatment of postmenopausal osteoporosis.
• SERMs are administered orally daily.
• SERMs increases the risk of DVT, pulmonary emboli, and stroke.
• Patients may report hot flashes (due to estrogen blockage in other tissues!).
• Intervene and educate about the risk for clots in the legs and lungs, and stroke.
• Legs: cramps, redness, swelling, warmth, unilateral
• Lungs: SOB, decreased oxygen saturation, difficulty breathing
• This is caused by an issue with hormone interference with FIBROGEN - so monitor RBC AND COAGS.
• SERMs Health Promotion includes consuming calcium and vitamin D, daily weight bearing (running, weights), using contraception to avoid getting pregnant, and reporting signs/symptoms of clots.

Bisphosphonates

• Common Drug: alendronate (Fosamax)
• Bisphosphonates are used for the prevention or treatment of postmenopausal or glucocorticoid-related osteoporosis.
• Bisphosphonates work by decreasing bone absorption/inhibiting osteoclasts. administer Bisphosphonates orally daily.
• Bisphosphonates should be taken with a full glass of water.
• The patient should remain upright and avoid eating/drinking or taking a calcium supplement for 30 minutes afterwards.
• Bisphosphonates may cause GI upset.
• Bisphosphonates mostly cause GI EFFECTS!, such as nausea, vomiting, ABD pain, and esophagitis.
• The risk of esophagitis can be decreased by staying straight 30 minutes and drinking with lots of water.
• Muscle and joint pain is also a side effect of bisphosphonates.
• If the patient has muscle and joint pain, they may need to stop or take pain medication.
• Monitor for decrease bone resorption to evaluate the medication effectivness.
• Bisphosphonates must be taken with full glass of water and the client must sit/stand for 30 minutes with the drug as it can't be taken with Calcium supplement or antacid.
• Contraindications: Pt already as esophageal strictures, or other disorders calcium inhibits drugs absorption, so don't give within 30 minutes of administration!

Calcitonin

• Common Drug: calcitonin-salmon (Calcimar/Miacalcin)
• Calcitonin is used for the treatment of established postmenopausal osteoporosis or hypercalcemia related to hyperparathyroidism.
• Calcitonin is administered intranasally or as an injection.
• Calcitonin should be avoided in patients with a salmon or other fish protein allergy- anaphylactic reaction. Watch for hypocalcemia when adminstering Calcitonin.

Calcium Supplements

• Common Drug: citrate (Citracal), calcium carbonate (Tums)
• Calcium Supplements are used for the treatment of hypocalcemia, or for osteoporosis prevention in conjunction with another medication.
• Calcium Supplements administered orally - often with vitamin D.
• Watch for hypercalcemia – nausea, vomiting, constipation and monitor for signs of kidney stones.

Gabapentin

• Gabapentin (Neurontin) takes aim at the dysfunctional release of pain-controlling neurotransmitters, decreasing or stabilizing irritated nerve membranes to soften their response.

Connection Check Questions and Answers

• The nurse anticipates which follow-up test after a postmenopausal woman presents with a tibial fracture confirmed by x-ray? D. DEXA scan. Rationale: Use a DEXA scan to check for bone density problems due to loss of estrogen due to menopause, which is implicated in increased fracture risk.
• What are the most important supplements for bone health for patients of advancing age? A. Calcium and vitamin D. Rationale: Adequate calcium levels are associated with bone health. Vitamin D aids in the Gl absorption of calcium.
• The nurse knows that a decrease in estrogen levels is implicated in the development of osteoporosis. Rationale: A decrease in estrogen levels inhibits bone formation. Calcitonin decreases osteoclastic activity. Decreases in parathyroid hormone would decrease osteoclastic activity. A decrease in phosphorus levels is inversely proportional to an increase in calcium levels.