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KEY CONCEPTS

KEY CONCEPTS

  • imageThe etiology of rheumatoid arthritis is unknown but is thought to result from a combination of genetic and environmental factors.

  • imageRheumatoid arthritis is a systemic autoimmune condition in which inappropriate activation of innate and adaptive immune responses cause inflammation leading to bone, cartilage, and synovium erosion.

  • imageThe primary goal of treatment includes targeting disease remission/low disease activity ultimately aiming at enhancing quality of life.

  • imageCare should be provided by a rheumatology-trained clinician.

  • imageOptimizing mental health and completing physical therapy are both crucial nonpharmacologic therapies in addition to providing comprehensive disease and treatment education.

  • imageDrug treatment should be started as soon as a diagnosis is established.

  • imageChoice of therapy depends on the level of disease activity, comorbid health conditions, patient preference, and often insurance coverage.

  • imageNonsteroidal anti-inflammatory drugs, analgesics, and corticosteroids are used as adjunctive therapy to disease-modifying antirheumatic drug therapy.

  • imageResponse to therapy is evaluated by patient subjective reports, physical examination, laboratory markers, and imaging.

PATIENT CARE PROCESS

Patient Care Process for Rheumatoid Arthritis

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Collect

  • Patient characteristics (eg, age, sex, pregnancy status, insurance)

  • Social history (eg, tobacco/alcohol use, activity)

  • Patient medical history (eg, health conditions, immunizations, recent infections)

  • Family medical history (eg, autoimmune conditions)

  • Current medications

  • Past RA medication trials

  • Subjective symptom report

  • Objective data such as blood pressure, labs (eg, ESR, CRP, CBC), imaging (eg, DEXA, x-ray films, ultrasound), physical examination (eg, number of tender/swollen joints)

Assess

  • Patient subjective report (eg, pain score, duration of morning joint stiffness, adherence to therapy, injection technique/medication storage, side effects to drug therapy, disability, fatigue)

  • Change in number of tender/swollen joints, labs, or imaging

  • Cardiovascular risk factors

  • Infection risk and upcoming procedures

  • Patient treatment preference (utilize motivational interviewing as appropriate)

Plan*

  • Drug therapy (see Table 107-2)

  • Referrals when appropriate (eg, tobacco treatment clinic, podiatry, mental health, social work, physical and/or occupational therapy)

  • Patient education (eg, dosing, side effects, infection risk management, symptom self-monitoring)

  • Order follow-up labs based on therapy chosen (see Table 107-4)

Implement*

  • Provide patient education regarding rationale for and follow-up of treatment plan

  • Provide patient with written medication changes, time frame for follow-up, and clinic/emergency contact information

  • Coordinate and schedule follow-up

Follow-up: Monitor and Evaluate

  • Subjective symptom changes and impact on daily activities

  • Presence of adverse effects and infections

  • Laboratory results as indicated for therapy

  • Patient adherence to treatment plan

  • Time frame dependent on treatment plan (generally every 1-3 months)

*Collaborate with a rheumatologist.

PRECLASS ACTIVITY

Preclass Engaged Learning Activity

In 2009, the US Congress created an abbreviated pathway for approval and licensure of biologic products that are verified to have no clinically meaningful differences with a biologic product already approved by the US Food and Drug Administration (FDA). Agents approved through this abbreviated pathway are known as biosimilars. As the generic versions of small-molecule drugs, the goal in developing biosimilars is to increase the number of treatment options without ...

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