Author : Neysa,
Cindra, Shiddiq
A 37-year-old woman gradually
developed painful wrists over 3 months; she consulted her doctor only when the
pain and early morning stiffness stopped her from gardening. On examination,
both wrists and metacarpophalangeal joints of both hands were swollen and
tender but not deformed. There were no nodules or vasculitic lesions. On
investigation, she was found to have a raised C-reactive protein (CRP) level
(27 mg/l) (NR<10) but a normal haemoglobin and white cell count. A latex
test for rheumatoid factor was negative and antinuclear antibodies were not
detected.
The clinical diagnosis was early
rheumatoid arthritis and she was treated with ibuprofen. Despite some initial
symptomatic improvement, the pain, stiffness and swelling of the hands
persisted and 1 months later both knees became similarly affected, she was
referred to a rheumatologist.
Six months after initial
presentation, she developed two subcutaneous nodules on the left elbow; these
were small, painless, firm and immobile but not tender. A test for rheumatoid
factor was now positive (titer 1/64). X rays of the hands showed bony erosions
in the metacarpal heads. She still had raised CRP (43mg/l) but normal serum
complement (C3 and C4) levels and she had a biopsy, pannus would have been
demonstrable histologically.
This woman now had definite x-ray
evidence of rheumatoid arthrotis and in view of the continuing arthropathy, her
treatment was changed to weekly low dose methotrexate. This has controlled the
arthritis for several years and no further erosions have developed.
Unfamiliar Term
·
C-reactive protein (CRP)
C-reactive
protein (CRP) is a protein that can be measured in your blood. It appears in
higher amounts when there's swelling (inflammation) somewhere in your body.
A C-reactive protein (CRP) test is done to:
o
Check for infection after surgery. CRP levels normally rise within
2 to 6 hours of surgery and then go down by the third day after surgery. If CRP
levels stay elevated 3 days after surgery, an infection may be present.
o
Identify and keep track of infections and diseases that cause
inflammation, such as:
Diseases of the immune system, such as lupus.
Painful swelling of the blood vessels
in the head and neck (giant cell
arteritis).
Painful swelling of the tissues that
line the joints (rheumatoid
arthritis).
Swelling and bleeding of the intestines (inflammatory
bowel disease).
Infection of a bone (osteomyelitis).
o
Check to see how well treatment is working, such as treatment for
cancer or for an infection. CRP levels go up quickly and then become normal
quickly if you are responding to treatment measures.
·
latex test
The latex test is a laboratory method to check for certain antibodies or antigens in a variety of
bodily fluids including saliva, urine, cerebrospinal fluid, or blood.
·
Rheumatoid Arthritis
Rheumatoid
arthritis (RA) is an autoimmune disease where the body's immune system attacks
normal joint tissues, causing inflammation of the joint lining. This
inflammation of the joint lining (called the synovium) can cause pain,
stiffness, swelling, warmth, and redness.
Problem
definition:
1. Symptoms of Rheumatoid Arthritis
2. The main causes of an elevated
C-reactive protein?
3. The diagnosis of RA
4. Ibuprofen for Rheumatoid arthritis
5. Treatment for Rheumatoid arthritis
analyze problems
1.
Symptoms of Rheumatoid Arthritis
Rheumatoid
arthritis (RA) is a chronic
(long-term) disease. Rheumatoid arthritis symptoms can come and go, and each person with RA is
affected differently. Some people have long periods of remission. Their
rheumatoid arthritis is inactive, and they have few or no symptoms during this
time. Other people might have near-constant rheumatoid arthritis symptoms for
months at a stretch.
Although rheumatoid arthritis can
involve different parts the body, joints are always affected. When the disease
acts up, joints become inflamed. Inflammation is the body's natural response to
infection or other threats, but in rheumatoid arthritis inflammation occurs
inappropriately and for unknown reasons.
Rheumatoid Arthritis and Joint Inflammation
Joint inflammation is a hallmark of rheumatoid arthritis. That
includes:
-
Stiffness. The joint is harder to use and might have a limited range of
motion. "Morning stiffness" is one of the hallmark symptoms of
rheumatoid arthritis. While many people with other forms of arthritis
have stiff joints in the morning,
it takes people with rheumatoid arthritis more than an hour (sometimes several
hours) before their joints feel loose.
-
Swelling. Fluid enters into the joint and it becomes puffy; this also
contributes to stiffness.
- Pain. Inflammation inside a
joint makes it sensitive and tender. Prolonged inflammation causes damage that
also contributes to pain.
- Redness and warmth. The joints may be somewhat warmer and more pink or red
than neighboring skin.
Which joints does RA affect?
The hands are
almost always affected, although literally any joint can be affected with
rheumatoid arthritis symptoms: knees, wrists, neck, shoulders, elbows, feet,
hips, even the jaw. Joints are usually affected in a symmetrical pattern -- the
same joints on both sides of the body.
Rheumatoid Arthritis Symptoms That
Affect the Entire Body
Rheumatoid
arthritis can affect many areas of the body. These effects all result from the
general process of inflammation, leading to a wide variety of symptoms of
rheumatoid arthritis:
-
Fatigue
-
Malaise (feeling ill)
-
Loss of appetite, which can lead to weight lose
- Muscle aches
These feelings have
been compared to having the flu, although they are usually less intense and longer
lasting. Rheumatoid arthritis may affect other areas of your body. Involvement
of multiple areas of the body occurs and is more common with moderate to severe
rheumatoid arthritis.
· Rheumatoid nodules are bumps under the skin that most
often appear on the elbows. Sometimes they are painful.
· Lung involvement,
due to either damage to the lungs or inflammation of the lining around the
lungs, is common but sometimes causes no symptoms. If shortness of breath
develops, it can be treated with drugs that
reduce inflammation in the lungs.
· Rheumatoid arthritis can even affect a joint in
your voice box or larynx (cricoarytenoid joint), causing hoarseness.
· Rheumatoid arthritis can cause inflammation in the
lining around the heart, but it usually has no symptoms. If symptoms do develop,
it may cause shortness of breath or chest pain. In addition, people with rheumatoid arthritis are
more likely to develop clogged arteries in their heart, which can lead to chest
pain and heart attack.
· The eyes are
affected in less than 5% of people with rheumatoid arthritis. When the eyes are
affected, symptoms can include red, painful eyes or possibly dry eyes.
When you have
symptoms of rheumatoid arthritis, early and aggressive treatment can help
prevent further symptoms as well as stop progression of rheumatoid arthritis.
2. The main causes of an elevated
C-reactive protein?
In general, the main causes of increased CRP and other
markers of inflammation are: burns, trauma, infections, inflammation,
active inflammatory arthritis, and certain cancers.
3.
The
diagnosis of RA
Diagnosis of rheumatoid arthritis
(RA), in the early stages, can be difficult. There is no single test that can
clearly identify rheumatoid arthritis. Instead, doctors diagnose rheumatoid
arthrit based on the factors strongly associated with this disease. Using
American College of Rheumatology criteria list:
1) The morning stiffness in and around
joints a minimum of one hour.
2) Swelling or fluid around three or
more joints simultaneously.
3) Least one swelling in the wrist,
hand, or finger joints.
4) Arthritis involves the same joints on
both sides of the body (symmetric arthritis).
5) Rheumatoid nodules, bumps on the skin
of patients with rheumatoid arthritis. These nodules are usually on pressure
points of the body, most often the elbow.
6) Amount of rheumatoid factor in the
blood are abnormal.
7) X-ray look at the changes in the
hands and wrists typical of rheumatoid arthritis, with bone destruction around
the joints involved.
4. Ibuprofen for Rheumatoid arthritis
Information specific
to: Ibuprofen 100mg/5ml oral suspension when used in Rheumatoid
arthritis.
Ibuprofen (I-bue-proh-fen) is a medicine which is used in
a number of conditions - an example is rheumatoid arthritis. The information in
this Medicine Guide for ibuprofen varies according to the condition being
treated and the particular preparation used.
Your medicine
Ibuprofen helps to reduce inflammation and to reduce pain.
Ibuprofen works by blocking the production of some of the body chemicals that
cause inflammation, pain, stiffness, tenderness, swelling and increased
temperature.
By reducing inflammation in conditions affecting muscles and
joints Ibuprofen helps to improve movement.
Other information about Ibuprofen: this medicine will
normally be prescribed at the lowest possible dose for the shortest time to
reduce the chance of side-effects
Do not share your medicine with other people. It may not be
suitable for them and may harm them. The pharmacy label on your medicine
tells you how much medicine you should take. It also tells you how often you
should take your medicine. This is the dose that you and your prescriber have
agreed you should take. You should not change the dose of your medicine unless
you are told to do so by your prescriber. If you feel that the medicine
is making you unwell or you do not think it is working, then talk to your
prescriber.
Whether this medicine is suitable for
you
Ibuprofen is not suitable for everyone and some people should
never use it. Other people should only use it with special care. It is
important that the person prescribing this medicine knows your full medical
history.
Your prescriber may only prescribe this medicine with special
care or may not prescribe it at all if you:
·
are a female who is trying to have a baby or if you are having
difficulty with conceiving
·
are allergic or sensitive to or have had a bad reaction to aspirin,
ibuprofen or NSAIDs in the past
·
are allergic or sensitive to or have had a reaction to any of
the ingredients in the medicine
·
are dehydrated
·
are elderly
·
are pregnant
·
are prone to bleeding
·
have an autoimmune problem
·
have an infection
·
have bleeding problems
·
have cerebrovascular problems
·
have connective tissue problems
·
have kidney problems
·
have liver problems
·
have lupus or a lupus-like problem
·
have or have had asthma
·
have or have had Crohn's disease
·
have or have had gastrointestinal problems such as ulcers or
bleeding
·
have or have had heart problems
·
have or have had high blood pressure
·
have or have had ulcerative colitis
·
have peripheral vascular disease
·
have risk factors for heart or circulation problems such as:
diabetes, hyperlipidaemia or smoking
Furthermore the prescriber may only prescribe this medicine with
special care or may not prescribe it at all for a child who weighs less than 7
Kg. As part of the process of assessing suitability to take this medicine a
prescriber may also arrange tests: to check that this medicine is not having
any undesired effects. Over time it is possible that Ibuprofen can become
unsuitable for some people, or they may become unsuitable for it. If at any
time it appears that Ibuprofen has become unsuitable, it is important that the
prescriber is contacted immediately.
5. Treatment for Rheumatoid arthritis
The main treatment goals with rheumatoid arthritis are to
control inflammation and slow or stop the progression of RA. Treatment is
usually a multifaceted program that consists of medications, occupational or
physical therapy, and regular exercise. Sometimes, surgery is used to correct
joint damage. Early, aggressive treatment is key to good results. And with
today’s treatments, joint damage can be slowed or stopped in many cases.
Drugs for Rheumatoid Arthritis
NSAIDs
As part of rheumatoid arthritis treatment, your doctor will
probably prescribe a nonsteroidal anti-inflammatory drug (NSAID). These drugs
reduce pain and inflammation but do not slow progression of RA. Therefore,
people with moderate to severe RA often require additional drugs to prevent
further joint damage.
Over-the-counter NSAIDs include ibuprofen (Advil or Motrin) and
naproxen sodium (Aleve). Most people with RA require a prescription NSAID as
they offer a higher dose with longer lasting results and require fewer doses
throughout the day. There are many prescription NSAIDs to choose from.
All prescription NSAIDs carry a warning regarding the increased
risk of heart attack and stroke. NSAIDs can also raise blood pressure. In
addition, NSAIDs can cause stomach irritation, ulcers, and bleeding.
You and your doctor can weigh the benefits of NSAIDs against the
potential risks. You may have to try a few different ones to find the one
that’s right for you.
DMARDs
Disease-modifying antirheumatic drugs (DMARDs) help slow or stop
progression of RA. The most common DMARD used to treat rheumatoid arthritis is
methotrexate. Other DMARDs include Arava, Azulfidine, Cytoxan, Imuran,
Neoral, P laquenil, and Xeljanz.
In rheumatoid arthritis, an overactive immune system targets
joints and other areas of the body. DMARDs work to suppress the immune system.
However, they aren't selective in their targets. Thus, they decrease the immune
system overall and increase the likelihood of catching some infections.
DMARDs, particularly methotrexate, have produced dramatic
improvements in severe rheumatoid arthritis and can help preserve joint
function.
Biologics
The newest and most effective treatments for rheumatoid
arthritis are biologics. Biologics are genetically engineered proteins. They
are designed to inhibit specific components of the immune system that play a
pivotal role in inflammation, a key component in rheumatoid arthritis.
Biologics are usually used when other drugs have failed to stop
the inflammation of rheumatoid arthritis. Biologics may slow or even stop RA
progression.
TNF blockers help to reduce pain and joint damage by blocking an
inflammatory protein called tumor necrosis factor (TNF). For some patients, TNF
blockers stop the progression of rheumatoid arthritis. Studies show benefits
when TNF blockers are combined with methotrexate. TNF blockers include Enbrel,
Humira, Remicade, Cimzia, and Simponi.
Other biologics suppress different areas of the immune system
and include Actemra, Kineret, Orencia, and Rituxan.
Since biologics suppress the immune system, they also increase
the risk of infection. Severe infections have been reported with biologics.
Steroids
For severe RA or when RA symptoms flare, your doctor may
recommend steroids to ease the pain and stiffness of affected joints. In most
cases, they can be used temporarily to calm a symptom flare. However, in
certain people, steroids are needed long term to control pain and inflammation.
Steroids can be given as injections directly into an inflamed
joint or can be taken as a pill. Potential side effects of long-term steroid
use include high blood pressure, osteoporosis, and diabetes. But when used
appropriately, steroids are often effective and quickly improve pain and
inflammation.
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