LaMonicaFamily_JointPain_Bruce_N752

The LaMonica Family: Joint Pain

Molly Bruce, RN, BSN, FNP-StudentNURO 752

Mrs. Sofia LaMonica is a 78-yr-female who presents with c/o shoulder pain, hip pain, fatigue, and weakness that began about one month ago. She was diagnosed with mild iron deficiency anemia (improved with treatment), depression, Vitamin D deficiency (corrected on replacement), and fibromyalgia by her previous PCP. She has not noted improvement in sxs on current regimen of cyclobenzaprine 10 mg at bedtime and duloxetine 60 mg daily. Her daughter is with her and reports that her mother has difficulty dressing herself, needs help to stand from a chair, and has difficulty lifting her arms. She denies headaches or changes in vision or hearing.

Social HistoryMoved from Sicily 7 years ago to live with her daughter and her son-in-law. Her primary language is Italian and she speaks little English. Never smoker. Occasional glass of wine. Former elementary school teacher. Four children, 3 of whom live in the US, one is deceased. Widowed x 25 yrs, not sexually active since her husband died.

Past Medical History: HTN controlled on meds x 6 years, OA for which she takes occasional ibuprofen. Hysterectomy age 38, no HRT, DEXA 4 years ago normal BMD.

Family Medical Hx: Adopted, knows no biologic family hx. Oldest daughter died age 24 from Lupus Nephritis complications. All other children are well.

Medications

• Duloxetine 60 mg daily

• Cyclobenzaprine 10 mg at bedtime

• Valsartan 160 mg daily

• HCTZ 25 mg each morning

• Calcium 600 mg twice daily

• Vitamin D 2000 mg daily

• Ibuprofen 400-600 mg up to three times daily PRN

Considerations

• What are some socio-cultural considerations that should be implemented for this patient?• Consider the patient’s religious beliefs, family

structure, ethnic value, and cultural identity.

• Would it be appropriate to use her daughter as a translator?• No!

• What are the legal implications for using her daughter as a translator? • Misinterpretation of information could lead to

mistakes or misdiagnosis.

ROS: Pertinent Findings• General: positive for – fatigue, weakness

• Psychological: negative for anxiety, depression, memory loss

• Ophthalmic: positive for dry eyes. Negative for blurry vision, vision loss other than r/t age

• ENT: Positive for decreased hearing r/t age. Negative for - earache, sore throat, hoarseness, dysphagia, facial pain, and dry mouth, jaw claudication

• Allergy and Immunology: negative for hx of allergies or frequent infections

• Hematological and Lymphatic: negative for excessive bruising, swollen or painful nodes

• Endocrine: negative for hx of diabetes, thyroid problems

• Respiratory: negative, denies SOB,

wheezing, cough

• Cardiovascular: positive for peripheral edema in the evenings, resolves by morning; negative for Chest pain, palpitations

• Gastrointestinal: positive for occasional indigestion; negative for reflux, black or bloody stools

• Genitourinary: positive for hx of UTI, otherwise negative

• Musculoskeletal: Positive for - Joint pain, Stiffness and Morning stiffness; negative for joint swelling or redness

• Neurological: negative for - headaches and numbness/tingling; positive for occasional vertigo

• Skin/Hair/Nails: Negative for rash, itch, unusual lesions, dandruff, abnormal nails.

Joints

Physical Exam• VS: BP 124/62 | Pulse 68 |

Temp 97.9 °F (36.6 °C) (Oral) | Resp 16 | Ht 1.626 m (5' 4") | Wt 60.782 kg (134 lb) | BMI 23.00 kg/m2

• General: NAD

• HENT: TM Pearly Gray, no enlarged or tender nodes, thyroid normal, PERLA, EOM intact, no nystagmus

• Mouth: MMM, no lesions noted, good dentition, uvula midline, pharynx without erythema or exudate

• Skin/Nails: warm & dry w/out rash, no increased warmth or tenderness

• CV: RRR: Temporal pulse 2+, equal with no masses or tenderness; trace edema from toes to mid calf, cap refill bilateral great toes <3 secs, Pedal & PT pulses 1+, Radial pulse 2+

• Lungs: CTA throughout; Normal respiratory effort & rate

• Sensation: intact to touch, position

• Strength: 4/5 UE & LE bilateral, unable to stand without assistance

• Neuro: Neg Romberg, finger to nose & rapid alternating movements normal

• DIP: no swelling, normal motion, Heberden’s nodes 2,3 bilaterally

• PIP: no swelling, tenderness; minor Bouchard’s nodes throughout

• MCP: no swelling or tenderness

• Grip: mildly decreased strength, complete, equal

• Wrist: decreased motion, no swelling or tenderness

• Elbow: normal motion, no swelling or tenderness

• Shoulder: limited, painful motion, 5/10 tenderness, no swelling

• Hip: mildly decreased adduction and abduction

• Knee: normal motion, no swelling, mild crepitus

• Ankle: normal motion, no redness or swelling

• Foot/Toes: + squeeze

• Tender points: Widespread, 18/18 positive 3-4/10

• Other: Normal gait

Osteoarthritis

Osteoarthritis • Definition: A degenerative disorder of the joints, with a prevalence

that increases with age. Joints affected normally involve the knee, hip, hands, cervical and lumbar spine. These patients may have stiffness and joint pain WORSE with activity.

• Pharmacologic Treatment Options• Hand OA: Topical capsaicin or topical NSAIDs, oral NSAIDs/COX-2

inhibitors, tramadol• >75 years-old, use topical rather than oral NSAIDs.

• Knee OA: Acetaminophen, oral NSAIDs, topical NSAIDs, tramadol, intraarticular corticosteroid injections

• Hip OA: Acetaminophen, oral NSAIDs, tramadol, intraarticular corticosteroid injections

• Risk Factors• Older age• Sex (females>males) • Obesity • Occupation: repetitive movement of joints

(Hochberg et al, 2012)

Diagnostics

• What studies/labs should be ordered?CBC, CMP, Vitamin D, Inflammatory Markers, UA

Lab Results: CBC

Lab Results: CMP

Question• Were there any CMP or CBC values that were

significant to developing differentials?

WBC: 13.0 (H)Hemoglobin: 11.1 (L)Seg (neutrophils): 88.9% (H) Lymphocytes: 9.1% (L)Monocytes: 1.8% (L)Absolute neutrophils: 11.6 (H)Urea Nitrogen: 24 (H)Glucose: 102 (H)BUN/Creatinine: 21.6 (H)

• Look at inflammatory markers and urinalysis!

Additional Work-Up • ESR (Sed Rate): 84 (H)

• CRP: <0.8

• CPK: 189 U/L

• Rheumatoid Factor <30.0 IU/ML

• Vitamin D : 46 (25-Hydroxy)

• Color, UA yellow

• Appearance, Urine clear

• Glucose, Ur neg

• Bilirubin Urine neg

• Ketones, Ua neg

• Specific Gravity, Urine 1.005

• Blood, Urine neg

• pH, Urine 5

• Protein Urine neg

• Urobilinogen, Ua 0.2

• Nitrite, Urine neg

• WBC Esterase/Urine neg

Labs in Inflammatory Disorders

Acute Phase Reactants: Blood proteins that are either increased or decreased w/in hours of inflammatory response.

CBC w/ diff: blood counts

CMP: liver and kidney functions

ANA: Elevated in SLE, Sjogren’s syndrome, RA, mixed connective tissue disease, scleroderma, polymyositis/dermatomyositis

Anti-extractable nuclear antigen (ENA): Highly specific for SLE, but only found in around 25% of SLE patients. Also found in systemic sclerosis and mixed connective tissue disease

Rheumatoid factor: Sensitive for detecting RA

Anti-cyclic citrullinated peptide antibody (CCP): A newer biomarker for RA. Do this lab w/ RF for RA dx. CCP can also be found in psoriatic arthritis, lupus, Sjogren’s syndrome, TB, and inflammatory myopathies.

(Castro & Gourley, 2010)

Differential Diagnosis

Mrs. LaMonica: 78 years-old w/ shoulder and hip pain, fatigue, morning stiffness and weakness x 1 month in addition to difficulty dressing herself, lifting her arms, and standing up from a seated position. Elevated ESR.

• Polymyalgia Rheumatica

• Rheumatoid Arthritis

• Fibromyalgia

• Polymyositis

• Overuse bursitis/tendonitis

Polymyalgia Rheumatica (PMR): An inflammatory rheumatologic disorder with manifestations of aching and morning stiffness that could involve the neck, hips, shoulders, and torso.

Polymyalgia Rheumatica

• Pathophysiology: The cause of PMR is not known, but inflammation is thought to occur due to an autoimmune reaction causing the immune system to attack the synovium. The reason for this is unknown. Environmental and genetic factors are thought to play a role.

• Risk Factors• Older age• Average age of onset is 70 years-old

• Sex• Females are twice as likely to develop PMR

• Ethnicity• Caucasian patients are more likely to develop PMR

(Saad, 2014)

Polymyalgia Rheumatica: ACR Diagnostic Criteria

1: An age of 50 years-old+ at onset

2: Bilateral aching & morning stiffness that lasts 30 minutes or more that persists for at least 1 month, and involves at least 2/3 following areas: neck or torso, shoulders or proximal regions of the arms, and hips or proximal aspects of the thighs

3: ESR (Westergren) elevated to 40 mm/h or more

4: Normocytic, normochromic anemia in approximately 50% of patients

Mrs. LaMonica: PMR Symptoms/RFs

• Shoulder and hip pain

• Morning stiffness

• >50 years-old

• Female

• Difficulty standing from seated position

• Elevated ESR

• Swelling in lower extremities

• Depression

• Rapid onset of symptoms; symptoms for one month

• Decreased ROM in wrists, shoulders, hips

PMR: Treatment• PO Steroid and Tapering Regimen

• Prednisone 15mg QD x 3 weeks• Then 12.5 mg QD x 3 weeks• Then 10 mg QD x 4-6 weeks• Then reduce by 1 mg Q 4-8 weeks OR alternate day reductions (7.5

mg/10 mg alternate days)

• IM Methylprednisolone: Used in milder cases. May reduce risk of steroid-induced complications.• Initial dose of 120 mg Q 3-4 weeks• Reduce by 20 mg Q 2-3 months

• Duration of Treatment: Normally, 1-3 years of treatment is needed. Some require small doses beyond this. Stop steroids when continued lack of inflammatory symptoms. If needing > 3 years of treatment, may need to consider alternative dx.

• Additional Therapies: Bone protection needed with LT corticosteroid therapy. (Dasgupta, 2010)

PMR: Relapse

Relapse should be treated ONLY under specialist care.

• Relapse includes recurring symptoms of PMR or new onset of GCA.

• Treating Relapse:• Onset of GCA• Follow usual treatment guidelines for GCA.

• Recurring PMR• Increase prednisone to previous higher dose

• Administer a single dose of IM methylprednisolone 120 mg

• After 2 relapses, need to consider immunosuppressive therapy.

(Dasgupta, 2010)

PMR and GCA can occur together. We need to assess Mrs. LaMonica for this, before implementing her

treatment plan!

Giant Cell Arteritis: A chronic systemic inflammatory vasculitis of both medium and large arteries that occurs in patients >50 years-old. It often affects superficial temporal arteries, and occurs due to an autoimmune reaction.

• Risk Factors: Etiology and pathogenesis unknown. • Diagnosis of PMR (15% w/ PMR will develop GCA)• Age (>50)• Sex (F>M)

(Dasgupta et al., 2010)

GCA• Diagnostics• Temporal Artery Biopsy• Can be negative in some patients. If they have a typical

clinical picture of GCA and respond to steroids, should be regarded as having GCA.

• Others: CBC, urea, electrolytes, LFTs, CRP, ESR• Acute-phase response is characteristic: elevated ESR,

CRP, anemia, abnormal LFTs, thrombocytosis, raised alk phos

(Dasgupta et al., 2010)

American College of Rheumatology Classification

Criteria for Giant Cell Arteritis Criterion[∗] DefinitionAge at disease onset ≥50 yr Development of symptoms or findings

beginning at age 50 or older

New headache New onset or new type of localized pain in the head

Temporal artery abnormality Temporal artery tenderness to palpation or decreased pulsation, unrelated to arteriosclerosis of cervical arteries

Elevated erythrocyte sedimentation rate (ESR) ESR ≥50 mm/hr by the Westergren method

Abnormal artery biopsy Biopsy specimen with artery showing vasculitis characterized by a predominance of mononuclear cell infiltration or granulomatous inflammation, usually with multinucleated giant cells

Symptoms of Giant Cell Arteritis

Symptom Frequency (%)

Headache 76

Weight loss 43

Fever 42

Fatigue 39

Any visual symptom 37

Anorexia 35

Jaw claudication 34

Polymyalgia rheumatica 34

Arthralgia 30

Unilateral visual loss 24

Bilateral visual loss 15

Vertigo 11

Diplopia 9

Mrs. LaMonica: GCA Symptoms/RFs

• 15-20% of patients with PMR might also have Giant Cell Arteritis (GCA).

• Positive findings: • >50 years-old • Elevated ESR• Occasional vertigo

• Negative findings:• No headache• No tenderness to temporal artery or decreased pulsation • No jaw claudication

Is it likely that Mrs. LaMonica could also have GCA?

If we had a strong suspicion for GCA, would a referral be urgent?

GCA: TreatmentIf Mrs. LaMonica were to develop GCA it would require a

PROMPT REFERRAL!• 1/5th of GCA cases result in irreversible blindness.

Preventable with prompt diagnosis and treatment.

• Glucocorticosteroids: Start while awaiting results from temporal artery biopsy. • Uncomplicated GCA (NO visual disturbance or jaw

claudication): 40-60 mg prednisone QD• Complicated GCA (evolving visual loss): 500 mg- 1 g of

IV methylprednisolone for 3 days before PO glucocorticosteroids

• Visual Loss: 60 mg prednisone QD to protect contralateral eye

• May require 1-2 years of treatment

(Dasgupta et al., 2010)

Plan• Pharmacologic: • Prednisone 15mg PO daily x 3 weeks, then 12.5mg PO daily x 3

weeks, then 10mg PO daily x 4-6 weeks, then reduce by 1mg Q 4-8weeks

• Continue calcium and vitamin D. Add a Bisphosphonate (Alendronate 10mg PO daily).

• D/C Ibuprofen. Start topical capsaicin for OA, 0.025 to 0.075% TID-QID, as needed. Acetaminophen 650-1000mg up to QID, as needed (no more than 4000mg/day to avoid liver toxicity).

• D/C Cyclobenzaprine. Increased r/of serotonin syndrome w./ Cymbalta. Also, increased r/of drowsiness and fatigue.

• Nonpharmacologic: Limit ETOH, do not smoke cigarettes, weight-bearing exercise (as tolerated)

• Education: Educate on prednisone therapy- can weaken immune system, no live vaccines, take w/ food, side effects; Educate on S/S of GCA and importance of seeking emergent care if these develop. Do NOT abruptly stop taking steroids.

(Dasgupta et al., 2009)

Recommendations for Glucocorticoid Treatment

Falls: Risk Factors

• Polypharmacy: 4+ medications

• Accident, environmental hazard

• Confusion, cognitive impairment

• Postural hypotension

• Medications: corticosteroids, sedatives, anxiolytic drugs, antihypertensive meds

Preventing Falls in the Elderly

• Elimination of environmental hazards

• Review and modify medications

• Provide balance training

• Involve family

• Provide follow-up

PMR: Follow-up & Monitoring

• Follow-up schedule: 24-72 hours; weeks 1-3, 6; months 3, 6, 9, 12 in first year (+ extra visits if relapse of adverse events)

• Clinical Monitoring: At each follow-up visit, assess for…• Response to treatment and disease activity• Disease complications (ex. GCA)• Atypical features• Side effects r/t steroid therapy

• Laboratory Monitoring • CBC, ESR, CRP, urea, electrolytes, glucose

Follow-upMrs. LaMonica returns two days later. Her HPI, ROS, and PE remain unchanged. You review the lab results with her and her daughter and discuss the likely differentials with patient as well as your plan of care.

Should we refer Mrs. LaMonica to a specialist?

Consider referral if…

A) Presentation with atypical features/features that are unlikely in PMR:

1. <60 years-old

2. >2 months onset

3. No shoulder involvement

4. No inflammatory stiffness

5. Prominent systemic features, night pain, wt loss, neuro signs

6. Symptoms of other rheumatic disease

7. Normal or extremely high acute-phase response

B) Dilemmas in treatment including:

1. Unresponsive or incomplete response to corticosteroids

2. Contraindications to corticosteroid therapy

3. A need for corticosteroid therapy that will be prolonged (>2 years)

Patients with typical clinical presentations, adequate response to treatment, and no adverse events can be managed in a primary care setting.

(Dasgupta et al., 2009)

Osteoporosis • Primary• Postmenopausal: low estrogen• Senile: occurs > 70 years-old

• Secondary: Caused by other etiologies• Diseases• Pharmacological therapy• Lifestyle behaviors

• Imaging Recommendations• BMD every two years, in the absence

of new risk factors.

• FRAX• http://www.shef.ac.uk/FRAX/

Mrs. LaMonica’s FRAX Score

Health Maintenance

What health maintenance does Mrs. LaMonica need, being that she is a 78 year-old female?

• Bone Mineral Density (every other year): Last done 4 years ago

• Colonoscopy (every 5-10 years after age 50)

• Mammogram (annually after age 40)

• Vaccinations: PNA (>65 years-old), Zostavax (>60 years-old), Tetanus

Sarah LaMonica

History of Present Illness

Sarah LaMonica is a 27-yr-old female who presents today with c/o painful red and swollen fingers, elbows, and knees for the past 3 weeks. She states her joints began to hurt after she returned from a 2 week backpacking trip with her partner along the Appalachian Trail. She denies injury but did have a tick bite. She c/o feeling fatigued even though she states she is resting well at night. She has not been able to do her usual daily workout or runs because of the stiffness and pain. She states it takes her “all morning to loosen up” and then she is still stiff, but not as bad. States this “has really messed my life up”. She denies other health issues other than PTSD. Reports her LMP was 1 week ago. Her grandmother, Sophia LaMonica is a patient here, and was recently diagnosed with PMR. Sarah wonders if she could have that too since she is so tired.

Social History• Lives with her partner, Diane and 9 month old adopted daughter,

Abbie. She attended college for one year but dropped out and joined the army. She had two tours in Iraq, one for 6 months followed by a second tour for 12 months. Manages a food co-op and taking some education classes.

• Denies smoking. Drinks 1-2 beers each weekend with her friends. Denies recreational drugs. Sexually active in monogamous relationship with partner of 5 years. States she has a good family relationship which has helped her deal with her PTSD since leaving the military. The food co-op does not provide health insurance and she cannot get coverage under her partner’s policy.

Family History

• Mother: 49yo- HTN, OA

• Father: 56yo- HTN, COPD, former smoker

• Brother: 18yo- healthy

• Sister: 16yo- asthma

• Paternal Grandmother: deceased 78yo- COPD, CHF

• Paternal Grandfather: deceased 82yo- COPD, MI

• Maternal Grandmother: 76yo- HTN, OA, PMR

• Maternal Grandfather: deceased 53yo- MI, HTN, CVA

• Maternal Aunt: deceased r/t SLE nephritis

Past Medical History

• PTSD

• Anxiety

• Appendectomy, age 9

Current Medications

• No prescription medications

• Takes daily MVI, Benadryl at night for sleep

• Was on Zoloft and Xanax for anxiety but could not afford it

Review of Systems• General: positive for – fatigue, negative

for weakness

• Psychological: positive anxiety, depression related to PTSD

• Ophthalmic:. Negative for blurry vision, vision loss, dry eyes

• ENT: Negative for - earache, sore throat, hoarseness, dysphagia, facial pain, and dry mouth

• Allergy and Immunology: negative for hx of allergies or frequent infections

• Hematological and Lymphatic: negative for excessive bruising, swollen or painful nodes

• Endocrine: negative for hx of diabetes, thyroid problems

• Respiratory: negative, denies SOB, wheezing, cough

• Cardiovascular: negative for Chest pain, palpitations, edema

• Gastrointestinal: negative for reflux, black or bloody stools, indigestion

• Genitourinary: negative for hx of UTI, menorrhagia, metrorrhagia

• Musculoskeletal: Positive for - Joint pain, Stiffness and Morning stiffness, joint swelling

• Neurological: negative for - headaches and numbness/tingling

• Skin/Hair/Nails: Negative for rash, itch, unusual lesions, abnormal nails.

Physical Exam• General: healthy, NAD

• Skin/Nails: no rashes, ulcers; nails normal

• Lymph: no adenopathy noted

• Scalp/Hair: no scaling, no alopecia

• Eyes: non injected, PEERLA, EOMS full

• Mouth: normal mucosa moisture, no ulcers

• Neck: no masses, thyroid normal

• CV: RRR, normal S1 & S2, no murmurs or rubs

• Lungs: clear to auscultation

• Abd: non tender, no organomegaly

• C-Spine: normal lateral rotation, lateral bending, flexion and extension

• T-Spine: normal flexion and extension, no tenderness, normal alignment

• L-S Spine: normal flexion and extension, no tenderness, normal alignment

• Reflexes: 2+ biceps, triceps, brachioradialis, knee and ankle

• Muscles: 5/5 for deltoids, biceps, triceps, quadriceps, hamstrings and hip flexors

• Sensation: normal to light touch, vibration and position

• Shoulders: FROM, no swelling

• Elbows: 1+ swelling R elbow; trace L elbow

• Wrists: trace swelling & tenderness bilateral wrists

• MCPs: 3+ tenderness throughout with trace swelling 1, 2 L, 1+ 1,2 R

• PIPs: 2+ swelling & tenderness 2-5 bilaterally

• DIPs: no swelling, no tenderness

• HIPs: FROM, no swelling

• Knees: L FROM, Tenderness; R 1 + tenderness, 1-2+ swelling, no redness, mildly increased warmth

• Ankles: no tenderness or swelling

• Feet/toes: no swelling or tenderness

• Bursa: no tenderness or swelling

Physical Exam

Swollen PIPs

5

43

2

1

No swollen DIPs

Swollen MCPs

Physical Exam

Swollen knee

Evaluation

• Differential Diagnosis• Rheumatoid arthritis• Lyme disease• SLE• Osteoarthritis • Psoriatic arthritis

Labs and Diagnostics

• CBC w/ differential

• CMP

• Rheumatoid Factor

• Acute Phase Reactants: ESR, CRP

• Anticyclic citrullinated peptide (Anti-CCP) antibodies

• Imaging: Ms. LaMonica is uninsured. Would you obtain an X-ray on this patient?

Lab Results: CBC

Lab Results: CMP

Lab Results

The 2010 ACR-EULAR Classification Criteria for RA

Score

A) Joint Involvement

1 large joint 0

2-10 large joints 1

1-3 small joints (w/ or w/o involvement of large joints)

2

4-10 small joints (w/ or w/o involvement of large joints)

3

>10 joints (at least 1 small joint) 5

B) Serology (at least 1 test result needed for classification)

Negative RF and negative anti-CCP 0

Low-positive RF or low-positive anti-CCP 2

High-positive RF or high-positive anti-CCP 3

C) Acute-phase reactants (at least 1 needed for class.)

Normal CRP and normal ESR 0

Abnormal CRP or abnormal ESR 1

D) Duration of symptoms

<6 weeks 0

>/=6 weeks 1

Sarah LaMonica

Score

A) Joint Involvement

1 large joint 0

2-10 large joints 1

1-3 small joints (w/ or w/o involvement of large joints)

2

4-10 small joints (w/ or w/o involvement of large joints)

3

>10 joints (at least 1 small joint) 5

B) Serology (at least 1 test result needed for classification)

Negative RF and negative anti-CCP 0

Low-positive RF or low-positive anti-CCP 2

High-positive RF or high-positive anti-CCP 3

C) Acute-phase reactants (at least 1 needed for class.)

Normal CRP and normal ESR 0

Abnormal CRP or abnormal ESR 1

D) Duration of symptoms

<6 weeks 0

>/=6 weeks 1

Rheumatoid Arthritis

• Definition: An inflammatory disease characterized by swelling, pain, stiffness, and loss of function of joints. Commonly occurs in wrist and fingers.

• Pathophysiology: Autoimmune. WBCs travel to synovium and cause synovitis, resulting in warm, red, swollen, and painful joints. With progression of disease, inflammation of the synovium results in destruction of cartilage and bone in the joint. Thought to be caused by environmental and genetic factors.

• Risk Factors:• Sex: F>M• Age: middle-age• Family history

(U.S. National Library of Medicine, 2015)

Rheumatoid Arthritis

(ACR, 2012)

Clinical Practice Guidelines: Treatment of Early RA

(Singh et al, 2012)

(Singh et al, 2012)

Pharmacological Interventions for RA

There is NO cure for RA. The goal of treatment is to lessen symptoms and slow progression of disease.

• Glucocorticoids: May be prescribed at initial presentation of RA symptoms or for flares. Resolution of joint pain and inflammation after steroid therapy can help further confirm susceptibility of RA.

• NSAIDs: Improve mobility. Help with pain.

• DMARDs: Mainstay treatment; methotrexate, hydroxychloroquine, sulfasalazine, leflunomide

• Biologic agents: abatacept, humira, anakinra, etanercept, remicaide, rituxan, etc.; normally taken w/ methotrexate

(ACR, 2012)

Non-pharmacological Interventions for RA

• Diet• Low cholesterol (at risk for CAD)• Fish oils, plant oils can improve pain and swelling of joints

• Occupational/physical therapy: Can help preserve joint function

• Splints: Reduce joint pain and improve function of joints

• Exercise• Increase ROM: preserve/restore joint function• Increase strength: isotonic, isometric, isokinetic • Increase endurance: walking, cycling, swimming

• Surgery: End-stage RA; damaged joints

(National Guideline Clearinghouse, 2012)

Sarah LaMonica: Plan• What medications will you prescribe, if any?• Prednisone, taper as directed.

• What education will you provide the patient with?• Take prednisone with food. Discuss side effects:

emotional lability, appetite changes, anxiety, insomnia, headache, weight gain, etc.

• What are her options for obtaining health insurance?• Medicaid: see if she meets qualifications• Medically Indigent Adult Programs• Veterans Benefits

(Forester, 2009)

Follow-up

Ms. LaMonica returns to the clinic in one week. Her joint swelling has improved on prednisone and she generally is feeling much better. She continues on prednisone taper.

PE: Unchanged other than she now has no swelling in her joints.

What is your diagnosis, based on the findings?

Plan

• Prescriptions: NSAIDs, if still having joint pain. Continue prednisone taper.

• Referrals: Rheumatology, first available appointment. Send over copies of her office notes, labs, and current medications.

• Patient Education: Educate patient on rheumatoid arthritis and how it can be managed. Educate on importance of seeing rheumatologist.

• Follow-up: After rheumatology consult, and as needed.

The Uninsured

Resources for PCP:

• GoodRx

• What You Can Do to Help Uninsured Patients: http://www.aafp.org/fpm/2009/0900/p21.html• Is the patient really uninsurable?• Review OOP costs of labs/diagnostics with patients• Prescribe generic medications• Be aware of large retail companies offering more

affordable medication prices • Offer discounts to cash-paying patients

PTSDSarah, returns several months later. She has been diagnosed with RA. The diagnosis seems to have triggered her nightmares, anxiety and insomnia. She is having a hard time taking care of Abbie and had to quit her job. Things were going so well. Now she needs your help. Can you give her something for sleep? She just wants to be knocked out.

PTSD

• Definition: Occur in patients for >1 month after being exposed to a traumatic event causing them significant distress or impairment in occupational, social or other areas of functioning.

• Symptoms: avoidance of stimuli associated w/ traumatizing event, re-experiencing of the traumatic event, numbing sensation, increased arousal • PTSD can appear alone, or more commonly w/ co-occurring

conditions (insomnia, identity problems, mood changes, difficulties in interpersonal relationships, nightmares, chronic pain) or with other psychiatric disorders (anxiety, depression, substance abuse)

May have delayed onset (at least 6 months after the event).

(Department of Veterans Affairs, 2010)

PTSD: ScreeningIn primary care, the PTSD Screen is used:

In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you:

1. Have had nightmares about it or thought about it when you did not want to?

YES / NO

2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?

YES / NO

3. Were constantly on guard, watchful, or easily startled?YES / NO

4. Felt numb or detached from others, activities, or your surroundings?YES / NO

The results of this test are considered "positive" if a patient answers "yes" to any three items.

(Department of Veterans Affairs, 2010)

PTSD: Treatment• First-line treatment for PTSD based on guidelines suggest

the initiation of psychotherapeutic interventions using effective modalities of trauma-focused therapy or stress management AND/OR initiating pharmacotherapy (mono-therapy using SSRI or SNRI)

• Adjunctive therapy might include treatment of symptom-specific management including insomnia, pain, or anger.

• Ensure the patient has an adequate support system.

(Department of Veterans Affairs, 2010)

PTSD: Resources• General and mental

health; Refer patient!

• Support groups

• VA Benefits Counselors

• PTSD Association

• Anxiety and Depression Association of America

• National Alliance for Mental Illness

References • American College of Rheumatology. (2012). Rheumatoid arthritis. Retrieved from:

https://www.rheumatology.org/Practice/Clinical/Patients/Diseases_And_Conditions/Rheumatoid_Arthritis/

• American College of Rheumatology. (2010). Rheumatoid arthritis classification. Retrieved from: https://www.rheumatology.org/practice/clinical/classification/ra/ra_2010.asp

• Castro, C. & Gourley, M. (2010). Diagnostic testing and interpretation of tests for autoimmunity. The Journal of Allergy and Clinical Immunology, 125(2), 238-247.

• Clauw, D.J. (2014). Fibromyalgia: A clinical review. The Journal of the American Medical Association, 311(15), 1547-1555.

• Dasgupta, B., Borg, F., Hassan, N., Barraclough, K., Bourke, B., Fulcher, J.,… & Hollywood, J. (2009). BSR and BHPR guidelines for the management of polymyalgia rheumatica. Oxford Journals, 109(10), 1-5.

• Dasguta, B. (2010). Concise guidance: Diagnosis and management of giant cell arteritis. Retrieved from: https://www.rcplondon.ac.uk/sites/default/files/giant-cell-arteritis-concise-guideline.pdf

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