Rheumatoid Arthritis - Diffuse Connective Tissue Diseases

RHEUMATOID ARTHRITIS

Pathophysiology

RA is commonly used as the prototype for inflammatory arthritis. The incidence rate is approximately 3%, with a two to three times greater incidence in women (Ruddy et al., 2001). In RA, the autoimmune reaction (Fig. 54-3) primarily occurs in the synovial tissue. Phagocytosis produces enzymes within the joint. The en-zymes break down collagen, causing edema, proliferation of the synovial membrane, and ultimately pannus formation. Pannus destroys cartilage and erodes the bone. The consequence is loss of articular surfaces and joint motion. Muscle fibers undergo de-generative changes. Tendon and ligament elasticity and contrac-tile power are lost.

Clinical Manifestations

Clinical manifestations of RA vary, usually reflecting the stage and severity of the disease. Joint pain, swelling, warmth, ery-thema, and lack of function are classic. Palpation of the joints re-veals spongy or boggy tissue. Often fluid can be aspirated from the inflamed joint. Characteristically, the pattern of joint in-volvement begins with the small joints in the hands, wrists, and feet. As the disease progresses, the knees, shoulders, hips, elbows, ankles, cervical spine, and temporomandibular joints are in-volved. The onset of symptoms is usually acute. Symptoms are usually bilateral and symmetric. In addition to joint pain and swelling, another classic sign of RA is joint stiffness, especially in the morning, lasting for more than 30 minutes (Klippel, 2001).

In the early stages of disease, even before bony changes occur, limitation in function can occur when there is active inflamma-tion in the joints. Joints that are hot, swollen, and painful are not easily moved. The patient tends to guard or protect these joints through immobilization. Immobilization for extended periods can lead to contractures, creating soft tissue deformity.

Deformities of the hands and feet are common in RA (Fig. 54-4). The deformity may be caused by misalignment re-sulting from swelling, progressive joint destruction, or the sub-luxation (partial dislocation) that occurs when a bone slips over another and eliminates the joint space.

RA is a systemic disease with multiple extra-articular features. Most common are fever, weight loss, fatigue, anemia, lymph node enlargement, and Raynaud’s phenomenon (cold- and stress-induced vasospasm causing episodes of digital blanching or cyanosis). 

Rheumatoid nodules may be noted in patients with more advanced RA and develop at some time in up to half of pa-tients (Klippel, 2001). These nodules are usually nontender and movable in the subcutaneous tissue. They usually appear over bony prominences such as the elbow, are varied in size, and can disappear spontaneously. Nodules occur only in individuals who have rheumatoid factor. The nodules often are associated with rapidly progressive and destructive disease. Other extra-articular features include arteritis, neuropathy, scleritis, pericarditis, spleno-megaly, and Sjögren’s syndrome (dry eyes and dry mucous membranes).

Assessment and Diagnostic Findings

Several factors can contribute to a diagnosis of RA: rheumatoid nodules, joint inflammation detected on palpation, and certain laboratory findings. The history and physical examination ad-dress manifestations such as bilateral and symmetric stiffness, ten-derness, swelling, and temperature changes in the joints. The patient is also assessed for extra-articular changes; these often in-clude weight loss, sensory changes, lymph node enlargement, and fatigue. Rheumatoid factor is present in more than 80% of pa-tients with RA, but its presence alone is not diagnostic of RA. The erythrocyte sedimentation rate (ESR) is significantly elevated with RA. The red blood cell count and C4 complement compo-nent are decreased. C-reactive protein and antinuclear antibody test results may also be positive. Arthrocentesis shows synovial fluid that is cloudy, milky, or dark yellow and contains numerous inflammatory components, such as leukocytes and complement.

X-ray studies, performed to help diagnose and monitor the progression of disease, show characteristic bony erosions and nar-rowed joint spaces occurring later in the disease.

Medical Management

EARLY-STAGE RA

In patients with early RA, treatment begins with education, a bal-ance of rest and exercise, and referral to community agencies for support. Medical management begins with therapeutic doses of salicylates or NSAIDs. When used in full therapeutic dosages, these medications provide both anti-inflammatory and analgesic effects. Taking medications as prescribed to maintain a consistent blood level is necessary to optimize the effectiveness of the anti-inflammatory medication.

Several COX-2 inhibitors, another class of NSAIDs, have been approved for treatment of RA. COX (cyclo-oxygenase) is an enzyme involved in the inflammatory process. COX-2 inhibitors block the enzyme involved in inflammation while leaving intact the enzyme involved in protecting the stomach lining. As a result, COX-2 inhibitors are less likely to cause gastric irritation and ulceration than other NSAIDs (Bombardier et al., 2000).

The trend in management is toward a more aggressive pharma-cologic approach earlier in the disease. A window of opportunity for symptom control and improved disease management occurs within the first 2 years of disease onset. Therefore, the disease-modifying antirheumatic agents (antimalarials, gold, penicillamine, or sulfasalazine) are initiated early in treatment. If symptoms ap-pear to be aggressive (ie, early bony erosions as seen on x-rays), methotrexate may be considered. Methotrexate is currently the gold standard in the treatment of RA because of its success in im-proving disease parameters (ie, pain, tender and swollen joints, quality of life). The goals are to control symptoms and prevent destruction of the joints (Koopman, 2001).

An alternative treatment approach for RA has emerged in the area of biologic therapies. Biologic response modifiers are a group of agents that consist of molecules produced by cells of the im-mune system or by cells that participate in the inflammatory re-actions (Koopman, 2001). Recent studies (Moreland et al., 1999; Weinblatt et al., 1999) using tumor necrosis factor-alpha in-hibitors, both alone and in combination with other medications, have shown that patients demonstrate significant improvement based on American College of Rheumatology criteria (Felson et al., 1995). Two examples of biologic response modifiers that are cur-rently available are enatercept (Enbrel) and infliximab (Remicade). These agents inhibit the function of tumor necrosis factor-alpha, a key cytokine known to play a role in the disease process in RA (Miller, 2001). Research in this area is ongoing.

Additional analgesia may be prescribed for periods of extreme pain. Opioid analgesics are avoided because of the potential for continuing need for pain relief. Nonpharmacologic pain man-agement techniques (eg, relaxation techniques, heat and cold applications) are taught.

MODERATE, EROSIVE RA

For moderate, erosive RA, a formal program with occupational and physical therapy is prescribed to educate the patient about principles of joint protection, pacing activities, work simplifica-tion, range of motion, and muscle-strengthening exercises. The patient is encouraged to participate actively in the management program. The medication program is reevaluated periodically, and appropriate changes are made if indicated. Cyclosporine,an immunomodulator, may be added to enhance the disease-modifying effect of methotrexate.

PERSISTENT, EROSIVE RA

For persistent, erosive RA, reconstructive surgery and cortico-steroids are often used. Reconstructive surgery is indicated when pain cannot be relieved by conservative measures. Surgical pro-cedures include synovectomy (excision of the synovial membrane), tenorrhaphy (suturing a tendon), arthrodesis (surgical fusion of the joint), and arthroplasty (surgical repair and replacement of the joint). Surgery is not performed during disease flares.

Systemic corticosteroids are used when the patient has un-remitting inflammation and pain or needs a “bridging” medication while waiting for the slower disease-modifying antirheumatic agent (eg, methotrexate) to begin working. Low-dose cortico-steroid therapy is prescribed for the shortest time necessary to minimize side effects. Joints that are severely inflamed and fail to respond promptly to the measures outlined previously may be treated by local injection of a corticosteroid (Ruddy et al., 2001).

ADVANCED, UNREMITTING RA

For advanced, unremitting RA, immunosuppressive agents are prescribed because of their ability to affect the production of anti-bodies at the cellular level. These include high-dose methotrexate (Rheumatrex), cyclophosphamide (Cytoxan), and azathioprine (Imuran). These medications, however, are highly toxic and can produce bone marrow suppression, anemia, gastrointestinal dis-turbances, and rashes.

Through all stages of RA, depression and sleep deprivation may require the short-term use of low-dose antidepressant med-ications, such as amitriptyline (Elavil), paroxetine (Paxil), or ser-traline (Zoloft), to reestablish an adequate sleep pattern and to manage chronic pain better.

The FDA has approved a medical device for use in treating pa-tients with more severe and longstanding cases of RA who have failed to respond to or are intolerant of disease-modifying anti-rheumatic drugs. The device, a protein A Immunoadsorption column (Prosorba), is used in 12 weekly 2-hour apheresis treat-ments to bind IgG (ie, circulating immune complex). In this unique population of patients, a significant improvement using the American College of Rheumatology Criteria for Improvement has been demonstrated in several studies using the Prosorba column (Felson et al., 1999; Gendreau, 2001).

Nutrition Therapy

Patients with RA frequently experience anorexia, weight loss, and anemia. A dietary history identifies usual eating habits and food preferences. Food selection should include the daily requirements from the basic food groups, with emphasis on foods high in vit-amins, protein, and iron for tissue building and repair. For the extremely anorexic patient, small, frequent feedings with in-creased protein supplements may be prescribed. Some medica-tions (ie, oral corticosteroids) used in RA treatment stimulate the appetite and, when combined with decreased activity, may lead to weight gain. Therefore, patients may need to be counseled about eating a healthy, calorie-restricted diet.

Nursing Management

Nursing care of the patient with RA follows the basic plan of care presented earlier. The most common issues for the patient with RA include pain, sleep disturbance, fatigue, altered mood, and limited mobility. The patient with newly diag-nosed RA needs information about the disease to make daily self-management decisions and to cope with having a chronic disease.

Because of repeated contact with the patient, the nurse has the opportunity to assess and intervene in patient concerns and issues that occur with the diagnosis of a chronic illness such as RA. Because the disease commonly affects young women, major con-cerns may be related to the effects of the disease on childbearing potential, caring for family, or work responsibilities. The patient with a chronic illness may seek a “cure” or have questions about alternative therapies. Frequently, however, patients are hesitant to share their concerns with health care professionals (American College of Rheumatology, 1998).