NUR 635 Topic 8 DQ 1

Sample Answer for NUR 635 Topic 8 DQ 1 Included After Question

AJ is a student enrolled in the FNP program at Grand Canyon University. She is on her first clinical rotation, and she is asked to review a patient chart. AJ notices rheumatoid arthritis (RA) on a patient’s past medical history. AJ is not familiar with the treatment of RA, so her preceptor encourages her to do some research on the topic to gain a better understanding of RA. She is given the American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis to read.

Briefly describe the pathophysiology associated with rheumatoid arthritis. Based on the most current version of the American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis, use the following drug classes to complete the questions below:

  • Conventional DMARDs
  • Biologic DMARDs
  • Targeted synthetic DMARDs
  • Glucocorticoids

Identify a medication from one of the above drug classes, and briefly describe how the mechanism of action can treat rheumatoid arthritis. Determine monitoring, side effects, and drug-drug interactions associated with each medication. Based on the American College of Rheumatology, discuss the place in therapy for each medication class. 

American Association of Colleges of Nursing Core Competencies for Professional Nursing Education 

This assignment aligns to AACN Core Competencies 1.2, 2.2, 2.5. 4.2, 6.4, 9.2

A Sample Answer For the Assignment: NUR 635 Topic 8 DQ 1

Title: NUR 635 Topic 8 DQ 1

Pathophysiology of Rheumatoid Arthritis (RA):

RA is an autoimmune disease characterized by chronic inflammation of the synovial lining of the joints. In RA, the immune system mistakenly attacks the synovium, leading to the formation of a hyperplastic synovial membrane. This results in the production of inflammatory cytokines, which, in turn, cause destruction of cartilage and bone in the affected joints, leading to symptoms such as pain, swelling, stiffness, and joint deformities (Chauhan, 2023).

Current Drug Classes for RA Treatment:

Conventional DMARDs (Disease-Modifying Antirheumatic Drugs):
   – Medication Example: Methotrexate
   – Mechanism of Action: Methotrexate inhibits immune cell proliferation, particularly lymphocytes, and reduces the production of inflammatory cytokines, thus suppressing the autoimmune response (Rosenthal, 2020).
   – Monitoring: Patients on methotrexate require regular blood tests to monitor liver function, blood counts, and kidney function.
   – Side Effects: Common side effects include nausea, liver toxicity, and bone marrow suppression.
   – Place in Therapy: Methotrexate is often considered a first-line treatment for RA due to its efficacy and relatively favorable side effect profile.

Biologic DMARDs


   – Medication Example: Adalimumab (a TNF-alpha inhibitor)
   – Mechanism of Action: Adalimumab and other biologics target specific proteins or cells in the immune system to reduce inflammation. In this case, it inhibits TNF-alpha, a pro-inflammatory cytokine (Rosenthal, 2020).
   – Monitoring: Regular monitoring for infections, including tuberculosis, is necessary as biologics can suppress the immune system.
   – Side Effects: Common side effects include an increased risk of infections and injection site reactions.
   – Place in Therapy: Biologics are often used when conventional DMARDs have not been effective or in more severe cases of RA.

Targeted Synthetic DMARDs:


   – Medication Example: Tofacitinib
   – Mechanism of Action: Tofacitinib is a Janus kinase (JAK) inhibitor that modulates the immune response by interfering with the signaling pathways of certain cytokines (Pang, 2022).
   – Monitoring: Regular monitoring for side effects, including liver enzyme levels and blood counts, is required.
   – Side Effects: Potential side effects include an increased risk of infections, liver problems, and changes in blood cell counts.
   – Place in Therapy: Targeted synthetic DMARDs are often used in cases where other treatments have not been effective, similar to biologics.

Glucocorticoids:


   – Medication Example: Prednisone
   – Mechanism of Action: Glucocorticoids, such as prednisone, have anti-inflammatory and immunosuppressive effects, helping to reduce inflammation and pain in RA (Rosenthal, 2020).
   – Monitoring: Patients on long-term glucocorticoid therapy may require monitoring for bone density and potential side effects.
   – Side Effects: Long-term use can lead to numerous side effects, including weight gain, bone thinning, and an increased susceptibility to infections.
   – Place in Therapy: Glucocorticoids are often used as a bridge therapy to manage acute symptoms of RA while waiting for other DMARDs to take effect or to control flares.

For the most current and specific information on the guidelines and medications for RA treatment, it is essential to refer to the most recent version of the American College of Rheumatology Guidelines (Singh, 2015) or consult with a healthcare professional.

Chauhan K, Jandu JS, Brent LH, et al. Rheumatoid Arthritis. [Updated 2023 May 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441999/

Rosenthal, L. D., & Burchum, J. R. (2020). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants – e-book (2nd ed.). Elsevier Health Sciences.

Pang, M., Sun, Z., & Zhang, H. (2022). Biologic DMARDs and targeted synthetic DMARDs and the risk of all-cause mortality in rheumatoid arthritis: A systematic review and meta-analysis. Medicine101(32), e29838. https://doi.org/10.1097/MD.0000000000029838

Singh JA, Saag KG, Bridges SL Jr, Akl EA, Bannuru RR, Sullivan MC, et al. 2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Rheumatol 2016;68:1–26.

A Sample Answer 2 For the Assignment: NUR 635 Topic 8 DQ 1

Title: NUR 635 Topic 8 DQ 1

Pathophysiology Associated with Rheumatoid Arthritis

Rheumatoid Arthritis (RA) is an autoimmune inflammatory disorder primarily affecting the joints, but also many tissues and organs. This is thought to result from genetic and unknown environmental factors (McCance & Huether, 2018). RA is chronic and progressive. Pharmacological therapy may slow progression or alleviate symptoms and achieve remission, but RA has no cure. 

Characteristics of RA are synovial inflammation, joint swelling, and ankylosis, and destruction of articular cartilage (McCance & Huether, 2018). The exaggerated immune response results in leukocyte infiltration into the synovium and precedes the development of synovitis and eventual joint damage. Inflammatory cytokines convert the synovium into a thick, abnormal layer of granulation tissue that acts like an invasive tumor with joints. Eventual loss of range of motion, cartilage fibrosis, and joint ankylosis destroys the symmetric joints involved (McCance & Huether, 2018). Virtually any joint may be affected, but most often the fingers, feet, wrists, elbows, shoulders, hips, cervical spine, and knees. The tissues of the lungs, kidneys, heart, and skin become involved as well. Fever, malaise, skin rashes, lymph node or spleen enlargement are possible symptoms. Raynaud phenomenon is also associated with RA (McCance & Huether, 2018).

American College of Rheumatology Treatment Guidelines

Treatment is directed at maintaining function, relieving symptoms, minimizing systemic involvement, and delaying disease progression. Early treatment of RA begins with disease-modifying antirheumatic drugs (DMARDs) monotherapy with methotrexate (MTX) (Fraenkel et al., 2018). Sulfasalazine is conditionally recommended over methotrexate for people with low disease activity who do not tolerate MTX. The most recent ACR update recommends an initial trial of hydroxychloroquine or sulfasalazine for those with low disease activity (Fraenkel et al., 2018).

Conventional Disease-Modifying Antirheumatic Drugs (DMARDs)

Conventional DMARDs were the first developed for RA management. These drugs cost much less than the biologic and targeted DMARDS, largely because the conventional agents are easier to make. Conventional DMARDs are small molecules that are synthesized using conventional chemicaltechniques. Some examples are Methotrexate, Sulfasalazine, Leflunomide, Hydroxychloroquine.

Sulfasalazine (Azulfidine, Azulfidine EN-tabs)

Sulfasalazine is used in RA management to slow the progression of joint deterioration. Immunosuppression is a key mechanism for this drug. Sulfasalazine is recommended over methotrexate because it is less immunosuppressive, and the patient panel felt that many patients with low disease activity would prefer to avoid the side effects associated with methotrexate (Fraenkel et al., 2018).

Gastrointestinal reactions such as nausea, vomiting, diarrhea, anorexia, abdominal pain are the most common reasons for stopping treatment (Rosenthal & Burchum, 2020). These reactions can be minimized by using an enteric-coated formulation and dividing the daily dosage. Other common side effects are pruritus, rash, or urticaria. Periodic monitoring for hepatitis and bone marrow function are recommended due to a rare risk of drug-induced effects. Sulfasalazine should not be prescribed for patients with sulfa allergy. The drug is prepared in Immediate or extended release 500mg tablets. Standard dosing begins at 0.5g-1g per day and maintenance dosing 1g three times daily.

Biologic DMARDs

The biologic DMARDs are large molecules produced through recombinant DNA technology to target specific components of the inflammatory process. These drugs are usually combined with methotrexate (Rosenthal & Burchum, 2020).

Targeted synthetic DMARDs

Targeted DMARDs act on the immune system and pose a risk for serious and sometimes life-threatening infections.

Glucocorticoids

According to the ACR guidelines, glucocorticoids should not be systematically prescribed. Short-term glucocorticoids are frequently necessary to alleviate symptoms prior to the onset of action of DMARDs. Significant toxicity is why glucocorticoids are recommended to be intermittent or short term. However, glucocorticoids may be indicated over starting a new DMARD drug.

References

McCance, K. L., & Huether, S. E. (2018). Pathophysiology – e-book (8th ed.). Elsevier Health Sciences.

Fraenkel, L., Bathon, J. M., England, B. R., St. Clair, E. W., Arayssi, T., Carandang, K., Deane, K. D., Genovese, M., Huston, K. K., Kerr, G., Kremer, J., Nakamura, M. C., Russell, L. A., Singh, J. A., Smith, B. J., Sparks, J. A., Venkatachalam, S., Weinblatt, M. E., Al‐Gibbawi, M., . . . Akl, E. A. (2021). 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis & Rheumatology (Hoboken, N.J.), 73(7), 1108-1123. https://doi.org/10.1002/art.41752

Rosenthal, L. D., & Burchum, J. R. (2020). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants – e-book (2nd ed.). Elsevier Health Sciences.