Case 063: Rheumatoid Arthritis

PATIENT PRESENTATION

Chief Complaint

“Everything hurts”

History of Present Illness

Ester presents to the office today with complaints of increased joint pain and swelling and increased frequency of migraines (every other day for the last month). She states that it is very difficult for her to start her day because it takes almost 90 minutes for her joint stiffness to decrease enough for her to function.

Link to EMR

Student Work-Up

TARGETED QUESTIONS

1. What are the patient’s risk factors for rheumatoid arthritis?

   Hint: See Epidemiology and Etiology in PPP

2. What are the comorbidities associated with RA?

   Hint: See Pathophysiology in PPP

3. Does rheumatoid factor negativity make a difference in deciding which medication to initiate in this patient?

   Hint: See Treatment in PPP

4. After further discussion, it is determined that the patient would prefer to receive medication via infusion rather than self-administer injections. How will this influence your treatment recommendation?

   Hint: See Treatment and Table 58-4 in PPP

5. When should this patient be evaluated again? How will you determine if the regimen is safe and effective?

   Hint: See Treatment in PPP

FOLLOW-UP

The patient returns in 6 months and indicates that she is considering pregnancy. What modifications, if any, would you recommend to her RA medication regimen?

Hint: See Treatment in PPP

CASE SUMMARY

Global Perspective

A significant worldwide challenge in health care is medication shortages and the impact it has on delivering patient care. There are many factors that may lead to a shortage, for example, manufacturing, regulatory, and procurement issues. Shortages place significant burdens on pharmacists and prescribers to find alternative treatments, if available, and may lead to adverse clinical or economic outcomes. For purposes of this case, there is currently a hypothetical global shortage of infliximab and golimumab.

Key References