HESI PHARMACOLOGY EXAM Drug Therapy of Rheumatoid Arthritis

A patient about to begin therapy with etanercept has a positive tuberculin skin test. A chest radiograph is negative. The nurse will expect this patient to: a. begin taking antituberculosis drugs at the beginning of treatment with etanercept. b. have periodic chest radiographs during treatment with etanercept. c. have regular monitoring of symptoms to detect active tuberculosis. d. undergo tuberculosis treatment prior to beginning etanercept treatment. ANS: D Since tuberculosis (TB) in a patient taking etanercept is often extrapulmonary and disseminated, it is important to test all patients for TB. Those who test positive for latent TB should be treated for TB before etanercept treatment is begun. It is not correct to begin TB treatment concurrently with etanercept treatment. Latent TB must be treated and not monitored. A child who has juvenile idiopathic arthritis and who has been taking methotrexate [Rheumatrex] will begin a course of abatacept [Orencia]. What will the nurse include when teaching the child's family about this drug? a. That abatacept and methotrexate must both be taken to be effective b. To continue getting vaccinations during therapy with abatacept c. That signs of infection may warrant immediate discontinuation of abatacept d. That a tumor necrosis factor (TNF) antagonist may be added if this therapy is not effective ANS: C Abatacept suppresses immune function and can increase the risk of serious infection. Parents should report any signs of infection, which may warrant discontinuation of abatacept. Abatacept may be taken alone. Abatacept may blunt the effectiveness of vaccines, and vaccines should be up to date prior to therapy and may need to be delayed until 3 months after therapy. Live vaccines should be avoided. Abatacept should not be given with TNF antagonists because of the increased risk of serious infections. A patient will begin taking hydroxychloroquine [Plaquenil] for rheumatoid arthritis. The patient is currently taking high-dose NSAIDs and methotrexate. What will the nurse teach the patient? a. That an eye examination is necessary at the beginning of therapy with this drug b. That the dose of NSAIDs may be decreased when beginning hydroxychloroquine c. To obtain tests of renal and hepatic function while taking this drug d. To stop taking methotrexate when starting hydroxychloroquine ANS: A Hydroxychloroquine can cause retinal damage so an eye examination is necessary at the onset of treatment as well as every 6 months during treatment. Patients taking other drugs should continue to take those when beginning treatment with hydroxychloroquine since full therapeutic effects take months to develop. Renal and hepatic toxicity are not concerns. The drug is usually combined with methotrexate. A patient will begin taking etanercept [Enbrel] for severe rheumatoid arthritis. The patient has been taking methotrexate [Rheumatrex]. The patient asks if the etanercept is stronger than the methotrexate. The nurse will tell the patient that etanercept __ methotrexate. a. has synergistic effects with b. helps reduce adverse effects associated with c. is better at delaying progression of joint damage than d. has fewer adverse effects than ANS: C Etanercept has been shown to reduce symptoms in patients with moderate to severe RA who have not responded to methotrexate. It does not have synergistic effects with methotrexate or reduce adverse effects of methotrexate. It has many adverse effects. A patient with rheumatoid arthritis is taking leflunomide [Arava] and an oral contraceptive. She tells the nurse she would like to get pregnant. What will the nurse tell her? a. That leflunomide is not dangerous during the first trimester of pregnancy. b. That plasma levels of leflunomide will drop rapidly when she stops taking it. c. To ask her provider about an 11-day course of cholestyramine. d. To stop taking leflunomide when she stops using contraception. ANS: C Leflunomide is contraindicated during pregnancy. Patients desiring pregnancy must follow a three- step protocol that includes stopping the drug, taking cholestyramine to chelate the leflunomide, and ensuring that leflunomide drug levels are below 20 μg/L before getting pregnant. Leflunomide is teratogenic and is not safe during pregnancy. Plasma levels of leflunomide may take 2 years to drop without using cholestyramine. It is not correct to stop taking leflunomide without following the protocol. A patient is beginning therapy with oral methotrexate [Rheumatrex] for rheumatoid arthritis. The nurse will teach this patient about the importance of: a. having routine renal and hepatic function tests. b. limiting folic acid consumption. c. reporting alopecia and rash. d. taking the medication on a daily basis. ANS: A Periodic tests of renal and liver function are mandatory for patients taking methotrexate. Patients taking methotrexate should take folic acid supplements. Alopecia and rash are not worrisome side effects. Methotrexate is taken once weekly. A nurse is discussing the administration of an intravenous infusion of rituximab (Rituxan) with a nursing student. Which statement by the student indicates a need for further education about the care of a patient receiving this drug? a. "Angioedema and hypersensitivity may occur, but they are usually self-limiting and mild." b. "I should be prepared to administer epinephrine, glucocorticoids, and oxygen if needed." c. "I will administer an antihistamine and acetaminophen before beginning the infusion." d. "I will monitor this patient's blood pressure, respiratory rate, and oxygen saturation closely." ANS: A Rituximab can cause severe infusion-related hypersensitivity reactions. Nurses should be prepared to administer epinephrine, steroids, and O2 if needed. Antihistamines and acetaminophen are given before infusion. Close monitoring of vital signs and oxygenation are indicated. A patient who has been diagnosed with rheumatoid arthritis (RA) for 1 month and has generalized symptoms is taking high-dose nonsteroidal anti-inflammatory drugs (NSAIDs) and an oral glucocorticoid. The provider has ordered methotrexate [Rheumatrex]. The patient asks the nurse why methotrexate is necessary since pain and swelling have been well controlled with the other medications. The nurse will tell the patient that: a. a methotrexate regimen can reduce overall costs and side effects of treatment. b. starting methotrexate early can help delay joint degeneration. c. starting methotrexate now will help increase life expectancy. d. with methotrexate, doses of NSAIDs can be reduced to less toxic levels. ANS: B Current guidelines for treatment of RA recommend starting a disease-modifying antirheumatic drug (DMARD) early—within 3 months of diagnosis for most patients—in order to delay joint degeneration. Methotrexate may take up to 3 to 6 weeks to be at therapeutic levels, so NSAIDs and glucocorticoids should be continued until this occurs. Methotrexate is expensive and has more toxic side effects. Patients taking methotrexate have been shown in some data to have decreased life expectancy. Patients may eventually be able to stop taking NSAIDs altogether. Treatment of RA 1. Relieve symptoms (pain, inflammation, stiffness) 2. Maintain joint function and range of motion 3. Minimize systemic involvement 4. Delay disease progression (aggressive and managed by rheumatologist) Rheumatoid Arthritis (RA) Autoimmune, inflammatory disorder. It follows a progressive course and can eventually cause joint deformities and functional limitations. Drug therapy can delay disease progression and sometimes are limited to symptomatic relief. Rheumatoid Arthritis Patho Joint stiffness, pain. Symptoms are most intense in the morning and abate us day advances. Joints are swollen, tender, warm spontaneous remission may occur injury progresses steadily for most fever, weakness, fatigue, weight loss, thinning of the skin, scleritis, corneal ulcers, vasculities can be severe Inflammation begins in the synovium - the membrane that encloses the joint cavity. Pannus : as inflammation intensifies, the synovial membrane thickens and begins to develop the articular cartilage. Damage to the cartilage is caused by enzymes released from the pannus and by chemicals and enzymes produced by inflammatory process raging within the synovial space. Articular cartilage undergoes total destruction, resulting in direct contact between bones of joint, followed by eventual bone fusion. Inflammation then subsides. Rheumatoid Arthritis & joint destruction This is caused by an autoimmune process in which the immune system mounts and attack against synovial tissue. During attack, mast cells, macrophages and T-lymphocytes produce cytokines and cytotoxins - compounds that promote inflammation and joint destruction.