A 68-year-old woman has a history of rheumatoid arthritis and has been taking
nabumetone (Relafen) 1000 mg po qd for 2 years. Other pertinent past medical
history includes: occasional incontinence, Crohn’s disease with frequent
exacerbations, and well-controlled diabetes type 2. Recently, her arthritis pain
has been much worse and she is requesting additional medication for her
rheumatoid arthritis. What would be appropriate additional therapy for this
patient? What monitoring would be appropriate to monitor this medication? What
monitoring would be appropriate to monitor this medication?
Answer the questions below using clinical
practice guideline where applicable. Explain the problem and explain how you would
address the problem. If prescribing a new drug, write out a complete medication order
just as you would if you were completing a prescription.
Comprehensive Treatment Plan for Rheumatoid Arthritis in a 68-Year-Old Woman
Assessment and Problem Identification
A 68-year-old woman with a history of rheumatoid arthritis, currently on nabumetone 1000 mg PO daily, presents with worsening arthritis pain. Her medical history includes Crohn's disease, diabetes type 2, and occasional incontinence. To address her escalating arthritis symptoms while considering her comorbidities, a tailored treatment plan is essential.
Proposed Treatment Plan
1. Assessment of Current Medications:
- Nabumetone (Relafen): Evaluate the efficacy of nabumetone in managing arthritis pain and assess for any adverse effects or interactions with the patient's other conditions.
2. Addition of Disease-Modifying Antirheumatic Drug (DMARD):
- Methotrexate:- Prescription Order: Methotrexate 10 mg PO once weekly
- Rationale: Methotrexate is a first-line DMARD for rheumatoid arthritis that can help reduce inflammation, slow disease progression, and improve pain and joint function.
3. Monitoring Parameters:
- Liver Function Tests (LFTs) and Complete Blood Count (CBC): Regular monitoring of LFTs and CBC is essential to assess for potential methotrexate-related hepatotoxicity and myelosuppression.
- Renal Function Tests: Given the patient's medical history, monitoring renal function periodically is important to detect any nephrotoxic effects of medications and ensure renal health.
4. Patient Education and Follow-Up:
- Education on Methotrexate: Provide detailed information on methotrexate, including dosing instructions, potential side effects, and the importance of regular monitoring.
- Rheumatology Consultation: Consider referring the patient to a rheumatologist for further evaluation and management of her rheumatoid arthritis, especially in the context of her complex medical history.
Sources:
1. American College of Rheumatology. (2021). Rheumatoid Arthritis Clinical Practice Guidelines.
2. Centers for Disease Control and Prevention. (2020). Rheumatoid Arthritis.
3. National Institute of Arthritis and Musculoskeletal and Skin Diseases. (2019). Rheumatoid Arthritis.
By incorporating methotrexate as an additional therapy for rheumatoid arthritis in this patient, healthcare providers can target disease progression and alleviate pain while maintaining awareness of potential side effects and interactions. Regular monitoring of relevant parameters and collaborative care with specialists can optimize treatment outcomes and enhance the patient's quality of life despite her complex medical history.