Pharmacological management of using Disease-Modifying Antirheumatic Drugs (DMARD) and nursing implications Medical Presentation

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Pharmacological management of using Disease-Modifying Antirheumatic Drugs (DMARD) and nursing implications Week 2 Project Luis Oquendo Dr. Shiller South University
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Objectives The purpose of this presentation is to define and explain the pharmacological management of Disease-Modifying Antirheumatic Drugs (DMARD). A saturated market of DMARD present a different issues for the emerging nurse practitioner who will come across to make the appropriate medication or combination as care plan for patient’s acute or chronic rheumatic diseases. The proper combination of DMARD will affect patients physiological and psychological. This presentation will focus on pharmacological management of DMARDS and nursing implications. Nursing implication using this type of medication or the combinations to treat rheumatic chronic diseases.
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Presentation Overview Disease-Modifying Antirheumatic Drugs (DMARD) is a new nomenclature This biological and synthetic drugs are comprised on traditional antirheumatic medications There is two categories of DMARD sDMARD =Synthetics bDMARD =Biologics DMARDs Medication are prescribed to individuals diagnosed with: Rheumatoid Arthritis Ankylosis Spondylitis Psoriatic Arthritis Lupus Juvenile Idiopathic Arthritis
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Pharmacological Managements of DMARD The medication are often used to decrease the prominent immunologic abnormalities like: immune complexes produced by synovial lining cells inflamed blood vessels Plasma cells produce antibodies rheumatoid factor [RF] anticyclic citrullinated peptide [anti-CCP] antibody) macrophages also migrate to diseased synovium in early disease increased macrophage-derived lining cells are prominent along with vessel inflammation Lymphocytes that infiltrate the synovial tissue are primarily CD4+ T cells. Macrophages and lymphocytes produce pro-inflammatory cytokines and chemokines various ILs, interferon-gamma) in the synovium. Releasing inflammatory mediators and various enzymes contribute to the systemic and joint manifestations of RA, including cartilage and bone destruction.
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Type of DMARD bDMARDS anakinra, Infliximab etanercept adalimumab rituximab abatacept tocilizumab golimumab certolizumab pegol sDMARDS methotrexate Leflunomide Sulfasalazine gold/auranofin Azathioprine Hydroxychloroquine Cyclophosphamide Cyclosporin mycophenolate minocycline Penicillamine Tacrolimus tofacitinib This photo shows fingers are abnormally bent (ulnar deviation) in a patient with rheumatoid arthritis.
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Disease-Modifying Antirheumatic Drugs (DMARD) Traditional DMARDs Azathioprine (Azasan, Imuran, generic): Comes in tablet only; used most commonly in lupus. This drug depends on a specific enzyme to work and some people lack enough of this enzyme to make the drug effective. Your doctor will test your levels before prescribing azathioprine. Cyclophosphamide (generic only): Comes in capsule, tablet or infusion. Can be used in lupus in patients who do not respond to traditional therapy or who experience kidney damage. Cyclosporine (Neoral, Gengraf, Sandimmune, generic): Comes in capsule or syrup. This medicine is used sometimes for lupus in people who do not respond to other therapies. Swan neck deformity is characterized by extension at proximal interphalangeal joint and flexion at distal interphalangeal joint.
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Disease-Modifying Antirheumatic Drugs (DMARD) Hydroxychloroquine sulfate (Plaquenil, generic): Comes in tablet only. Antimalarial drugs are commonly used to treat rheumatoid arthritis and can help improve the skin lesions of lupus, and can hold off disease recurrence and prevent organ damage. Serious side effects for antimalarial drugs are rare. Leflunomide (Arava, generic): Comes as a pill taken once a day. People who cannot tolerate methotrexate may take leflunomide. It can also be taken in combination with methotrexate. Methotrexate (Rheumatrex, Trexall, Otrexup, Rasuvo, generic): This drug is taken once a week and comes in tablet or as a self-injectable. It is for adults with active RA and children with active juvenile idiopathic arthritis with more than one affected joint. Subcutaneous rheumatoid nodules (arrow) commonly form over pressure points as in this patient with olecranon bursitis. The nodules may be within subcutaneous tissue overlying the bursae or may be subperiosteal to the extensor surface of the ulna.
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Disease-Modifying Antirheumatic Drugs (DMARD) Mycophenolate mofetil (CellCept, generic): Comes in tablet, capsule and as a self-injectable. This drug may be used in people whose RA does not respond to other therapies. Sulfasalazine (Azulfidine, Sulfazine, generic): Comes in regular or extended-release tablets. This drug is most commonly used in a triple therapy combination for RA (methotrexate, sulfasalazine, hydroxychloroquine). Targeted DMARDs Apremilast (Otezla): Comes in tablet only. Approved for use in people with psoriatic arthritis. Tofacitinib (Xeljanz): Comes in immediate or extended-release tablets. Approved for use in people with rheumatoid arthritis
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Nursing Implications Implications: DMARD recommendation required a careful review and comprehensive monitoring. Nurse practitioner play a important role advocating for the early treatment with DMARD to prevent erosion and progressive deformation or loss of a joint. The optimal combination of DMARDS is not yet determine; however, data of clinical trials reflect that the combination of DMARD can improve the life of patient with rheumatic acute or chronic illness. Aspirin is not longer use to treat RA because of its toxicity. Corticosteroids decrease inflammation and other symptoms more rapidly and to a greater degree than other drugs. They also seem to slow bone erosion. However, they may not prevent joint destruction, and their clinical benefit often diminishes with time. Furthermore, rebound often follows the withdrawal of corticosteroids in active disease. Because of their long-term adverse effects, some doctors recommend that corticosteroids are given to maintain function only until another DMARD has taken effect.
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Works Cited DMARDs (Disease-Modifying Antirheumatic Drugs) Overview | Treatments. (n.d.). Retrieved August 2, 2018, from http://www.arthritis.org/living-with- arthritis/treatments/medication/drug-types/disease-modifying- drugs/drug-guide-dmards.php Ramiro, S., Gaujoux-Viala, C., Nam, J. L., Smolen, J. S., Buch, M., Gossec, L., … Landewé, R. (2014). Safety of synthetic and biological DMARDs: a systematic literature review informing the 2013 update of the EULAR recommendations for management of rheumatoid arthritis. Annals of the Rheumatic Diseases; London, 73(3), 529. http://dx.doi.org.contentproxy.phoenix.edu/10.1136/annrheumdi s- 2013-204575 Rheumatoid Arthritis (RA) - Musculoskeletal and Connective Tissue Disorders. (2017). Retrieved August 2, 2018, from https://www.merckmanuals.com/professional/musculoskeletal-and- connective-tissue-disorders/joint-disorders/rheumatoid-arthritis-ra