Barbara is a 40-year-old woman with a 18 year history of rheumatoid arthritis. She had previously worked as a nurse but has been on permanent disability since 1993. She is the mother of two children, aged eight and five. Mrs. Jones had one miscarriage before the births of her children. She has been on a number of different remittive agents for rheumatoid arthritis including aspirin which was ineffective; Auranofin which caused rash and weight loss (20 lbs); Methotrexate which caused some nausea, fatigue and increased yeast infections; Hydroxychloroquine which was well tolerated but not sufficiently effective, Leflunomide which caused nausea, diarrhea, and possibly hypertension, and more recently she has been on Etanercept 25 mg subcutaneously twice weekly and Vioxx.
Over this time, she has had very difficult to control rheumatoid arthritis characterized by pain, stiffness, and gelling, and swelling and tenderness in most synovial joints. She has had intense fatigue, associated depression, was diagnosed with osteoporosis following her two pregnancies and having been on Prednisone in doses of no more than 15 mg. The osteoporosis has been variously treated with Alendronate and more recently Miacalcin. She was switched from Alendronate to Miacalcin because she had problems with nausea and heartburn. Miacalcin is well tolerated. She had a first trimester miscarriage and then two normal pregnancies during which she tended to feel better from the second trimester on. She breastfed both children and did flare up within about six weeks postpartum with both children.
Her x-rays show significant erosive disease in her hands and feet consistent with longstanding rheumatoid arthritis and she still has some or a lot of difficulty with most of her activities of daily living and rates her pain at about 60/100 where 100 is very severe pain. This has improved with the Etanercept given that her morning stiffness has markedly decreased and her overall pain level has decreased down to about 10/100. On x-ray, she shows marked secondary osteoarthritis in her right knee.
Barbara has also tried alternative medicine treatments. "I've tried soaking my hands in iron hands, a Chinese mixture of herbs, used to strengthen the joints of karate practitioners. I've also tried homeopathic remedies and magnetic and heat treatments. Recently I took up yoga and find it helpful in learning how to breathe and stretch properly."
She recently went to an orthopedic surgeon who thinks that the knee needs to be replaced, but she has reservations, including the 18 month waiting list, the risks of infection given the medications she is on and how she will look after her children while recuperating.
There is no huge family history of arthritis, but one uncle had Rheumatoid arthritis. During the interview, the doctor suggested that Barbara look into taking sulphasalazine and intramuscular gold injections.
1985 - 1990
- stiffness and swelling in joints
- began aspirin (for a short time), then Naproxen, then Plaquenil
- began Auranofin (stopped in late 80s because of weight loss, rash, low energy)
- began Methotrexate (caused yeast infections, eventually caused fatigue)
- ongoing pain, stiffness and swelling in joints
- quit work indefinitely
- stopped Methotrexate and birth control pill
- began Prednisone
- pregnancy & miscarriage
- 2nd pregnancy (improved energy, decreased pain and swelling)
- birth of son (increased pain)
- 3rd pregnancy (again felt better)
- birth of daughter (significant increase in pain)
- increased dose of Prednisone
- diagnosis of osteoporosis
- resumed Methotrexate (increased dose), Plaquenil, Naproxen and birth control pill
- began Alendronate for osteoporosis, later replaced with Miacalcin
- began Leflunomide (still taking Methotrexate) which helped but caused nausea and depression - stopped Plaquenil - began Zoloft (anti-depressant)
- Began Etanercept injections
- Started Vioxx
- Discontinued Vioxx when it was pulled off the market, which was frustrating since she heard about it on the news
- Etanercept (increased energy)
- decreased Prednisone (5mg/day)
- Methotrexate (17.5mg/week)
- Zoloft (100mg daily)
- Miacalcin (osteoporosis)
- Tri-cyclen (birth control)
- increased knee pain (osteoarthritis), surgeon recommends knee replacement
- Compare and contrast the clinical course, management and outcomes of rheumatoid arthritis and systemic lupus erythematosus.
- Discuss the psychosocial impact of such chronic diseases on patients and their families. What are some constructive things to be done with / without the help of the physician?
Some other possible learning issues are suggested by the case or were brought up in class:
- Management of RA through pregnancy; symptom changes dring pregnancy ; why?
- Management / referral of RA patients by FPs.
- Physiotherapy, occupational therapy, CAM.
- In-hospital counselling and care program(s).
- Availability of assistive devices for individuals suffering from RA to help with with activities of daily living.
- The new 'biologics'? How are they different from other pharmacologics? Costs? Drug plan reimbursement?
- Healthcare challenges: surgery waiting times; physician shortages (FPs, specialists).