A 50 year old woman has had rheumatoid arthritis for 3 years and has been taking multiple NSAID’s. She has taken corticosteroids a few times during flare ups. The disease seems to be progressing with stiffness and swelling in her hands and wrists. Examination reveals rheumatoid nodules, synovitis of both wrists and metacarpo-phalangeal joints. This is an indication of an acute exacerbation of rheumatoid arthritis. She is prescribed methotrexate with sulfasalazine and a short course of prednisone.
Introduction
Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by inflammation and joint damage. It affects approximately 1% of the global population and is more common in women than in men. The disease typically presents with pain, stiffness, and swelling in the affected joints, most commonly the hands and feet.
Case Description
In this case, a 50-year-old woman with a 3-year history of rheumatoid arthritis is experiencing an acute exacerbation of her symptoms. She has been taking multiple nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief and has used corticosteroids intermittently during flare-ups. Despite these interventions, her disease seems to be progressing, as indicated by the increasing stiffness and swelling in her hands and wrists.
Physical Examination Findings
Upon examination, the patient is found to have rheumatoid nodules, as well as synovitis of both wrists and metacarpo-phalangeal joints. Rheumatoid nodules are firm, non-tender, subcutaneous nodules that can develop in various locations, commonly in areas subjected to pressure or friction, such as the elbows and hands. They are a characteristic finding in RA and can vary in size from a few millimeters to several centimeters.
Synovitis, characterized by joint swelling and tenderness, is a hallmark feature of RA. It results from the inflammation of the synovial membrane, which lines the joints and is responsible for the production of synovial fluid. The synovial fluid helps to lubricate and nourish the joint, but in RA, the immune system mistakenly attacks the synovium, leading to inflammation and joint destruction.
Management Approach
Based on the patient’s clinical presentation and disease progression, the management plan includes the prescription of methotrexate with sulfasalazine and a short course of prednisone.
Methotrexate is a disease-modifying antirheumatic drug (DMARD) that is considered the first-line treatment for RA. It works by inhibiting the activity of an enzyme called dihydrofolate reductase, which is essential for the synthesis of DNA and RNA. By interfering with this process, methotrexate reduces inflammation and slows down the progression of joint damage. It is available in oral or injectable forms, and the recommended starting dose is usually 7.5-15 mg per week.
Sulfasalazine is another DMARD that is commonly used in combination with methotrexate for the management of RA. It has antibacterial and anti-inflammatory properties and works by reducing the production of inflammatory chemicals called cytokines. Sulfasalazine is taken orally, and the dosage is usually titrated up to a maximum of 2-3 grams per day.
Prednisone, a corticosteroid, is prescribed as a short-term treatment to provide rapid relief from the symptoms of acute exacerbation. Corticosteroids have potent anti-inflammatory effects and can quickly suppress the immune response in RA. However, due to their potential side effects, such as osteoporosis, weight gain, and increased susceptibility to infections, they are typically used for short durations and at low doses.
Conclusion
In summary, the case of the 50-year-old woman with an acute exacerbation of rheumatoid arthritis demonstrates the need for a comprehensive management approach to alleviate symptoms, slow down disease progression, and improve long-term outcomes. The combination of methotrexate with sulfasalazine and a short course of prednisone is a commonly employed treatment strategy in such cases. Regular monitoring and close follow-up are essential to evaluate treatment response, adjust medication dosages as needed, and manage any potential side effects.