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Mansoura UniversityFaculty of PharmacyDepartment of Pharmaceutics

Clinical management of rheumatoid arthritis in peptic and duodenal ulcer patients

By Mohamed Fathi Mahmoud Eissa

Under the supervision of

Prof Dr.THANAA M. BORG 

Pharmaceutics department

Faculty of Pharmacy 

An EssaySubmitted in Partial Fulfillment for the diploma degree

In Hospital and clinical pharmacy2015

Rheumatoid Arthritis“A chronic autoimmune disease characterized by the inflammation of the synovial joints”

Has a symmetrical bilateral effect on joints

Results in joint deformity and immobilization

Multiple factors increase one’s risk

(The Arthritis Society, 2012; Gulanick & Myers, 2011; Firth, 2011)

Symptoms•Morning stiffness lasting more than half an hour•Simultaneous symmetrical joint swelling•Not relieved by rest•Fever•Weight loss•Fatigue•Anemia•Lymph node enlargement•Nodules

(The Arthritis Society, 2012; Firth, 2011; Oliver, 2010; Day et al., 2010)

Diagnosis

• CBC• Radiographs of involved joints• CT/MRI scans• Direct arthroscopy• Synovial/Fluid aspirate • Synovial membrane biopsy• Arthrocentesis

(National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2012)

No single test is specific to Rheumatoid Arthritis

Antibody Tests:Rheumatoid Factor Test

Other blood tests check for the presence of antibodies that are not normally present in the human body

(National Rheumatoid Arthritis Society, 2012; Day et al., 2010)

Synovial/Fluid aspirate Synovial membrane biopsy

ArthrocentesisAthrocentesis: synovial fluid is aspirated and analysed for inflammatory components

(Day et al., 2010)

Abnormal synovial fluid: cloudy, milky, or dark yellow containing leukocytes

X-Ray CT/MRI scans

(Gulanick & Myers, 2011; Day et al., 2010)

X-rays are an important diagnostic test for monitoring the disease progression

Patients may reveal NO changes on an X-ray in the early stages

Used for better visualization of soft tissueMRI is particularly sensitive for the early and subtle features of RACan detect changes of Rheumatoid Arthritis prior to an X-Ray

(Radiopaedia, 2010; Dat et al., 2010)

Peptic ulcer

A break in superficial epithelial cells penetrating down to muscularis mucosa

Protective factors Protective factors vs.vs. hostile factors hostile factors

PathogenesisPathogenesis : :

EndoscopyEndoscopy Biopsy – bacteria & malignancyBiopsy – bacteria & malignancy H.Pylori:H.Pylori:

Endoscopy cytologyEndoscopy cytology Biopsy – Special stainsBiopsy – Special stains Culture - difficultCulture - difficult Urease Breath test.Urease Breath test.

DiagnosisDiagnosis

Bleeding – Chronic, Acute, MassiveBleeding – Chronic, Acute, Massive

Fibrosis, Stricture obstruction – pyloric stenosis.Fibrosis, Stricture obstruction – pyloric stenosis.

Perforation – Peritonitis- emergency.Perforation – Peritonitis- emergency.

Gastric carcinoma. (not duodenal carcinoma)Gastric carcinoma. (not duodenal carcinoma)

Complications

Non-pharmacological Treatment of Peptic ulcer

1-Avoid spicy food.2-Avoid xanthin containing beverges.3-Avoid Alcohol.4-Avoid Smoking.5-Avoid heavy meals.6-Encourage small frequent low caloric meals.7-Avoid ulcerating drugs e.g. NSAIDs, corticosteroids, xanthines and parasympathomimetics

Triple therapy for 14 days is considered the treatment of choice. – Proton Pump Inhibitor + clarithromycin and amoxicillin

• Omeprazole (Prilosec): 20 mg PO bid for 14 d or

Lansoprazole (Prevacid): 30 mg PO bid for 14 d or

Rabeprazole (Aciphex): 20 mg PO bid for 14 d or

Esomeprazole (Nexium): 40 mg PO qd for 14 d plus

Clarithromycin (Biaxin): 500 mg PO bid for 14 and

Amoxicillin (Amoxil): 1 g PO bid for 14 d

• Can substitute Flagyl 500 mg PO bid for 14 d if allergic to Penicillin.

– In the setting of an active ulcer, continue on proton pump inhibitor therapy for

additional 2 weeks.

Treatment

Clinical management of rheumatoid arthritis in peptic and duodenal ulcer patients

COX-2 Non-steroidal anti-inflammatory drugs (NSAIDs)

ExamplesGeneral UseSide Effectspharmacist patient counselling

Celecoxib (Celebrex®).Rofecoxib (Vioxx®) and Valdecoxib (Bextra®)

•It is simply a safer alternative for those patients with an increased risk of stomach ulcers and/or bleeding.

• anti-inflammatory:Used in the management inflammatory conditions •Analgesic:Control mild to moderate pain•The general dose For rheumatoid arthritis is 200 mg up to twice a day (McCormack, 2011).

Both rofecoxib (Vioxx®) and valdecoxib (Bextra®) have been removed from the market because of concerns of an increased risk of heart attacks or stroke.•insomnia, •abdominal pain, •flatulence (gas), •headache, •nausea, and •diarrhea.

•NSAIDs may decrease response to diuretics or antihypertensive therapy•can raise blood pressure in some people

(The Arthritis Society, 2011; Day et al., 2010)

CorticosteroidsExamplesGeneral UseSide Effectspharmacist patient

counselling

Cortisone, Hydrocortisone, Prednisone, Betamethasone , Dexa-methasone

• Used in the management inflammatory conditions •When NSAIDS may be contraindicated•Promptly improve symptoms of RA

•Increased appetite•Weight gain•Water/salt retention•Increased blood pressure•Thinning of skin•Depression•Mood swings•Muscle weakness•Osteoporosis•Delayed wound healing•Onset/worsening of diabetes

•Take medications as directed (adrenal suppression)•Used with caution in diabetic patients•Encourage diet high in protein, calcium, potassium and low in sodium and carbohydrates•Discuss body image•Discuss risk for infection

(The Arthritis Society, 2011; Day et al., 2010)

Disease-modifying anti-rheumatic drugs(DMARDS)ExamplesGeneral UseSide Effectspharmacist patient

counselling

Methotrexate (the gold standard), gold salts, cyclosporine, sulfasalazine, azathioprine

•immunosuppressive activity•Reduce inflammation of rheumatoid arthritis•Slows down joint destruction•Preserves joint function

•Dizziness, drowsiness, headache•Pulmonary fibrosis•Nausea•Hepatotoxicity•Infertility•Alopecia•Skin ulceration•Aplastic anemia•Thrombocytopenia•Leukopenia•Nephropathy

•May take several weeks to months before they become effective•Discuss teratogenicity, should be taken off drug several months prior to conception•Discuss body image

(The Arthritis Society, 2011; Day et al., 2010)

Biologic Response Modifiers (“Bioligics”)

ExamplesGeneral UseSide Effectspharmacist patient counselling

Leufunomide (Avara ) , Etanercept (Enbrel )Adalimumab ( Humira) Tocilizumab (Actemra )

• Used in the management inflammatory conditions •When NSAIDS may be contraindicated•Promptly improve symptoms of RA

•Increase risk of infection•Leufunomide (Avara is generally avoided in women who might become pregnant.

•Take medications as directed•Discuss body image•Discuss risk for infection

(The Arthritis Society, 2011; Day et al., 2010)

• In severe cases of rheumatoid arthritis, surgery may be needed to reduce pain and improve joint function. Some surgeries include joint replacement, fusion of joints (arthrodesis), tendon reconstruction, and removal of inflamed tissues (synovectomy).

Surgery

Alternative MedicineOlive leaf extract

Aloe Vera

Green Tea

Omega 3

Ginger Root Extract

Cats Claw

Omega 3 interferes with blood clotting drugs!

(American College of Rheumatology, 2012)

ExerciseBeing overweight strains joints and leads to further inflammation

(Arthritis Foundation, 2012)

4 times a week for 30 minutes

•Walking•Light jogging•Water aerobics•Cycling•Yoga•Tai chi•stretching

Nutrition

(Johns Hopkins Arthritis Center, 2012)

The most commonly observed vitamin and mineral deficiencies in patients with RA are:o folic acido vitamin Co vitamin Do vitamin B6o vitamin B12o vitamin Eo calciumo magnesiumo zinc o selenium

Conclusion • Rheumatoid Arthritis

• “A chronic autoimmune disease characterized by the inflammation of the synovial joints”

• Has a symmetrical bilateral effect on joints , Results in joint deformity and immobilization

• Peptic ulcer

• A break in superficial epithelial cells penetrating down to muscularis mucosa .

• Triple therapy for 14 days is considered the treatment of choice.

Clinical management of rheumatoid arthritis in peptic and duodenal ulcer patients .

• COX-2 Non-steroidal anti-inflammatory drugs (NSAIDs)

• Corticosteroids

• Disease-modifying anti-rheumatic drugs(DMARDS)

• Biologic Response Modifiers (“Bioligics”)

• Alternative Medicine Olive leaf extract ,Aloe Vera , Omega 3

• Exercise

• Nutrition

THANK YOU