Question 1

A patient has recent weight loss,fatigue,and recurrent low-grade fever along with pain and stiffness of knees and hands.The primary care nurse practitioner (NP)notes symmetric joint swelling and warmth of these joints.The NP should:

A) refer the patient to a specialist.
B) order erythrocyte sedimentation rate (ESR), rheumatoid factor (RF), and antinuclear antibody (ANA) tests.
C) begin therapy with methotrexate.
D) order x-rays of the affected joints.

Accepted Answer

ESR is a very nonspecific but sensitive indication of inflammation.RF is positive in 75% to 85% of patients with rheumatoid arthritis (RA).ANAs are elevated in approximately 20% of patients with RA.These tests help confirm the diagnosis of RA.Once the diagnosis is more likely,referral to a specialist is warranted.Drug therapy is not begun until the diagnosis is confirmed.X-rays are usually the earliest way to detect changes but are not diagnostic in the early stages of the disease.

Question 2

A patient who is taking methotrexate for RA sees the primary care NP for an annual physical examination.The patient's alanine aminotransferase (ALT)and AGT are elevated.The NP should:&#10;A) decrease the dose of methotrexate.&#10;B) recheck ALT and AGT levels in 2 weeks.&#10;C) contact the patient's rheumatologist to discuss discontinuing the drug.&#10;D) counsel the patient not to take acetaminophen while taking methotrexate.

Accepted Answer

Liver enzyme elevations are frequent,are usually transient and asymptomatic,and do not appear predictive of subsequent hepatic disease.A decrease in dose or discontinuation of the drug is not indicated.Coadministration with acetaminophen is not contraindicated.

Question 3

A patient who is being treated for RA reports having continued pain,which the patient describes as moderate and persistent.The NP should prescribe:&#10;A) acetaminophen.&#10;B) a cyclooxygenase-2 (COX-2) inhibitor.&#10;C) an opioid analgesic.&#10;D) an NSAID.

Accepted Answer

NSAIDs are recommended for RA pain because RA is an inflammatory disease.Acetaminophen may be used for mild pain.COX-2 inhibitors appear to cause more stomach ulcers and gastrointestinal (GI)bleeds in patients with RA and so should not be used unless other therapies are ineffective.Opioids should be used for patients with RA when other medications and nonpharmacologic interventions produce inadequate pain relief and the patient's quality of life is affected by pain.

Question 4

The primary care NP follows a patient who is being treated for RA with methotrexate.The patient asks the NP why the medication does not seem to alleviate pain.The NP tells the patient that:&#10;A) an immunomodulator may be needed to control pain.&#10;B) a higher dose of methotrexate may be needed to achieve pain control.&#10;C) if methotrexate does not control pain, an opioid analgesic may be necessary.&#10;D) methotrexate is used to slow disease progression and preserve joint function.

Accepted Answer

Disease-modifying antirheumatic drugs (DMARDs)have antiinflammatory effects that may slow disease progression and preserve joint function.Acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs)are common adjuncts to therapy to treat pain.

Question 5

A patient has been taking a COX-2 selective NSAID to treat pain associated with a recent onset of RA.The patient tells the primary care NP that the pain and joint swelling are becoming worse.The patient does not have synovitis or extraarticular manifestations of the disease.The NP will refer the patient to a rheumatologist and should expect the specialist to prescribe:

A) methotrexate.
B) corticosteroids.
C) opioid analgesics.
D) hydroxychloroquine.

Accepted Answer

In mild RA disease,patients are given NSAIDs first for 2 to 3 months,and then either hydroxychloroquine or sulfasalazine is added if the disease does not remit.Methotrexate is a first-line drug for patients with more aggressive symptoms,such as synovitis or extraarticular symptoms.Opioid analgesics are used as adjuncts for pain relief along with DMARDs.

Question 6

A patient who has just been diagnosed with RA is experiencing minimal pain and mild symptoms.The primary care NP should consult with a rheumatologist and should recommend:&#10;A) ibuprofen.&#10;B) methotrexate.&#10;C) acetaminophen.&#10;D) herbal remedies.

Accepted Answer

If the disease is mild,NSAIDs are recommended at full therapeutic doses for the first 2 to 3 months before starting DMARDs such as methotrexate.Acetaminophen and herbal remedies are not recommended as monotherapy.

Question 7

A patient who has RA has been taking methotrexate for 6 months and tells the primary care NP that symptoms seem to be getting worse.The NP refers the patient back to the rheumatologist and should expect the rheumatologist to:

A) add prednisone to the drug regimen.
B) add adalimumab to the drug regimen.
C) change to a combination of adalimumab and etanercept.
D) discontinue methotrexate because 50% of patients do not respond.

Accepted Answer

Combination therapy generally is used because it is more effective and provides a more sustained response.Immunomodulators such as adalimumab are often used with methotrexate.Prednisone is not indicated.Immunomodulators are generally not used in combination.

Question 8

A patient who has a history of stomach ulcers is taking a nonselective NSAID along with a DMARD for RA.The primary care NP should:&#10;A) order a glucocorticoid.&#10;B) change to acetaminophen.&#10;C) order a proton pump inhibitor (PPI).&#10;D) change to a selective COX-2 inhibitor.

Accepted Answer

If GI risk factors are present,a prophylactic PPI should be given along with the nonselective NSAID.Glucocorticoids make ulcers worse.Acetaminophen is used only for mild pain or as adjunct pain therapy.A selective COX-2 inhibitor has an increased risk of stomach ulcers.

Question 9

A patient is taking a cytokine immunomodulator to treat RA.The primary care NP caring for this patient should:&#10;A) obtain periodic complete blood counts (CBCs) and liver function tests (LFTs).&#10;B) perform annual tuberculosis (TB) skin testing.&#10;C) advise the patient of an increased risk of bone cancer.&#10;D) administer the intranasal live attenuated influenza vaccine (LAIV) each year.

Accepted Answer

Routine monitoring for patients taking cytokine immunomodulators should include periodic CBCs and LFTs.TB skin testing should be performed before initiating therapy but is not indicated annually.Patients taking immunomodulators do not have an increased risk of bone cancer.Providers should administer the trivalent influenza vaccine intramuscularly and not the LAIV given intranasally because the LAIV is a live virus,which is contraindicated in patients who are immunosuppressed.

Deck 37: Disease-Modifying Antirheumatic Drugs and Immune Modulators