Question 1

A patient with rheumatoid arthritis is taking leflunomide [Arava] and an oral contraceptive. She tells the nurse she would like to get pregnant. What will the nurse tell her?

Accepted Answer

Leflunomide is contraindicated during pregnancy. Patients desiring pregnancy must follow a three-step protocol that includes stopping the drug, taking cholestyramine to chelate the leflunomide, and ensuring that leflunomide drug levels are below 20 mcg/L before getting pregnant. Leflunomide is teratogenic and is not safe during pregnancy. Plasma levels of leflunomide may take 2 years to drop without using cholestyramine. It is not correct to stop taking leflunomide without following the protocol.

Question 2

A patient about to begin therapy with etanercept has a positive tuberculin skin test. A chest radiograph is negative. The nurse will expect this patient to:

Accepted Answer

Since tuberculosis (TB) in a patient taking etanercept is often extrapulmonary and disseminated, it is important to test all patients for TB. Those who test positive for latent TB should be treated for TB before etanercept treatment is begun. It is not correct to begin TB treatment concurrently with etanercept treatment. Latent TB must be treated and not monitored.

Question 3

A patient will begin taking hydroxychloroquine [Plaquenil] for rheumatoid arthritis. The patient is currently taking high-dose NSAIDs and methotrexate. What will the nurse teach the patient?

Accepted Answer

Hydroxychloroquine can cause retinal damage so an eye exam is necessary at the onset of treatment as well as every 6 months during treatment. Patients taking other drugs should continue to take those when beginning treatment with hydroxychloroquine since full therapeutic effects take months to develop. Renal and hepatic toxicity are not concerns. The drug is usually combined with methotrexate.

Question 4

A patient who has been diagnosed with rheumatoid arthritis (RA) for 1 month and has generalized symptoms is taking high-dose nonsteroidal anti-inflammatory drugs (NSAIDs) and an oral glucocorticoid. The provider has ordered methotrexate [Rheumatrex]. The patient asks the nurse why methotrexate is necessary since pain and swelling have been well controlled with the other medications. The nurse will tell the patient that:

Accepted Answer

Current guidelines for treatment of RA recommend starting a disease-modifying antirheumatic drug (DMARD) early-within 3 months of diagnosis for most patients-in order to delay joint degeneration. Methotrexate may take up to 3 to 6 weeks to be at therapeutic levels, so NSAIDs and glucocorticoids should be continued until this occurs. Methotrexate is expensive and has more toxic side effects. Patients taking methotrexate have been shown in some data to have decreased life expectancy. Patients may eventually be able to stop taking NSAIDs altogether.

Question 5

A nurse is discussing the administration of an intravenous infusion of rituximab (Rituxan) with a nursing student. Which statement by the student indicates a need for further education about the care of a patient receiving this drug?

Accepted Answer

Rituximab can cause severe infusion-related hypersensitivity reactions. Nurses should be prepared to administer epinephrine, steroids, and O₂ if needed. Antihistamines and acetaminophen are given before infusion. Close monitoring of vital signs and oxygenation are indicated.

Question 6

A child who has juvenile idiopathic arthritis and who has been taking methotrexate [Rheumatrex] will begin a course of abatacept [Orencia]. What will the nurse include when teaching the child's family about this drug?

Accepted Answer

Abatacept suppresses immune function and can increase the risk of serious infection. Parents should report any signs of infection, which may warrant discontinuation of abatacept. Abatacept may be taken alone. Abatacept may blunt the effectiveness of vaccines, and vaccines should be up-to-date prior to therapy and may need to be delayed until 3 months after therapy. Live vaccines should be avoided. Abatacept should not be given with TNF antagonists because of the increased risk of serious infections.

Question 7

A patient will begin taking etanercept [Enbrel] for severe rheumatoid arthritis. The patient has been taking methotrexate [Rheumatrex]. The patient asks if the etanercept is stronger than the methotrexate. The nurse will tell the patient that etanercept ____ methotrexate.

Accepted Answer

Etanercept has been shown to reduce symptoms in patients with moderate to severe RA who have not responded to methotrexate. It does not have synergistic effects with methotrexate or reduce adverse effects of methotrexate. It has many adverse effects.

Question 8

A patient is beginning therapy with oral methotrexate [Rheumatrex] for rheumatoid arthritis. The nurse will teach this patient about the importance of:

Accepted Answer

Periodic tests of renal and liver function are mandatory for patients taking methotrexate. Patients taking methotrexate should take folic acid supplements. Alopecia and rash are not worrisome side effects. Methotrexate is taken once weekly.

Quiz 73: Drug Therapy of Rheumatoid Arthritis