Implications and Treatment Plans for Rheumatoid Arthritis

The given assignment focuses on understanding the knowledge and diagnostic skills related to rheumatoid arthritis. It highlights the importance of clinical medicine in addressing age-related diseases like arthritis. The assignment provides a short background about rheumatoid arthritis, followed by a comparison and contrast of different studies to establish findings and describe outcomes.

CLINICAL MEDICINE

TABLE OF CONTENTS
ABSTRACT.....................................................................................................................................1
INTRODUCTION...........................................................................................................................2
MAIN BODY...................................................................................................................................3
1. Ribeiro, N., and et.al., 2013.....................................................................................................3
2. O’Dell, J., and et.al., 1996.......................................................................................................4
3. Fleischmann, R., and et.al., 2017.............................................................................................5
4.Mazouyès and et.al., 2016.........................................................................................................5
5. Vollenhowen and et.al., 2009..................................................................................................6
6. Flesichmann,R and et.al.,2012 ................................................................................................7
7. Altawil, R., and et.al., 2016s....................................................................................................8
DESCRIPTION................................................................................................................................8
CONCLUSION ...............................................................................................................................9
REFERENCES..............................................................................................................................10

ABSTRACT
In this study seven different research paper studies were studied in order to understand
rheumatoid arthritis and the treatment related to it and their effectiveness. In this study all the
researcher researched about the early, mid and after effects of rheumatoid arthritis disease on the
patients body. Effectiveness of all the treatment given to the patients was also studied and
analysed. How this disease affect a patients body, how it can be diagnosed and the way it can be
treated all these things are addressed in these different studies conducted. This assignment will
mainly focus on methotrexate treatment that is given to the rheumatoid arthritis patients. The
efficiency and effectiveness of this treatment on the rheumatoid arthritis patients was studied. All
the research studies that were taken and critically evaluated in this research paper were those in
which participants were only of rheumatoid arthritis and were given methotrexate treatment. In
some of the studies methotrexate treatment is also compared with some other treatments and
effectiveness of all the treatments were evaluated and compared by analysing their effect on the
patients and the level till which they affect and cure the patient is also compared with their side
effects. So, for this assignment primary and secondary data was collected and evaluated from
seven research studies and the efficiency of methotrexate treatment of rheumatoid arthritis in
elderly patient was seen.
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INTRODUCTION
Background about the disease: The rheumatoid arthritis can be defined as the disorder that
affects many joints or sometimes even whole body. It is an progressive, long-term and disabling
autoimmune disease. Due to this disease the patient suffers swelling, body pain, inflammation all
around the joints as well as on all the other body organs. It slowly causes redness as well around
the joint or body part. This disease mostly occurs when immune system of a person mistake all
the healthy tissues of a persons to foreign invaders and as a result it starts targeting those tissues
and redness, swelling starts to occurs. Few of the most common symptoms of this disease are:
joint deformity, fever, mobility, loss of functions, weakness, weight loss, unsteadiness during
walking, redness etc. According to centre of disease control and prevention these symptoms
mostly affects the same joints that are one both the sides of the body. It is not clear that why is
immune system malfunction happens and becomes the main cause of this disease. According to a
theory due to some genetic factors in some people it is more likely to happen. As per some
theories there are some bacteria or some viruses that mostly triggers this RA disease in people
with genetic features. If this disease is left untreated then it can take a sever turn and can destroy
cartilages, connective tissues etc. Risk factors of this disease to occur are common in people
above 60 years, in females, in obese people, people who smoke more frequently etc.
Assessment method or diagnostic: The diagnostic treatment method that can be used for this
rheumatoid arthritis disease is methotrexate which is used in certain type of cancers, to control
rheumatoid arthritis especially when it doesn't respond to any other treatment. It is the first drug
that is given or subscribed to the patients with rheumatoid arthritis as soon as they are diagnosed
with it. It is given to the patients as it helps in easing patients with fatigue, joint pain, swelling, as
well as it also helps in preventing further damage to joints or organs. It is available to the patients
either in the form of pills or in form of shots. These pills and shots can be taken at home as well
by the patients. This treatment is quite efficient and effective but in elderly patients it has some
side effects as well. Most common side effect of this treatment is nausea,dizziness and if
overdose of this is taken then it can result in liver damage or kidney failure. If this medicine is
taken during pregnancy then it can also cause damage to the body.
Rationale behind doing the review: Rationale behind doing this review is to understand
rheumatoid arthritis disease in elderly patients and its methotrexate treatment. As today this
disease is growing quite frequently especially in elderly patients. This methotrexate treatment
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given to the patients is quite effective however it has some precautions and preventions of itself
as it this treatment is not given properly to the patients then it might damage some of their body
parts. So, in this review efficiency and safety of this treatment will be focused regarding
rheumatoid arthritis disease.
MAIN BODY
1. Ribeiro, N., and et.al., 2013
Study: the main aim of this study is to investigate prevalence of anxiety, depression and suicidal
ideation in patients with rheumatoid arthritis in use of methotrexate, hydroxychloroquine,
leflunomide and biological drugs to control the disease.
Participants: For this study 105 patients participated who were suffering from rheumatoid
arthritis disease and were treated with methotrexate and various other drugs.
Intervention: All the 105 participants were assessed with the help of international
neuropsychiatric interview, anxiety and depression scale and beak scale of suicide ideation. With
the help of this the way they were treated, effect of the treatment on them and the effectiveness
of that treatment on the patients were seen.
Control: All the patients treated with methotrexate were tried to given a lower dose of the
medicines as a measure of control because as a side effect they suffered anxiety, depression. So
to control these side effects dose of this treatment was reduced.
Outcome measure: the outcome and effectiveness of this treatment was measured with the help
of Mann-Whitney test. All the patients who were given higher or lower dose of methotrexate had
undergone through Suicide ideation scale test in order to identify the rate of suicidal tendencies
in the patients.
Findings: It was founded that both depression and anxiety were the cause of suicidal tendencies
within the patients which was the side effect of rheumatoid arthritis treatment which was given
to them. It was also observed that the patients who were given methotrexate treatment had less
suicidal tendencies as compared to other patients who were given other treatments.
Limitations: There were several limitation of this disease regarding human body such as it
required specific care, assistive help in their daily lives. Patients also needed assistance in their
daily routines. The researcher also faced lots of limitations while conducting this research like in
collection of primary data from the patients, exact and correct information related to the disease
and treatment given to the patients.
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2. O’Dell, J., and et.al., 1996
Study: the main aim of this study was to evaluate the treatment of rheumatoid arthritis with
methotrexate alone, sulfasalazine and hydroxychloroquine, or a combination of all three
medications together.
Study design: the researcher enrolled all the participants in randomized, two-year, controlled
study. Researcher divided all the patients who received treatment of methotrexate alone,
sulfasalazine and hydroxychloroquine, or a combination of all three separately. All the patients
were evaluated per week for six months. All the patients were followed in every three months for
the reminder of two years study period.
Participants: For this study 102 patients between the age group of 19 to 70 were enrolled with
rheumatoid arthritis and were given the treatment of methotrexate alone, sulfasalazine and
hydroxychloroquine, or a combination of all three.
Intervention: all the patients were divided into a group of three and were observed. Doses of all
the patients were increased and were observed on the basis of per week for 6 months. Then
improvement in those patients were observed and effect of those medicines were seen on those
patients.
Control: Control measures that were taken were: All the patients results were verified on the
basis of per week. If within three months treatment failed on any patient then they were then the
treatment was stopped they were brought back to the normal treatment. All the patients were
continuously scaled from 0 to 3 for tenderness and swelling on regular basis.
Outcome measure: Outcome of this study was measured by measuring the stiffness, tenderness
and swelling among the patients and on the scale of three they were continuously measured per
week as well as the efficiency and effectiveness of the patients were also measured per week.
Findings: The findings of this study was that almost 50 percent of the patients had improved
within 9 months of the time period and improved completely within 2 years. 31 out of 24 were
cured by all the three medicines, 36 out of 12 were cured by only methotrexate and 35 out of 14
were cured by the combinations of sulfasalazine and hydroxychloroquine treatment.
Limitations: there were many limitations that were faced by the researcher such as: limited data
information regarding the patients, their disease and related to their treatment, time duration was
also one of the main restriction for this study as the time in which it was to be completed was
very short and observation time needed was quite long.
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3. Fleischmann, R., and et.al., 2017
Study: the main aim of this study was to analyse the Efficacy and safety of tofacitinib
monotherapy, tofacitinib with methotrexate, and adalimumab with methotrexate
in patients with rheumatoid arthritis.
Study design: this study was done at 194 centres in 25 countries. All the patients were head to
head controlled with trial assessed.
Participants: participants for this study that were taken were 1126 patients. All the patients and
the treatment given to them were observed
Control: First major control that was taken was that all the patients that were 18 or above
suffering from rheumatoid arthritis despite methotrexate therapy were taken. As the study was
done in 25 countries, rules and regulations of all the countries regarding medical field were taken
into consideration.
Outcome measure: All the patients were asked to fill a questionnaire form, and were assessed
based on the chronic illness therapy, their fatigue scale was also measured, all the safety were
assessed for all the serious events, adverse events etc.
Findings: All the patients were assessed in the full analysis set. The ratio of patients who
discontinued treatment was similar between all three treatment arms.
Limitations: limitation of this study were that all the therapies that were shared had a common
mechanism action. Collection of data from all the patients in all the countries was a bit difficult.
4.Mazouyès and et.al., 2016
Study: This is based on studying the Efficacy of triple association methotrexate, sulfasalazine
and hydroxychloroquine in early treatment of rheumatoid arthritis with insufficient response to
methotrexate: Meta-analysis of randomized Controlled trials.
Study design: This contains randomized study trials where comparative analysis has been made
to understand the efficacy and safety of triple combination (MTX+SSZ+HCQ) against
bDMARD for knowing the entire treatment plan of patients suffering from RA (Rheumatic
Arthritis)
Participants: In this, 1225 approximately patients were considered to conduct the meta analysis
and out of 515 were into triple combination group and 710 included in the bDMARD group.
Alongside, a summary was given on the basis of trials including about TEAR,RACAT and more.
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Intervention: Here two authors (A.M. And A.C.B) assessed the qualitative analysis of each
study/trial and in the time of disagreement between them, a third reviewer (A.B) was consulted.
Control: In order to reach out analysis with different approaches, chi-square test was used
between the 2-3 sub groups that were made. Moreover, funnel plots were also used for meta
analysis and included more than 3 studies where no funding were received.
Outcome measure: This highlighted the recommendations given by the Cochrane
Musculoskeletal Group to gain knowledge about the ACR70 response, Sharp van der Heijde
Score (SHS) and remission. Here, the patients with SHS > 0.5
point were taken for two years as a proxy for clinically significant radiological progression.
Findings: Out of 1225 abstracts which were screened, it was shown that ACR70 response in
patients were treated with bDMARDs and the radiological progression was not different from
patients suffering from triple combination.
Limitations: Infectious adverse events were frequent while doing the triple combination group.
Additionally, there was an incremental value in the gastro intestinal events which has impacted
adversely. The inclusion criteria of RCT patients has hampered the external validity of
conducting the analysis.
5. Vollenhowen and et.al., 2009
Study: Addition of infliximab compared with addition of sulfasalazine and hydroxychloroquine
to methotrexate in patients with early rheumatoid arthritis (Swefot trial):1-year results of a
randomised trial.
Study design: The focus is on taking new treatment strategies for patients suffering from
rheumatoid arthritis which is in rapid emergence. In addition, there is a comparative studies
about addition of tumour necrosis factor antagonist and the conventional disease modifying anti
rheumatic drugs.
Participants: There were total 487 patients who were initially considered.
Intervention: The randomized trial was undertaken in 15 units of rheumatology department in
Sweden where the patients were diagnosed with the symptoms in less than a year. Non responder
imputation were taken by analysis and the findings were treated according to findings of 12
months.
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Control: The patients who were found out that they could tolerate the methotrexate were
randomly allocated through adoption of computer addition on the basis of either infliximab or
hydroxychloroquie and sulfasalazine.
Outcome measure: The patients with early RH failed in treatment with methotrexate and the
addition of tumour necrosis factor led to more superior therapy plan when compared to the
conventional disease modifying anti rheumatic drugs.
Findings: There were few adverse events which were balanced accordingly and out of which,
258 were at high activity with methotrexate and 130 were related to sulfasalazine and
hydroxychloroquine and 128 into infliximab. Along with, there were no deaths that took place in
any of the groups.
Limitations: There was comparative analysis of the secondary outcomes after conducting the
randomized trial in context to the randomisation time which proved more traditional and
conservative and hindered the entire comparative analysis with study time of inclusion. This
acted as hindrance in finishing the trial methodology.
6. Flesichmann,R and et.al.,2012
Study: Baricitinib, Methotrexate, or Combination in Patients With Rheumatoid Arthritis and No
or Limited Prior Disease-Modifying Antirheumatic Drug Treatment
Study design: This evaluated on the basis of phase III study where the evlaution of baricitinib
was used to inhibit the effects in patients with active RA
Participants: 588 patients were taken on the yearly randomized trial basis which were above the
age of 18 years of age.
Intervention: Efficacy and quality parameters were taken into considerations in order to
investigate the effects of MTX, baricitinib and combination of both MTX with baricitinib.
Control: This factor has shed light on the patients who were rescued or were discontinued from
the study or continuous treatment and termed as non-responders in all the categorical efficacy
outcomes.
Outcome measure: The participants were given MTX monotherapy in a week for one time,
baricitinib monotherapy was given on daily basis in the amount of 4 mg or the combination of
both baricitinib and MTX.
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Findings: The study has its objectives which were met and it was found that baricitinib
monotherapy is considered superior when compared to MTX monotherapy and the ACR20
response rate is towards the higher side.
Limitations: The CRP at baselines had an elevated level with a screen failure rate of more than
50 %. Moreover, the clinical response observed in the MTX monotherapy arm crossed the limits
and explained about the consistent power calculation in regard to usage of MTX monotherapy in
patients who were diagnosed with early RA. This cannot be examined whether the higher dose of
MTX would have been non-inferior or superior to baricitinib monotherapy.
7. Altawil, R., and et.al., 2016s
Study: the main aim of this study was to investigate the frequency of remaining pain in early
rheumatoid arthritis disease which is treated by giving the treatment of methotrexate.
Study design: In this study discrimination between inflammation and pain impact on disease
activity and clinical response were collected. Patients with early RA were followed and the
treatment given to them was observed.
Participants: 1241 patients were taken as participants. These patients were those who were
suffering from rheumatoid arthritis disease and were given a treatment of methotrexate.
Control: first control that was taken was that all the cases that were newly diagnosed within 10
months were taken. All the patients data fulfilled RA criteria and were approved by Ethical
Review Board.
Outcome measure: Outcome measure for this study was correlated with pain measurement
whose values were associated between baseline parameters and remaining pain. This complete
measurement was independent of pain and were observed at different levels.
Findings: the main findings of the study were that the pain was not directly related to
inflammation but were insufficiently controlled by methotrexate treatment drug given to the
patients.
Limitations: the major limitation of this study was to collect and confirm all the data from both
the previous and extended study. Many patients discontinued with this study.
DESCRIPTION
From the above primary data it is clear that Rheumatoid Arthritis disease is an long term
and progressive disease in which immune system of the body mistakes healthy tissues of the
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body as foreign invaders. As a result patient suffers from redness, swelling, joint pains etc. This
disease has many treatments but however as per the primary research conducted above it is clear
that methotrexate is one of the best treatment that can be given to the patients as a cure of this
disease. It has also been seen that it is one of the best treatment in all the other treatments and the
effectiveness of this treatment is quite good as compared to others. But there were few
limitations of this treatment such as dose of this medicine given to the patients should be limited
i.e. overdose of this medicine should not be given to the patients as it can result in depression,
anxiety etc. There are many other treatments that can be given to the patients such as
sulfasalazine, hydroxychloroquine etc. are also one of the best medicines that can be given to the
patients. However, in this treatment of Rheumatoid Arthritis it should be known that overdose of
the treatment can result in drug toxicity in the patients.
CONCLUSION
It has been summarized that this clinical medicine is important in understanding the knowledge
and the entire diagnostic skills in context to any age related disease like arthritis. Moreover, the
prime focus was to understand its implications and treatment plans to gain insights for better
outcomes and effective results in recovery stage. In regard to the same, a short background about
the rheumatoid arthritis and its relevancy has been given. Nevertheless, the sources given here
were facilitated to compare and contrast the different studies. This helped in establishing the
findings to describe the outcomes in proper manner. One recommendation is that the patients
must never be overdosed with the prescribed medicines in the above mentioned studies or
sources, since the patients are affected form the ill effects on the longer run. Additionally, it
impacts the patients with side effects that degrade their overall systems ad hamper their living
conditions as well.
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REFERENCES
Books and Journals
Altawil, R., & et.al. (2016). Remaining pain in early rheumatoid arthritis patients treated with
methotrexate. Arthritis care & research. 68(8). 1061-1068.
de Oliveira Ribeiro, & et.al. (2013). Anxiety, depression and suicidal ideation in patients with
rheumatoid arthritis in use of methotrexate, hydroxychloroquine, leflunomide and
biological drugs. Comprehensive psychiatry. 54(8). 1185-1189.
Fleischmann, R., & et.al. (2017). Baricitinib, methotrexate, or combination in patients with
rheumatoid arthritis and no or limited prior disease‐modifying antirheumatic drug
treatment. Arthritis & Rheumatology. 69(3). 506-517.
Fleischmann, R., & et.al. (2017). Efficacy and safety of tofacitinib monotherapy, tofacitinib with
methotrexate, and adalimumab with methotrexate in patients with rheumatoid arthritis
(ORAL Strategy): a phase 3b/4, double-blind, head-to-head, randomised controlled
trial. The Lancet. 390(10093). 457-468.
Mazouyès, A., & et.al. (2017). Efficacy of triple association methotrexate, sulfasalazine and
hydroxychloroquine in early treatment of rheumatoid arthritis with insufficient response
to methotrexate: Meta-analysis of randomized controlled trials. Joint Bone Spine. 84(5).
563-570.
O'dell, J. R., & et.al. (1996). Treatment of rheumatoid arthritis with methotrexate alone,
sulfasalazine and hydroxychloroquine, or a combination of all three medications. New
England Journal of Medicine. 334(20). 1287-1291.
Van Vollenhoven, & et.al. (2009). Addition of infliximab compared with addition of
sulfasalazine and hydroxychloroquine to methotrexate in patients with early rheumatoid
arthritis (Swefot trial): 1-year results of a randomised trial. The Lancet. 374(9688). 459-
466.
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