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ABSTRACT INTRODUCTION
Patients diagnosed with rheumatoid arthritis The significance of joint damage in rheumatoid
face a lifelong condition that can be physically and arthritis (RA) lies in its impact on function. Even with
emotionally debilitating. Moreover, the medica- treatment, within a relatively short time, patients may
tions required for treatment can have serious and become unable to perform activities of daily living.
even life-threatening side effects. The role of nurs- According to a study conducted before the introduc-
es caring for patients with rheumatoid arthritis is to tion of biologic therapy, approximately 25% of US
provide support through education about the dis- patients are unable to work within 6 years of disease
ease process, treatment regimens, and identifying
onset, and up to 50% are disabled within 21 years.1 It
treatment response. A major goal for nurses must
be assisting patients in forming a self-management
is estimated that RA costs the average patient up to
plan. Patients should learn the difference between $8500 annually because of loss of employment and
pharmacological and nonpharmacological treat- medical costs.2
ment options, understand that rheumatoid arthritis Quality of life in patients with RA is also com-
is a lifelong, chronic illness that will need continu- monly affected by pain, feelings of dependence on oth-
al reassessment, and partner with their healthcare ers, fatigue, and sleep disturbance.3-5 In a survey
team to receive optimal benefit. Regularly docu- conducted in 2004 by the Arthritis Foundation, more
menting patients medications, pain scores, and than two thirds of 500 patients with RA reported that
ability to perform activities of daily living are only despite treatment with disease-modifying anti-
small parts of the nurses role. Counseling, case rheumatic drugs (DMARDs), they experience pain,
management, identification of psychosocial issues, stiffness, and fatigue daily.6 One half reported that
and assisting patients with selecting appropriate
they continue to modify their daily household activi-
complementary therapies and alternative treat-
ment options are significant responsibilities of
ties as a result of their arthritis.
rheumatology nurses. Patients with rheumatoid This article discusses how nurses can help patients
arthritis require careful screening and laboratory understand and manage RA as a chronic, life-altering
testing prior to initiating drug therapy and while disease. It also reviews how nurses can prevent and
treatment continues. The advent of biologics has identify adverse effects of drug therapy.
dramatically changed the prognosis for rheuma-
toid arthritis patients; however, these drugs come GOALS OF NURSING CARE IN RHEUMATOID ARTHRITIS
with significant risks.
(Adv Stud Nurs. 2007;5(1):23-31) Ac c o rding to the American College of
Rheumatology (ACR), a physicians goals during RA
*Director of Community Outreach and Occupational management should be to prevent or control joint
Health, Upper Chesapeake Health, Havre De Grace, damage, prevent loss of function, and decrease pain.7
Maryland. Table 1 lists a number of relevant nursing goals.
Address correspondence to: Vickie Ensor Bands, BSN, For patients newly diagnosed with RA referral to a
MSA, Director of Community Outreach and Occupational
Health, Upper Chesapeake Health, 501 S. Union Avenue, physical therapist, occupational therapist, and/or vo c a-
Havre De Grace, MD 21078. E-mail: Veb.01@ex.uchs.org. tional counselor should be considered early on.7 Some
patients may also benefit from consultation with an In addition to educating patients early and
o rthopedic surgeon, podiatrist, social work e r, health often, nurses can take the following steps to promote
educator, or health psychologist. The nurse and other adherence13:
members of the multidisciplinary team need to share Remind patients to hang in there; some
information about patients pro g ress. medications need time to start working.
Evaluation of RA is a repetitive process. Nurses Routinely ask patients about their adherence, in
should participate in periodically reassessing patients a nonjudgmental way, and discuss how they
for evidence of disease activity or progression, and for might overcome barriers. One suggestion may be
toxic effects of the drug regimen. They should also reg- to recommend the use of alarms (eg, on watches
ularly document patients medications, pain scores, or cell phones) as reminders to take their
and ability to perform activities of daily living. For the medications.
latter, the Health Assessment Questionnaire is becom- Make sure patients have the skills and knowledge
ing commonly used in clinical practice (Table 2).8,9 they need for managing their RA.
Refer patients to mental health professionals if
HELPING PATIENTS LIVE WITH needed.
RHEUMATOID ARTHRITIS
Patients with chronic illness tend to accept tre a t-
PATIENT EDUCATION ment recommendations best when they are able to par-
The ACR recommends that patients with
RA participate in developing a long-term tre a t-
ment plan that addresses their prognosis and
t reatment options.7 Educational sessions with a
nurse should precede and follow the deve l o p- Table 1. Nursing Goals in Rheumatoid Arthritis
ment of this plan. Nurses can help patients
understand their pharmaceutical and nonphar-
Upon Diagnosis Educate patients about rheumatoid arthritis, medications, and
maceutical options, evaluate later whether self-care, especially community resources for exercise and
t reatment needs to be adjusted, and begin to physical activity.
accept RA as a chronic disease that can be treat- In collaboration with the physician, screen patients for
ed but not cured. Two systematic reviews have contraindications to drug therapy and order baseline
determined that, at least in the short term, laboratory tests.
patient education in RA improves measures Arrange services of other healthcare professionals as needed.
such as disability, the number of tender joints, Regularly During
Follow-up Verify the medication list (agent and dosage).
patients assessments of their condition, psy-
Assess patient compliance with drug therapy.
chological status, and depre s s i o n .10,11 The
Assess and document activities of daily living and pain scores.
Arthritis Foundation offers a wide range of
Update the log on laboratory toxicity monitoring, if needed.
materials and programs that can be helpful,
Provide psychological support and reminders about self-care.
including an online discussion group for
patients with RA.12 Share information about the patients progress with other
healthcare professionals.
In collaboration with the physician:
PROMOTING ADHERENCE TO THERAPY
Monitor the incidence and severity of drug side effects.
Adherence to treatment by patients with RA
Counsel the patient about preventing complications such
is often suboptimal. Among adults part i c i p a t- as infection, osteoporosis, and cardiovascular disease.
ing in RA studies, adherence rates range fro m Monitor progression of rheumatoid arthritis, which may be
16% to 84% for pharmaceutical regimens and signaled by such signs as joint deformity or development
f rom 25% to 65% for nonpharmaceutical of extra-articular manifestations, including rheumatoid
treatments.13 Patients who are asymptomatic or nodules.
in remission, and conversely, those with persis- Encourage maintenance of mobility and protection of
tent symptoms, may see little reason to contin- unaffected joints through exercise, rehabilitation, and use
of supports/splinting.
ue following recommendations.
COMPLEMENTARY AND ALTERNATIVE MEDICINE put a strain on your relationship? (2) Ha ve you had any
The use of complementary and alternative medicine difficulty with pain affecting your sexual relationship?33
(CAM) by patients with rheumatic diseases is extre m e- Table 3 lists suggestions for patients who want to
ly common.21 Most patients use CAM as a supplement improve their sexual function.33 Also, the Arthritis
to standard medical care, rather than a replacement, Foundation offers a Guide to Intimacy with Arthritis,
often because they want more complete pain relief.22,23 available at its Web site or by calling 800-568-4045.12
When discussing medications and treatment
adherence, nurses should always ask in a nonjudgmen- COUNSELING ABOUT CARDIOVASCULAR DISEASE
tal way whether the patient uses CAM and, if so, what
types. According to well-designed studies or systemat- Cardiovascular disease accounts for most of the
ic reviews of multiple studies, promising CAM inter- excess mortality associated with rheumatoid diseases.34
ventions for RA include Chinese thunder god vine Atherosclerosis is now thought to be an inflammatory
(Tripterygium wilfordii),24 gamma-linolenic acid (bor- disorder, and recent studies suggest that the systemic
age seed oil, evening primrose oil, blackcurrant seed inflammation in RA is linked to heart disease and an
oil),25 omega-3 fatty acids (fish oil),26 spa therapy,27 Tai
Chi,28 and vitamin E supplementation.29
Nurses should inform patients that although herbs
a re natural, they are not necessarily safe in all cases. The
US Food and Drug Administration does not regulate
supplements or herbal preparations. Tripterygium wil- Table 3. A Rheumatoid Arthritis Patients Guide to
fordii is commonly associated with gastrointestinal side Improving Sexual Function
effects and amenorrhea,24 and its use has been associat-
ed with death caused by myocardial damage, renal fail- 1. Open communication between partners
Be honest with your partner about feelings, desires,
u re, and hypotension related to seve re gastrointestinal
and sexual needs.
effects.30 Some of the herbs used by patients with RA, Address each others fears of physical harm.
including feverf ew and devils claw, increase the risk of Discuss each others willingness to redefine intimacy
bleeding if used along with antiplatelet or anticoagu- through new positions, sexual aids, different techniques.
lant therapy. Others, including willow bark and echi- 2. Use tactile communication
nacea, should not be used with immunosuppre s s i ve Kissing, caressing, petting, or massage may help restore
d rugs such as methotrexate. Many patients expect clin- lost intimacy and assist in helping both partners relax.
Some couples may want to try using the hands or
icians to warn them about side effects of herbal re m e-
mouth to help achieve orgasm.
dies, but the long-term effects of these preparations
3. Environmental factors
h a ve not been well studied.30
Plan blocks of time within your regular schedule when
both of you are relaxed and comfortable.
SUPPORTING SEXUAL INTIMACY Make sure that you get rest ahead of time.
More than 50% of patients with RA re p o rt problems Avoid cold temperatures by taking a warm bath or
with sexual relationships.31,32 Symptoms such as fatigue, shower before sex.
Warm the bed by replacing cotton sheets with flannel
pain, and reduced joint function are the chief limita- sheets or turn on an electric blanket for a few minutes
tions, but medication side effects, depression, altered before getting into bed.
body image, and the effects of a partners assumption of
4. Medications
the caregiver role can also have an impact.33 Take pain medication at least 30 minutes before sexual
For most people, sexual activity is an integral part of activity.
life that contributes to their sense of well-being. Nurses Discuss any possible sexual side effects of medications
can support patients sexual health by integrating re l e- with a healthcare professional.
Water-based lubricants may be helpful in the presence
vant questions into routine care. To decrease embar- of vaginal dryness.
rassment, it helps to open with a statement such as:
Many people with arthritis mention changes in their Adapted with permission from Ruffing. Sexual intimacy. In: Bartlett SJ,
Bingham CO, Maricic MM, Iversen MD, Ruffing V, eds. Clinical Care in the
intimate physical re l a t i o n s h i p. Some questions that Rheumatic Diseases. 3rd ed. Atlanta, Ga: Association of Rheumatology
can open lines of communication are: (1) Has art h r i t i s Health Professionals; 2006.33
increased risk of early death.35-38 Other research has childbearing potential who use these medications are
shown that the mere presence of inflammation does using reliable birth control.40,41 If a patient (male or
not cause atherosclerosis; cardiovascular risk factors female) taking leflunomide decides to conceive, the
must also be present.39 Nurses can do a great service to following drug washout protocol is necessary: oral
patients with RA by helping them identify and aggres- cholestyramine, 8 g three times daily, for 11 days.
sively lower their risk factors for cardiovascular disease, Complete elimination of the drug can take as long as
such as hypertension, hypercholesterolemia, smoking, 2 years, so simply discontinuing it is insufficient.
and use of corticosteroids. Before conception is attempted, the plasma level of the
drug should be below 0.02 mg/L on 2 separate tests
COUNSELING ABOUT PREGNANCY AND LACTATION performed at least 14 days apart.42
Some experts advise that sulfasalazine and hydroxy-
Methotrexate and leflunomide are potent terato- chloroquine can be maintained during pregnancy and
gens. Nurses should periodically check that women of lactation.41 The safety of biologic DMARDs in this
regard has not been established.43 Patients should talk patients receiving methotrexate or leflunomide, the
with their physician while planning a pregnancy or principal concern is liver dysfunction, especially if the
immediately upon discovering they are pregnant. 2 drugs are given together.47
11. Riemsma RP, Kirwan JR, Taal E, Rasker JJ. Patient education 30. Kolasinski SL. Therapies from complementary and alterna-
for adults with rheumatoid arthritis. Cochrane Database Syst tive medicine. In: Bartlett SJ, Bingham CO, Maricic MM,
Rev. 2003:CD003688. Iversen MD, Ruffing V, eds. Clinical Care in the Rheumatic
12. Arthritis Foundation Web site. Available at: Diseases. Atlanta, Ga: Association of Rheumatology Health
http://www.arthritis.org. Accessed March 13, 2007. Professionals; 2006.
13. Rapoff MA, Bartlett SJ. Adherence in children and adults. 31. Kraaimaat FW, Bakker AH, Janssen E, Bijlsma JW.
In: Bartlett SJ, Bingham CO, Maricic MM, Iversen MD, Intrusiveness of rheumatoid arthritis on sexuality in male and
Ruffing V, eds. Clinical Care in the Rheumatic Diseases. female patients living with a spouse. Arthritis Care Res.
Atlanta, Ga: Association of Rheumatology Health 1996;9:120-125.
Professionals; 2006. 32. Hill J. The impact of rheumatoid arthritis on patients' sex
14. Thorne SE, Paterson BL. Two decades of insider research: lives. Nurs Times. 2004;100:34-35.
what we know and don't know about chronic illness experi- 33. Ruffing V. Sexual intimacy. In: Bartlett SJ, Bingham CO,
ence. Annu Rev Nurs Res. 2000;18:3-25. Maricic MM, Iversen MD, Ruffing V, eds. Clinical Care in
15. Coulter A. Patient-centered decision making: empowering the Rheumatic Diseases. 3rd ed. Atlanta, Ga: Association
women to make informed choices. Womens Health Issues. of Rheumatology Health Professionals; 2006.
2001;11:325-330. 34. Van Doornum S, McColl G, Wicks IP. Accelerated athero-
16. Gallant MH, Beaulieu MC, Carnevale FA. Partnership: an sclerosis: an extraarticular feature of rheumatoid arthritis?
analysis of the concept within the nurse-client relationship. J Arthritis Rheum. 2002;46:862-873.
Adv Nurs. 2002;40:149-157. 35. Solomon DH, Curhan GC, Rimm EB, et al. Cardiovascular
17. Fair BS. Contrasts in patients' and providers' explanations of risk factors in women with and without rheumatoid arthritis.
rheumatoid arthritis. J Nurs Scholarsh. 2003;35:339-344. Arthritis Rheum. 2004;50:3444-3449.
18. Minor MA, Sanford MK. The role of physical therapy and 36. Kremers HM, Nicola PJ, Crowson CS, et al. Prognostic
physical modalities in pain management. Rheum Dis Clin importance of low body mass index in relation to cardio-
North Am. 1999;25:233-248, viii. vascular mortality in rheumatoid arthritis. Arthritis Rheum.
19. Arthritis Foundation. Arthritis Foundation Aquatic Program 2004;50:3450-3457.
Instructors Guide. Atlanta, Ga: Arthritis Foundation; 2005. 37. Maradit-Kremers H, Nicola PJ, Crowson CS, et al.
20. Westby MD, Minor MA. Exercise and physical activity. In: Cardiovascular death in rheumatoid arthritis: a population-
Bartlett SJ, Bingham CO, Maricic MM, Iversen MD, Ruffing based study. Arthritis Rheum. 2005;52:722-732.
V, eds. Clinical Care in the Rheumatic Diseases. Atlanta, Ga: 38. Nicola PJ, Maradit-Kremers H, Roger VL, et al. The risk of con-
Association of Rheumatology Health Professionals; 2006. gestive heart failure in rheumatoid arthritis: a population-based
21. Hammond A. Rehabilitation in rheumatoid arthritis: a critical study over 46 years. Arthritis Rheum. 2005;52:412-420.
review. Musculoskeletal Care. 2004;2:135-151. 39. del Rincon I, Freeman GL, Haas RW, et al. Relative contri-
22. American College of Rheumatology Committee on bution of cardiovascular risk factors and rheumatoid arthritis
Rheumatologic Care. American College of Rheumatology clinical manifestations to atherosclerosis. Arthritis Rheum.
position statement: complementary and alternative medicine 2005;52:3413-3423.
for rheumatic diseases. Available at: http://www.rheuma- 40. Nelson JL, Ostensen M. Pregnancy and rheumatoid arthritis.
tology.org/publications/position/complementary.asp. Rheum Dis Clin North Am. 1997;23:195-212.
Accessed February 1, 2007. 41. Janssen NM, Genta MS. The effects of immunosuppressive
23. Kolasinski SL. Complementary and alternative therapies for rheu- and anti-inflammatory medications on fertility, pregnancy,
matic disease. Hosp Pract (Minneap). 2001;36:31-36, 39. and lactation. Arch Intern Med. 2000;160:610-619.
24. Tao X, Younger J, Fan FZ, et al. Benefit of an extract of 42. US Food and Drug Administration. Detailed view: safety
Tripterygium Wilfordii Hook F in patients with rheumatoid labeling changes approved by FDA Center for Drug
arthritis: a double-blind, placebo-controlled study. Arthritis Evaluation and Research October 2005. Arava tablets
Rheum. 2002;46:1735-1743. (leflunomide) prescribing information. Available at:
25. Soeken KL, Miller SA, Ernst E. Herbal medicines for the http://www.fda.gov/medwatch/SAFETY/2005/Oct_PI/
treatment of rheumatoid arthritis: a systematic review. Arava_PI.pdf. Accessed March 13, 2007.
Rheumatology (Oxford). 2003;42:652-659. 43. Furst DE, Breedveld FC, Kalden JR, et al. Updated consensus
26. Stamp LK, James MJ, Cleland LG. Diet and rheumatoid statement on biological agents for the treatment of rheumatic
arthritis: a review of the literature. Semin Arthritis Rheum. diseases, 2006. Ann Rheum Dis. 2006;65(suppl 3):iii2-iii15.
2005;35:77-94. 44. US Food and Drug Administration. Rituxan (rituximab) pre-
27. Verhagen AP, Bierma-Zeinstra SM, Cardoso JR, et al. scribing information. Available at: http://www.fda.gov/
Balneotherapy for rheumatoid arthritis. Cochrane Database cder/drug/infopage/rituximab/default.htm. Accessed
Syst Rev. 2003:CD000518. March 13, 2007.
28. Han A, Robinson V, Judd M, et al. Tai chi for treating 45. L e ff L. Emerging new therapies in rheumatoid arthritis: what's
rheumatoid arthritis. Cochrane Database Syst Rev. next for the patient? J Infus Nurs. 2006;29:326-337.
2004:CD004849. 46. Turkiewicz AM, Moreland LW. Rheumatoid arthritis. In:
29. Edmonds SE, Winyard PG, Guo R, et al. Putative analgesic Bartlett SJ, Bingham CO, Maricic MM, Iversen MD, Ruffing
activity of repeated oral doses of vitamin E in the treatment of V, eds. Clinical Care in the Rheumatic Diseases. 3rd ed.
rheumatoid arthritis: results of a prospective placebo controlled Atlanta, Ga: Association of Rheumatology Health
double blind trial. Ann Rheum Dis. 1997;56:649-655. Professionals; 2006.
47. O'Dell JR. Therapeutic strategies for rheumatoid arthritis. N 54. Baecklund E, Ekbom A, Sparen P, et al. Disease activity
Engl J Med. 2004;350:2591-2602. and risk of lymphoma in patients with rheumatoid arthritis:
48. Olsen NJ, Stein CM. New drugs for rheumatoid arthritis. N nested case-control study. BMJ. 1998;317:180-181.
Engl J Med. 2004;350:2167-2179. 55. Ekstrom K, Hjalgrim H, Brandt L, et al. Risk of malignant
49. Orencia (abatacept) prescribing information. New York, lymphomas in patients with rheumatoid arthritis and in their
NY: Bristol-Myers Squibb; 2007. Available at: first-degree relatives. Arthritis Rheum. 2003;48:963-970.
http://www.orencia.com. Accessed January 29, 2007. 56. Askling J, Fored CM, Brandt L, et al. Risks of solid cancers
50. Bieber J, Kavanaugh A. Consideration of the risk and treat- in patients with rheumatoid arthritis and after treatment with
ment of tuberculosis in patients who have rheumatoid arthri- tumour necrosis factor antagonists. Ann Rheum Dis.
tis and receive biologic treatments. Rheum Dis Clin North 2005;64:1421-1426.
Am. 2004;30:257-270, v. 57. Watson KD, Dixon WG, Hyrich KL, et al. Influence on anti-
51. Scott DL, Kingsley GH. Tumor necrosis factor inhibitors for TNF therapy and previous malignancy on cancer incidence
rheumatoid arthritis. N Engl J Med. 2006;355:704-712. in patients with rheumatoid arthritis (RA): results from the BSR
52. Doran MF, Crowson CS, Pond GR, et al. Frequency of Biologics Register (BSRBR) [abstract]. Rheumatology
infection in patients with rheumatoid arthritis compared with (Oxford). 2006;45:i10-i12.
controls: a population-based study. Arthritis Rheum. 58. Kwon HJ, Cote TR, Cuffe MS, et al. Case reports of heart
2002;46:2287-2293. failure after therapy with a tumor necrosis factor antagonist.
53. Bongartz T, Sutton AJ, Sweeting MJ, et al. Anti-TNF anti- Ann Intern Med. 2003;138:807-811.
body therapy in rheumatoid arthritis and the risk of serious 59. Cole J, Busti A, Kazi S. The incidence of new onset conges-
infections and malignancies: systematic review and meta- tive heart failure and heart failure exacerbation in Veteran's
analysis of rare harmful effects in randomized controlled tri- Affairs patients receiving tumor necrosis factor alpha antag-
als. JAMA. 2006;295:2275-2285. onists. Rheumatol Int. 2007;27:369-373.