Rheumatoid Arthritis Case Study
Case study: 01
Mrs JS is a 46-year-old woman who has been referred by her primary care doctor to the
rheumatology outpatient clinic in the local hospital. Her presenting complaint is a
symmetrical pattern of inflammation in the joints of her hands, knees and shoulders, and
severe pain and stiffness which are worse in the morning. She is a gardener and is finding it
increasingly difficult to continue her job due to limited joint function. Her investigations
and X-rays confirm a diagnosis of severe seropositive rheumatoid arthritis, including a
high CRP and ESR. She takes citalopram for depression and has no other remarkable
medical or drug history.
Questions
1. What treatment should be introduced for Mrs JS?
Answer: DMARD treatment should be initiated immediately for Mrs JS as she has seropositive disease
which is associated with a poorer outcome. She has no other co-morbidities which contraindicate her to
any of the DMARDs. Combination treatment should be started with methotrexate and sulphasalazine as
she has severe active disease. Folic acid should be also prescribed at 5 mg weekly. Some clinicians may
opt for triple combination therapy of methotrexate, sulphasalazine and hydroxychloroquine. Mrs JS is
started on methotrexate 7.5mg weekly and sulphasalazine 500mg twice a day as her disease-modifying
treatments.
2. What key counselling points should be covered regarding her DMARD therapy?
Answer: Mrs JS should be counselled on the following:
• Her dose of methotrexate is 3 × 2.5mg tablets and this should be taken as a single dose on the same
day each week. This dose will be increased over the next few weeks.
• Folic acid is given to minimize adverse effects of methotrexate, and should be taken weekly, but not on
the same day as methotrexate.
• Both DMARDs will take several weeks to take full effect.
• She will need regular blood monitoring and she should be counselled about possible adverse effects
on the liver and bone marrow.
• Warning symptoms to report to a healthcare professional include any sign of infection, unexplained
bleeding, bruising, purpura, sore throat, fever, malaise, dyspnea, persistent dry cough, mouth ulcers,
nausea or vomiting.
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, Case study: 02
Mr. TP is a 58-year-old man who has been on methotrexate 20mg weekly for the last 2years
for rheumatoid arthritis. He has found that his symptoms are worsening, and he has been
taking more regular NSAIDs and analgesia in the last month for pain relief. He has tried
sulphasalazine and leflunomide in the past, but was unable to continue therapy due to
gastro-intestinal side effects.
Questions 1. How would you manage Mr TP's worsening disease activity?
Answer: Mr TP is on DMARD monotherapy, and so an additional agent may be beneficial. However, he
has not tolerated sulphasalazine and leflunomide which are regarded as the more effective DMARDs, as
well as methotrexate. Hydroxychloroquine could be added in alongside methotrexate, but this is unlikely
to provide adequate disease modification. Another treatment option would be to introduce one of the
biological agents. The anti-TNF agents are licensed to be used after failure of DMARDs, and would be the
next logical step in Mr TP's treatment regimen.
2. After discussion with Mr TP and consideration of other co-morbidities, the treatment plan
is to add in an anti-TNF agent. What additional information is required to ensure Mr TP
meets eligibility criteria for treatment?
Answer: Patients should demonstrate severe active disease, measured by two DAS28 assessments
greater than 5.1, one month apart. A tender joint count and a swollen joint count should be carried out,
ESR should be measured, and Mr TP's perception of his disease severity should be scored on a scale from
0 to 100 on a visual analogue scale. These parameters can then be used to calculate a DAS28 using an
online calculator.
3. Mr TP admits that he is needle-phobic and does not like the idea of giving himself weekly
or fortnightly injections. What treatment options are available to him?
Answer: Adalimumab and etanercept are subcutaneous injections which are usually self-administered
by patients. In some cases, a district nurse may be organized to administer the injection at the patient's
home. For Mr TP, the thought of having such frequent injections is not desirable, and this may affect
adherence to the medication regimen. Infliximab is given as an intravenous infusion in hospital, and he
would not have to administer the drug himself. It has a less frequent dosing compared to the other anti-
TNF agents, and it should be discussed with Mr TP whether he is happy to have an infusion every
8weeks.
This study source was downloaded by 100000899606070 from CourseHero.com on 06-25-2025 01:27:58 GMT -05:00
https://www.coursehero.com/file/88524440/PHR326-case-studies-solution-files-fall20docx/
Case study: 01
Mrs JS is a 46-year-old woman who has been referred by her primary care doctor to the
rheumatology outpatient clinic in the local hospital. Her presenting complaint is a
symmetrical pattern of inflammation in the joints of her hands, knees and shoulders, and
severe pain and stiffness which are worse in the morning. She is a gardener and is finding it
increasingly difficult to continue her job due to limited joint function. Her investigations
and X-rays confirm a diagnosis of severe seropositive rheumatoid arthritis, including a
high CRP and ESR. She takes citalopram for depression and has no other remarkable
medical or drug history.
Questions
1. What treatment should be introduced for Mrs JS?
Answer: DMARD treatment should be initiated immediately for Mrs JS as she has seropositive disease
which is associated with a poorer outcome. She has no other co-morbidities which contraindicate her to
any of the DMARDs. Combination treatment should be started with methotrexate and sulphasalazine as
she has severe active disease. Folic acid should be also prescribed at 5 mg weekly. Some clinicians may
opt for triple combination therapy of methotrexate, sulphasalazine and hydroxychloroquine. Mrs JS is
started on methotrexate 7.5mg weekly and sulphasalazine 500mg twice a day as her disease-modifying
treatments.
2. What key counselling points should be covered regarding her DMARD therapy?
Answer: Mrs JS should be counselled on the following:
• Her dose of methotrexate is 3 × 2.5mg tablets and this should be taken as a single dose on the same
day each week. This dose will be increased over the next few weeks.
• Folic acid is given to minimize adverse effects of methotrexate, and should be taken weekly, but not on
the same day as methotrexate.
• Both DMARDs will take several weeks to take full effect.
• She will need regular blood monitoring and she should be counselled about possible adverse effects
on the liver and bone marrow.
• Warning symptoms to report to a healthcare professional include any sign of infection, unexplained
bleeding, bruising, purpura, sore throat, fever, malaise, dyspnea, persistent dry cough, mouth ulcers,
nausea or vomiting.
This study source was downloaded by 100000899606070 from CourseHero.com on 06-25-2025 01:27:58 GMT -05:00
https://www.coursehero.com/file/88524440/PHR326-case-studies-solution-files-fall20docx/
, Case study: 02
Mr. TP is a 58-year-old man who has been on methotrexate 20mg weekly for the last 2years
for rheumatoid arthritis. He has found that his symptoms are worsening, and he has been
taking more regular NSAIDs and analgesia in the last month for pain relief. He has tried
sulphasalazine and leflunomide in the past, but was unable to continue therapy due to
gastro-intestinal side effects.
Questions 1. How would you manage Mr TP's worsening disease activity?
Answer: Mr TP is on DMARD monotherapy, and so an additional agent may be beneficial. However, he
has not tolerated sulphasalazine and leflunomide which are regarded as the more effective DMARDs, as
well as methotrexate. Hydroxychloroquine could be added in alongside methotrexate, but this is unlikely
to provide adequate disease modification. Another treatment option would be to introduce one of the
biological agents. The anti-TNF agents are licensed to be used after failure of DMARDs, and would be the
next logical step in Mr TP's treatment regimen.
2. After discussion with Mr TP and consideration of other co-morbidities, the treatment plan
is to add in an anti-TNF agent. What additional information is required to ensure Mr TP
meets eligibility criteria for treatment?
Answer: Patients should demonstrate severe active disease, measured by two DAS28 assessments
greater than 5.1, one month apart. A tender joint count and a swollen joint count should be carried out,
ESR should be measured, and Mr TP's perception of his disease severity should be scored on a scale from
0 to 100 on a visual analogue scale. These parameters can then be used to calculate a DAS28 using an
online calculator.
3. Mr TP admits that he is needle-phobic and does not like the idea of giving himself weekly
or fortnightly injections. What treatment options are available to him?
Answer: Adalimumab and etanercept are subcutaneous injections which are usually self-administered
by patients. In some cases, a district nurse may be organized to administer the injection at the patient's
home. For Mr TP, the thought of having such frequent injections is not desirable, and this may affect
adherence to the medication regimen. Infliximab is given as an intravenous infusion in hospital, and he
would not have to administer the drug himself. It has a less frequent dosing compared to the other anti-
TNF agents, and it should be discussed with Mr TP whether he is happy to have an infusion every
8weeks.
This study source was downloaded by 100000899606070 from CourseHero.com on 06-25-2025 01:27:58 GMT -05:00
https://www.coursehero.com/file/88524440/PHR326-case-studies-solution-files-fall20docx/
