A 35 year old female patient was admitted to the female medicine ward with complaints of bodyache with weakness, pain in knee joint since 2-3 months, difficulty in walking. she had a past history of TB lymphadenopathy.

1. A Case Study
On
Rheumatoid
Arthritis
Ajita Sadhukhan
- Pharm D. 3rd year
- Roll No. : 1
- Enrolment No. : 150821207001
1

2. – RHEUMATOID ARTHRITIS: It is a chronic systemic autoimmune disorder causing
a symmetrical polyarthritis.
DEFINITION:2

3. IPD No.: 17015431
Age: 35 years
Weight :47 kg
Department: Female Medicine Ward
Sex: Female
Unit: I
Date of Admission: 04/12/17
Date of Discharge: 13/12/17
Patient Demographics3

4. – C/O bodyache with weakness, pain in knee joint since 2-3 months, difficulty in walking
PMHx : TB lymphadenopathy, RA
MHX: N/A
Family Hx : NAD
Social Hx: Housewife
Pregnancy Status: No
ALLERGIES : NKA
Reason for admission4

5. PHYSICAL EXAMINATION:
– General: decreased appetite
– R: 20/min
– SPO2: 98%
– CVS: S1 S2 normal
– RS: AEBE clear
– CNS: conscious
– BP: 120/80 mm Hg
– PR: 92/min
– TEMP: normal
– PA: Soft
OBJECTIVES5

6. LABORATORY PARAMETERS OBSERVED VALUE NORMAL RANGE UNIT
Hb 5.4 11.5-18 g%
WBC 5610 4000-11000 Cells/cu mm
Neutrophils 76 40-70 %
Eosinophils 02 1-6 /cu mm
Lymphocytes 18 20-40 /cu mm
Monocytes 04 2-10 /cu mm
Basophils 00 0-1 /cu mm
RBC 4.03*10^12 3.8-5.8*10^12 /cu mm
MCH 13.4 27-31 pg
PCV 19.9 40-54 %
Platelets 719000 1.5-4*10^5 /cu mm
MCV 49.5 78-100 fL
Se. Uric Acid 4.2 2.4-7.0 Mg/dL
Se. Creatinine 0.8 <1.5 Mg/dL
BSL (Random) 74 40-140 Mg/dL
Lab. Investigation reports [first day]6

7. LABORATORY PARAMETERS OBSERVED VALUE NORMAL RANGE UNIT
Hb 9.7 11.5-18 g%
WBC 7110 4000-11000 Cells/cu mm
Neutrophils 83 40-70 %
Eosinophils 01 1-6 /cu mm
Lymphocytes 15 20-40 /cu mm
Monocytes 01 2-10 /cu mm
Basophils 00 0-1 /cu mm
RBC 5.57*10^12 3.8-5.8*10^12 /cu mm
MCH 17.4 27-31 pg
PCV 33.6 40-54 %
Platelets 478000 1.5-4*10^5 /cu mm
MCV 60.4 78-100 fL
MCHC 28.9 32-36 g/dL
Lab. Investigation reports [3rd day]7

8. LABORATORY PARAMETERS OBSERVED VALUE NORMAL RANGE UNIT
Hb 9.5 11.5-18 g%
WBC 11290 4000-11000 Cells/cu mm
Neutrophils 82 40-70 %
Eosinophils 01 1-6 /cu mm
Lymphocytes 14 20-40 /cu mm
Monocytes 03 2-10 /cu mm
Basophils 00 0-1 /cu mm
RBC 5.42*10^12 3.8-5.8*10^12 /cu mm
MCH 17.5 27-31 pg
PCV 33.0 40-54 %
Platelets 469000 1.5-4*10^5 /cu mm
MCV 60.8 78-100 fL
MCHC 28.8 32-36 g/dL
Lab. Investigation reports [4th day]8

9. Others:
Se. Na+: 135 mEq/L (130-145)
Se. K+: 5.0 mEq/L (3-5)
Uric Acid: 6.0 mg/dL (10-45)
Se. Creatinine: 0.5 mg/dL (0.4-1.5)
MCHC: 27.1 g/dL (32-36)
RDW-CV: 92.5% (11-14)
USG of abdomen and pelvis: normal
TSH: 7.95 mcIU/mL (0.3-5.0)
ESR: 19.9 mm/hr (1-20)
Se. Fe: 24.8 mcg/dL (50-170)
RF: 60.8 IU/mL (<10)
Reticulocyte Count: 0.5% (0.5-2.5)
ANA profile immunodot: +ve
Urine analysis: normal
Urine pregnancy test: -ve
Se. LDH: 276.2 UL (103-227)
Se. Vit B12: 442 pg/mL (240-900)
Blood group: B +ve
9

10. RA ?
PROVISIONAL DIAGNOSIS10

11. – A 35 year old female patient was admitted to Med. ward-1 with complaints of bodyache
with weakness, pain in knee joint since 2-3 months, difficulty in walking.
– Based on lab report, patient’s Hb, RBC count, Lymphocytes, PCV, MCV, Se. Fe, MCHC, MCH,
and RF levels are abnormally decreased. ESR, Neutrophils, RDW-CV, TSH Platelets and WBC
count are abnormally increased. ANA Profile Immunodot was positive. Hence, patient was
diagnosed with Rheumatoid Arthritis.
11

12. FINAL DIAGNOSIS:
RA
12

13. For Rheumatoid Arthritis:
– It is an incurable disease so focus to stop inflammation (put disease in
remission).
– Relieve symptoms.
– Prevent joint and organ damage.
GOALS OF TREATMENT13

14. DAY 1
T: normal
P: 100/min
R: 20/min
B.P.: 130/80 mmHg
SPO2: 97%
RS: NAD
CVS: NAD
CNS: NAD
PA: soft
C/O bodyache with weakness, pain in knee joint since 2-3 months, difficulty in walking
ADV: RBS, ANA level, Se. Fe, Se. Vit B12, Reticulocyte Count, LDH, Se. TSH, CBC, Blood Group
14

15. Day 1 Medication chart15
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Tab. Hydroxychloroquine 200 mg P.O. 1-0-1 Painkiller
Tab. Methotrexate (on
Monday)
2.5mg P.O. Once weekly Rheumatoid Arthritis
Tab. Prednisolone 30 mg P.O. 1-0-0 Painkiller
Tab. Calcium + Vit. D3 250 mg P.O. 1-0-1 Calcium & Vit. D
supplement
Inj. PCV 2 pints I.V. - Increase Hb
Inj. Tramadol 1 amp in 100 ml NS I.V. SOS analgesic
Inj. Ranitidine 1 amp I.V. 1-1-1 Prevents acidity
Inj. Ondansetron 1 amp I.V. 1-1-1 Prevents emesis

16. DAY 2
T: normal
P: 80/min
R: 19/min
B.P.: 140/90 mmHg
SPO2: 97%
RS: NAD
CVS: NAD
CNS: NAD
PA: soft
C/O anorexia, pain in umbilical region
16

17. Day 2 Medication chart17
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Tab. Hydroxychloroquine 200 mg P.O. 1-0-1 Painkiller
Tab. Calcium + Vit. D3 250 mg P.O. 1-0-1 Calcium & Vit. D
supplement
Inj. Amoxicillin +
Clavulonic Acid
1.2 ml I.V. 1-1-1 antibiotic
Inj. Tramadol 1 amp in 100 ml NS I.V. SOS analgesic
Inj. Ranitidine 1 amp I.V. 1-1-1 Prevents acidity
Inj. Ondansetron 1 amp I.V. 1-1-1 Prevents emesis

18. DAY 3
T: normal
P: 80/min
R: 20/min
B.P.: 120/70 mmHg
SPO2: 99%
RS: NAD
CVS: NAD
CNS: NAD
PA: soft
C/O constipation, stool not passed since 2 days
Adv.: ANA profile, CBC, Rheumatologist reference
18

19. Day 3 Medication chart19
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Tab. Hydroxychloroquine 200 mg P.O. 1-0-1 Painkiller
Tab. Prednisolone 30 mg P.O. 1-0-0 Painkiller
Tab. Calcium + Vit. D3 250 mg P.O. 1-0-1 Calcium & Vit. D
supplement
Inj. Amoxicillin +
Clavulonic Acid
1.2 ml I.V. 1-1-1 antibiotic
Inj. Tramadol 1 amp in 100 ml NS I.V. SOS analgesic
Inj. Ranitidine 1 amp I.V. 1-1-1 Prevents acidity
Inj. Ondansetron 1 amp I.V. 1-1-1 Prevents emesis

20. DAY 4
T: normal
P: 93/min
R: 20/min
B.P.: 130/90 mmHg
SPO2: 99%
RS: NAD
CVS: NAD
CNS: NAD
PA: soft
20

21. Day 4 Medication chart21
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Tab. Hydroxychloroquine 200 mg P.O. 1-0-1 Painkiller
Tab. Prednisolone 30 mg P.O. 1-0-0 Painkiller
Tab. Calcium + Vit. D3 250 mg P.O. 1-0-1 Calcium & Vit. D
supplement
Inj. Amoxicillin + Clavulonic
Acid
1.2 ml I.V. 1-1-1 antibiotic
Inj. Tramadol 1 amp in 100 ml NS I.V. SOS analgesic
Inj. Ranitidine 1 amp I.V. 1-1-1 Prevents acidity
Inj. Ondansetron 1 amp I.V. 1-1-1 Prevents emesis
Tab. Sulfsalazine 500 mg P.O. OD Painkiller
Tab. Folic acid 5 mg P.O. 0-1-0 (except on Monday) Folate deficiency

22. DAY 5
T: normal
P: 85/min
R: 19/min
B.P.: 120/90 mmHg
SPO2: 99%
RS: NAD
CVS: NAD
CNS: NAD
PA: NAD
22

23. Day 5 Medication chart23
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Tab. Hydroxychloroquine 200 mg P.O. 1-0-1 Painkiller
Tab. Prednisolone 30 mg P.O. 1-0-0 Painkiller
Tab. Calcium + Vit. D3 250 mg P.O. 1-0-1 Calcium & Vit. D
supplement
Inj. Amoxicillin + Clavulonic
Acid
1.2 ml I.V. 1-1-1 antibiotic
Inj. Tramadol 1 amp in 100 ml NS I.V. SOS analgesic
Inj. Ranitidine 1 amp I.V. 1-1-1 Prevents acidity
Inj. Ondansetron 1 amp I.V. 1-1-1 Prevents emesis
Tab. Sulfsalazine 500 mg P.O. OD Painkiller
Tab. Folic acid 5 mg P.O. 0-1-0 (except on Monday) Folate deficiency

24. DAY 6
T: normal
P: 94/min
R: 20/min
B.P.: 100/80 mmHg
SPO2: 99%
RS: NAD
CVS: NAD
CNS: NAD
PA: soft
c/o: acidity
24

25. Day 6 Medication chart25
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Tab. Hydroxychloroquine 200 mg P.O. 1-0-1 Painkiller
Tab. Prednisolone 30 mg P.O. 1-0-0 Painkiller
Tab. Calcium + Vit. D3 250 mg P.O. 1-0-1 Calcium & Vit. D
supplement
Inj. Amoxicillin + Clavulonic
Acid
1.2 ml I.V. 1-1-1 antibiotic
Inj. Tramadol 1 amp in 100 ml NS I.V. SOS analgesic
Inj. Ranitidine 1 amp I.V. 1-1-1 Prevents acidity
Inj. Ondansetron 1 amp I.V. 1-1-1 Prevents emesis
Tab. Sulfsalazine 500 mg P.O. OD Painkiller
Tab. Folic acid 5 mg P.O. 0-1-0 (except on Monday) Folate deficiency

26. DISCHARGE MEDICATIONS26
– Adv.: follow up after 3 weeks with CBC, ESR, CRP, Se. Creatinine, SGPT
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Tab. Hydroxychloroquine 300 mg P.O. 1-0-1 Painkiller
Tab. Prednisolone 30 mg P.O. 1-0-0 Painkiller
Tab. Calcium + Vit. D3 250 mg P.O. 1-0-1 Calcium & Vit. D
supplement
Tab. Rabeprazole 40 mg P.O. 1-0-1 GERD
Tab. Sulfsalazine 500 mg P.O. OD Painkiller
Tab. Folic acid 5 mg P.O. 0-1-0 (except on Monday) Folate deficiency

27. TREATMENT PLAN:27
– For Rheumatoid Arthritis:
❖ Non-pharmacological treatment:
➢ Physiotherapy
➢ Swimming
➢ Free hand exercise
➢ Avoid cold
❖ Pharmacological therapy:
➢ There are three general classes of drugs commonly used in the treatment of rheumatoid
arthritis: non-steroidal anti-inflammatory agents (NSAIDs), corticosteroids, and disease
modifying anti-rheumatic drugs (DMARDs).

28. – CRP(C-reactive protein): NOT DONE
– SERIOUS → USE ALTENATIVE:
➢ Sulfasalazine + Methotrexate: Sulfasalazine increases levels of Methotrexate by decreasing renal clearance.
– MONITOR CLOSELY:
➢ Hydroxychloroquine + Methotrexate: Hydroxychloroquine decreases levels of Methotrexate by reducing its renal
clearance.
➢ Rabeprazole + Methotrexate: Rabeprazole increases levels of Methotrexate by reducing its renal clearance.
➢ Amoxicillin + Sulfasalazine: either increases levels of the other by plasma protein binding competition and
decreasing renal clearance.
➢ Amoxicillin + Methotrexate: Amoxicillin increases levels of Methotrexate by reducing its renal clearance.
➢ Sulfasalazine + Prednisolone: Either increases toxicity of the other by pharmacodynamics synergism.
POINTS TO BE INTERVENED WITH THE DOCTOR28

29. PATIENT COUNSELING29
ABOUT DISEASE
RA:
– It is an incurable but controllable disease.

30. About Medications:
– Dose of drugs
– Frequency of dose
– Route of administrations such as I.V, I.M., t/d, s/c, P.O., S/L.
– Counselling regarding overdose (may cause toxicity), underdose (submaximal or
no response) and missing of dose of medication. E.G. If a dose is missed, then
the patient is to be advised to go for the next dose, otherwise toxicity of drug
may occur.
– Contraindications
– Drug interactions (drug-drug, drug-food)
30

31. – Exercise (Walking and Swimming)
– Diet Control
– Low salt Intake
– Balanced diet
– Avoid red meat
– Reduce Weight
– Avoid Cold
Life Style Modifications31

32. 32