| HS5346: Pathophysiology and Pharmacology |
Case study
A 37- year- old woman gradually developed painful wrists over three months; she consulted her doctor only when the pain and early morning stiffness stopped her from gardening. On examination, both wrists and the metacarpophalangeal joints of both hands were swollen and tender but not deformed. There were no nodules or vasculitic lesions.
On investigation, she was found to have a raised C- reactive protein (CRP) level (27mg/L) (NR<10) but normal hemoglobin and white-cell count. A latex test for rheumatoid factor was negative and antinuclear antibodies were not detected.
The clinical diagnosis was made as early rheumatoid arthritis, and the patient was treated with ibuprofen. Despite some initial symptomatic improvement, the pain, stiffness, and swelling of the hands persisted and one month later both knees became similarly affected. The patient was referred to a rheumatologist.
Six months after the initial presentation, the patient developed two subcutaneous nodules on the left elbow. These were small, painless, firm, and immobile but not tender. A test for the rheumatoid factor was now positive (titer 1/64). X- rays of the hands showed bony erosions in the metacarpal heads. The patient still had a raised CRP (43mg/L) but normal serum complement (C3 and C4) levels and had she had a biopsy; pannus would have been demonstrable histologically. This woman now had definite X-ray evidence of rheumatoid arthritis and, in view of the continuing arthropathy, her treatment was changed to weekly low-dose methotrexate.
Although she receives maintenance methotrexate, periodically the patient has flares of her disease. She has ready access to her rheumatoid arthritis specialist nurse, and when flares occur the rheumatology team manages these, usually by adding prednisolone, an NSAID, and proton pump inhibitor, and increasing the dose of her methotrexate and/or adding another disease-modifying anti-rheumatic drug (DMARD). Her DMARD therapy is managed in accordance with a shared-care agreement with the rheumatologists. Recently, the patient has had several flares and this has resulted in several spells of corticosteroid therapy.
Questions
1. What is the rationale for prescribing ibuprofen, methotrexate, and prednisolone to this patient?
2. What advice would the nurse give to the patient about ibuprofen?
3. What adverse effects of methotrexate the patient might anticipate?
4. What adverse effects would the nurse be monitoring for the patient taking prednisolone?
Case study
Mr. Henry is a 55- year- old man who has recently been diagnosed with early Parkinson’s disease (PD). He has been quite upset and depressed about the diagnosis and has lost interest in his usual activities and hobbies. His wife reports that his tremors, slowness in movement, rigidity, and postural instability have worsened over the past 12 months. He has been taking the following medications for six months: carbidopa/levodopa 25mg/100mg four times a day.
Mr. Henry is now 67, with moderately advanced PD. He has had a fall at home, which has resulted in a humeral fracture. The fall occurred in the morning before he was able to take his medications and was related to his difficulty in initiating movements. On his current regimen, his PD symptoms are controlled. He is able to perform daily living activities independently and ambulates without assistance. He also performs more complex tasks. He has not exhibited any symptoms consistent with dementia.
He occasionally experiences dyspnoea on exertion and dysphagia, but he has not been evaluated for these complaints. He now takes carbidopa/levodopa 25mg/100mg four times a day and ropinirole 3mg three times a day. He is scheduled for open reduction internal fixation of his fracture. The orthopedic surgeon has requested a perioperative risk assessment and recommendations concerning medications.
Questions
1. Explain the pathophysiology of Mr. Henry’s Parkinson’s disease?
2. What is the mechanism of action of levodopa and what are the main adverse effects of this drug?
3. What is the rationale for adding ropinirole to Mr. Henry’s prescription and what are the potential adverse effects of this drug?
4. What is the nurse’s role in helping Mr. Henry comply with a complex regimen of drugs?
5. How should the patient PD medications be managed perioperatively?
