Rheumatoid Arthritis Patient Information

Dear Patient, (Courtesy Winelands Rheumatology Centre)

You have been diagnosed with Rheumatoid Arthritis, usually called RA. It is an Auto Immune Disease in which your immune system is over-active and causes inflammation in your joints, as well as other systems such as the lungs and skin. RA is also associated with an increased risk for heart attacks, increased risk for serious infections and some malignancies such as Lymphoma and skin cancers.

To reduce the risk of joint destruction you have been started on treatment, which changes the disease activity and protects you against joint destruction by stopping or slowing the destructive process.

The drugs that are most commonly used have all been shown to be effective in changing the course of RA and they have been shown to do “more good” than “bad”.

It is however important that you take note of the most important steps to reduce the risk for adverse drug reactions.

PREGNANCY
• If of child bearing age, please discuss available and preferred treatment options before and during pregnancy.
• If you take Methotrexate or Arava, you should discontinue these drugs for at least 6 months before falling pregnant.
• Males should be aware that they should also ensure that they also be careful to not cause a pregnancy whilst taking
Methotrexate and/or Arava.

CARDIOVASCULAR RISK
• All anti-inflammatory agents may increase the risk of having a heart attack or stroke.
This risk can be reduced by taking NSAIDS < 5 days per week and by continually monitoring blood pressure, glucose and cholesterol levels carefully. • All patients should have 6 monthly BP, Glucose and cholesterol checks and these need to be treated aggressively if found to be elevated. LIVER DISEASE AND RENAL DISEASE
• Anti-inflammatories, Methotrexate and Arava can all influence your liver functions and you have to undergo liver function tests
at 3 – 4 monthly intervals. Should the liver enzymes be elevated, your drug dose may have to be decreased or the drug may have
to be stopped. You should also decrease your intake of alcohol, should you liver functions be elevated.


SKIN CANCER
Patients on treatment with Biologic agents and/or Methotrexate have an increased risk for rapid progression of skin cancer. Should you have any suspicious looking skin lesion, you should visit a Dermatologist to exclude the diagnosis of a skin cancer and receive treatment for pre-malignant and malignant lesions.

INFECTION
All patients with RA, but especially those on treatment with Methotrexate, Arava and/or Biological agents are at increased risk for TB, other bacterial, fungal and viral infections.

We suggest the following steps to decrease the risk.

• Blood test or skin test for Tuberculosis before starting RA treatment.
• Chest x-ray before starting treatment and once yearly chest x-ray whilst on treatment.
• Yearly Flu vaccinations ( in April)
• 5 yearly anti-pneumococcal vaccination to prevent streptococcal pneumonia.
• No vaccinations with attenuated or live vaccine (e.g. Measles, yellow fever)
• Discuss use of DMARDS/Biologics before any surgery.

OSTEOPORSIS
RA patients (especially post-menopausal woman) are at increased risk for the development of Osteoporosis.
Suggest:

• Baseline bone DEXA scan at the age of 60 year with 2 yearly follow-up scans if baseline scan demonstrated
Osteopenia/Osteoporosis.

To prevent osteoporosis you should do the following:
• Embark on exercise programme.
• Avoid smoking and excessive intake of alcohol.
• Ensure regular periods of exposure to the sun.
• Take Vitamin D 50 000 units twice a month.
• Aim for prednisone dose < 5 mg per day. If you have evidence of Osteoporosis on bone DEXA scan we would advise you take specific treatment for Osteoporosis. SUMMARY

Check list for the Treatment of all patients with RA.

1. Contraception and family planning discussed.

2. Cardiovascular risk assessment.
• Blood Pressure.
• Blood Glucose.
• Fasting Lipogram.
• Counselled about smoking.
• Stress ECG if any other risk factor.

3.Liver disease.
• LFT
• Hep B and C and Ultrasound Scan if baseline LFT’s abnormal.
• Patient counselled about use of alcohol.
• Patient counselling about risk of NSAIDS, Salazopyrin, Methotrexate, Arava, Revellex and Actemra.

4.Renal Disease.
• U & E and urine dipstick at baseline.
• BP monitoring.
• Counselling about NSAIDS and dose adjustments for the drug.

5.Skin Cancer.
• Discuss the risk and need to see the Dermatologist.

6.Infection Risk.
• Counselling about increased risk of all infections.
• TB screening.
• Chest X-ray.
• PPD / Quantiferon TB Gold.
• Advice on yearly Flu vaccinations and 5 yearly Pneumovax vaccinations.

7.Osteoporosis.
• Counsel on risk for Osteoporosis.
• Baseline DEXA (age 60 years).
• Yearly follow-up DEXA.