Autoimmune Disorders

- 1st drug to treat SLE but there are so many complications that we don't use it - Increased risk for infection - No live vaccines 30 days prior to initiation of treatment - Avoid crowds

Describe belimumab (Benlysta).

RA destroys the connective tissue and the synovial membrane within the joints. The synovium thickens and accumulates in the joint spaces leading to pannus formation. Pannus is vascular granulation tissue composed of inflammatory cells that erodes articular cartilage and eventually destroys bone. Bone loses density and secondary osteoporosis occurs. RA is a systemic disease meaning that joints and body systems or organs can be affected.

Describe the pathophysiology of rheumatoid arthritis.

An autoimmune process where antinuclear antibodies attach to various parts of the cell. The bodies tolerance to the particular antigen is lost so it starts to attack its own healthy cells and tissues. Autoantibodies means antibodies that are attacking themselves. As a result, immune complexes form in the serum and organ tissues causing inflammation, damage, and destruction. These complexes invade organs directly or cause vasculitis (vessel inflammation), which deprives the organs of arterial blood and oxygen.

Describe the pathophysiology of systemic lupus erythematosus (SLE)

- Stage I: the patient appears with flu-like symptoms, erythema migrans (round or oval, flat, or slightly raised rash), and pain and stiffness in the muscles and joints. - Stage II: the patient may develop carditis with dysrhythmias, dyspnea, dizziness, or palpitations and CNS disorders such as meningitis, facial paralysis, and peripheral neuritis. - Stage III: occurs months to years after the tick bite. For some patients the only symptom is arthritis.

Describe the stages of lyme disease.

- Anti-inflammatory and analgesic - Promote comfort and decrease inflammation - Given with H2-blocking agent to help decrease GI problems - Take with food

Discuss NSAIDs (ibuprofen, naproxen).

Enbrel, remicade, humira - Decrease immune response and inflammation - Extremely expensive - Impaired immunity - Avoid in patients with MS, TB, and positive TB test - No live vaccines

Discuss biologic response modifiers (BBMs) (biologics) - Enbrel, remicade, humira

Hydroxychloroquine (Plaquenil) - Side effects: systemic discomfort, light headedness, and headache - MOST SERIOUS ADVERSE EFFECT: Retinal damage

Discuss disease-modifying antirheumatic drugs (DMARDs) - Hydroxychloroquine (Plaquenil)

Leflunomide (Arava) - Decreasing joint swelling and stiffness which leads to increased mobility - Side effects: hair loss, decreased WBC and platelets, diarrhea, and increased liver enzymes - Risk for infection - Avoid alcohol - Avoid pregnancy

Discuss disease-modifying antirheumatic drugs (DMARDs) - Leflunomide (Arava)

Methotrexate (MTX) (Rheumatrex) - If administered early enough in the process, then it will slow the progression of RA in the synovium (1st line - immunosuppressive) - LOW ONCE A WEEK DOSE - Monitor WBC, platelets, and kidney and liver function - Avoid pregnancy because of increased risk for birth defects - Avoid alcohol - Increased risk for infections - Make sure patient doesn't receive live vaccines

Discuss disease-modifying antirheumatic drugs (DMARDs) - Methotrexate (MTX) (Rheumatrex)

- Fast-acting anti-inflammatory and immunosuppressive effects - Complications: diabetes, decreased immunity, hyponatremia, HTN, osteoporosis, glaucoma - Report changes in BP and labs - Include vitamin D and Ca in diet - Make sure to rest joint for 24 hours - Cortisone injections - Bisphosphonate can be prescribed to help with bone loss - Bone density exam every 2-3 years

Discuss glucocorticoids (steroids) - Prednisone (Deltasone)

Upadacitinib (Rinvoq), Baricitnib (Olumiant), Tofacitinib (Xeljanz) - Blocks the pathway so it calms down the immune system and eases the RA symptoms - Side effects: nausea, cough, fever - Risk for infection - Avoid alcohol - Avoid pregnancy - No live vaccines - Take with full glass of water and at the same time everyday - Provider may ask for TB test prior intiating

Discuss janus kinase (JAK) inhibitors - Upadacitinib (Rinvoq), Baricitnib (Olumiant), Tofacitinib (Xeljanz)

- Topical cortisone - helps reduce inflammation and promote fading of the skin lesions - Acetaminophen or NSAIDs - used to treat joint and muscle pain and inflammation - Hydroxychloroquine (Plaquenil) - decreases the absorptions of UV light by the skin and therefore decreases the risk for skin lesions - Chronic steroid therapy - to treat the systemic disease process - Immunosuppressive agents such as methotrexate (rheumatrex) or azathioprine (Imuran)

Discuss pharmacological treatments for lupus.

Yes

Do we have to let the health department know about lyme disease?

2. Are you experiencing fever and fatigue as well? 4. Is your stiffness symmetrical on the body? 5. Do you notice swelling and redness on your joints?

During a routine health check-up visit a patient states, "I've been experiencing severe pain and stiffness in my joints lately." As the nurse, what other questions would help you assess for other possible signs and symptoms of RA? Select all that apply. 1. Does the pain and stiffness tend to be worse before bedtime? 2. Are you experiencing fever and fatigue as well? 3. Is your pain aggravated by activity? 4. Is your stiffness symmetrical on the body? 5. Do you notice swelling and redness on your joints?

MRI

Evaluation of soft tissues, the marrow structures, and the bone; allows for the differentiation of affected and non-affected tissues

Physician, nurse, PT, OT, case manager, PCT, social worker

Identify collaboration with other HCPs in the care of patients with RA, SLE, systemic sclerosis, and fibromyalgia.

Arthrocentesis

If its bad enough then the physician can use a needle to aspirate the synovial fluid

- Small, frequent meals - Minimize the intake of foods and liquids that stimulate gastric secretions such as spicy foods, caffeine, and alcohol - Keep HOB elevated for 1-2 hours after meals

If the patient has esophageal involvement, then what are some interventions we can do?

Remission

Improvement or absence of signs of disease

Dysphagia so we must assess for the ability of the patient to swallow before allowing him or her to drink or eat food

In systemic sclerosis, the esophagus loses its motility resulting in...

Non-systemic; skin biopsy

Is DLE systemic or non-systemic? What laboratory test can be done to test for DLE?

1. "I should take hot baths because they are relaxing."

The nurse provides home care instructions to a client with SLE and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instruction? 1. "I should take hot baths because they are relaxing." 2. "I should sit whenever possible to conserve my energy." 3. "I should avoid long periods of rest because it causes joint stiffness." 4. "I should do some exercises, such as walking, when I am not fatigued."

Secondary gout

Type of gout that involves hyperuricemia (excessive uric acid in the blood) caused by another disease or factor

X-ray

Visualizes the joints and changes in deformities

- Joint pain and stiffness - Edema - Tightening, hardening, and thickening of the skin tissue - "sausage fingers"

What are assessment findings of systemic sclerosis?

- Joint inflammation - Low-grade fever - Fatigue - Weakness - Anorexia - Paresthesia

What are early manifestations of rheumatoid arthritis?

- Deformities (e.g., swan neck or ulnar deviation) - Moderate to severe pain and morning stiffness - Osteoporosis - Severe fatigue - Anemia - Weight loss - Subcutaneous nodules - Peripheral neuropathy - Vasculitis - Pericarditis - Fibrotic lung disease - Sjögren's syndrome - Kidney disease - Felty's syndrome

What are late manifestations of rheumatoid arthritis?

- PT/OT: they can come up with exercises and maybe new ways to squeeze toothpaste for example - A synovectomy to remove inflamed synovium may be needed for joints such as the knee or elbow - Total joint arthroplasty (TJA) may be indicated when other measures fail to relieve pain - Adequate rest, proper positioning, ice, and heat - Heated paraffin (wax) dips - Recommend a hot shower rather than a bath - Plasmapheresis

What are non-pharmacologic interventions for RA?

Colchicine (Colcrys) and NSAIDs because the pain is so severe

What are pharmacologic treatments for acute attacks of gout?

Allopurinol (Zyloprim, Purinol) - take after meals and drink plenty of water (8 glasses of water to flush those kidneys and prevent formation of uric acid crystals) and expect periodic lab work Febuxostat (Uloric) - has potential cardiovascular complications

What are pharmacologic treatments for repeated attacks of gout?

- Polyarthritis - Osteonecrosis (mostly seen in patients with chronic steroid use) - Fever - Fatigue - Anorexia - Weight loss - Systemic involvement

What are some common assessment findings with SLE?

- Use a bed cradle or foot board to keep the bed covers away from the skin in severe cases - Adjust the room temperature to prevent chilling and keep it constant - Can wear gloves and socks to increase warmth - Teach the patient not to smoke and avoid extreme emotional stress because these can cause symptoms to reoccur

What are some interventions for the patient with Raynauds?

1. Asymptomatic hyperuricemia 2. Acute gouty arthritis 3. Chronic gout

What are the 3 clinical stages of gout? (dont need to know the details just know they exist)

- Alopecia - Individual round discoid (coinlike) lesions

What are the clinical manifestations of DLE?

GI, cardiovascular, pulmonary, renal

What body systems are systemically involved with systemic sclerosis?

Emotional stress and smoking (raynauds)

What can aggrivate systemic sclerosis?

Bed cradle or foot board

What can we use to keep bed covers away from the skin in severe cases of raynauds?

CT scan

What diagnostic test can we order if we are concerned with cervical spine involvement or if bones are difficult to see in an x-ray?

- Complete history - Severe joint pain - Serum acid level (more than 6.5 mg/dl) - Urinary uric acid levels (more than 750mg in 24 hours) - CMP to check for kidney function such as BUN and serum creatinine

What do we need to assess in a patient with gout?

- Avoid large crowds and people who are ill - Report any early sign of infection to health care providers - Observe for side effects and toxic effects and report immediately - Remind them to take their medication early in the morning before breakfast because that is the time when the body's natural corticosteroid level is the lowest

What do we need to teach our patients who are on immunosuppressant medications?

Have frequent eye exams (before starting the drug and every 6 months thereafter)

What do we need to teach our patients who are taking hydroxychloroquine?

Decreased blood flow in the GI tract

What does systemic involvement with the GI system lead too in patients with lupus?

Pericarditis, accelerated atherosclerosis, and damage to the valves

What does systemic involvement with the cardiovascular system lead too in patients with lupus?

Pericarditis

What does systemic involvement with the pulmonary system lead too in patients with lupus?

Large volumes of fluid, cloudy, and increased WBC's

What does the fluid extracted from the arthrocentesis typically reveal?

Bodentran (Tracleer)

What drug is used for severe Raynaud's?

Arthrocentesis

What is a definitive diagnostic test used for gout to detect needle-like crystals in the affected joint that are characteristic of this disorder?

Pregnancy and she also has in increased risk for miscarriage, stillbirth, or premature birth

What is a major stressor for women than can cause exacerbations of lupus?

If your patient isn't eating very well because there in pain then the levels will be decreased - Normal: 3.5-5 g/dL - Abnormal: decreased levels

What is albumin and what are the normal/abnormal values?

Any elevation can indicate lupus, system sclerosis, rheumatoid arthritis, or any other connective tissue disease - Normal: negative - Abnormal: elevation

What is articular antibody (ANA) and what are the normal/abnormal values?

- Combination of genetic and environmental factors - Female reproductive hormones (more common in women) - Stress - Epstein-Barr virus

What is believed to be the cause of RA?

Indicates that there is an inflammatory response, but it can also be elevated with bacterial infections and severe anemias as well - Normal: male - up to 15 mm/hr, female - up to 20 mm/hr - Abnormal: increased levels

What is erythrocyte sedimentation rate (ESR) and what are the normal/abnormal values?

- Systemic steroids and immunosuppressants - reduces immune responses and modifies or stimulates hormone effects; often used to tissue growth/repair and inflammation - Might recommend a cardiac medication such as an ACE for renal and cardiac function - Bodentran (Tracleer) - shows improvement in patients with breathing with increased pulmonary hypertension, but such a high dose is required so liver toxicity is a concern; also used for severe Raynaud's - Cancer agents but no specific medication that is not for systemic sclerosis

What is pharmacologic interventions used for systemic sclerosis?

This is not diagnostic of RA, it could be another connective tissue disease - Normal: negative - Abnormal: positive

What is rheumatoid factor and what are the normal/abnormal values?

Fever

What is the classic symptom of a flare up or exacerbation?

The main difference is pain. Inflammatory pain goes away with activity (rheumatoid arthritis), but noninflammatory pain worsens with activity (osteoarthritis).

What is the difference between inflammatory and non-inflammatory connective tissue (CT) disease?

Lupus nephritis

What is the leading cause of death from lupus?

"Butterfly rash" - dry, scaly, raised rash on the face

What is the major skin manifestation of lupus?

Aspirin and diuretics

What medications should a patient with gout avoid?

Tylenol and ice for pain relief

What nursing care can we provide after the arthrocentesis?

Kidneys

What organ is most commonly affected in lupus?

74% so be mindful of their kidney function and hypertension

What percentage of patients with lupus will have some sort of renal involvement?

5%

What percentage of perfectly healthy adults can have a positive articular antibody (ANA) result?

Nerve pain: - Gabapentin (Neurontin), Pregabalin (Lyrica), Duloxetine HCl (Cymbalta), and Milnacipran (Savella) - they cause drowsiness and avoid alcohol Sleep and muscle spasms: - Amitriptyline (Elavil) and nortriptyline (Pamelor) - be careful using in elderly because it can cause orthostatic hypotension and confusion (Trasadome would be preferred treatment in elderly) Pain - Tramadol (Ultram) Comfort - NSAIDs

What pharmacologic treatments are used in the treatment of fibromyalgia?

- Clean your skin with mild soap such as ivory - Dry your skin thoroughly by patting rather than rubbing - Apply lotion liberally to dry skin areas - Avoid powder and other drying agents such as rubbing alcohol - Use cosmetics that contain moisturizers - Avoid direct sunlight and any other type of UV lighting, including tanning beds - Wear a large-brimmed hat, long sleeves, and long pants when in the sun - Use a sun-blocking agent with a SPF of at least 30 - Inspect your skin daily for open areas and rashes

What should we teach our patients with lupus about skin care?

- Strict low-purine diet - Avoid foods such as organ meats, shellfish, and oily fish with bones (sardines) - Limiting protein foods, especially red and organ meats - Excessive alcohol intake and fad "starvation" diets can cause gouty attacks

What should we teach patients with gout in regards to their diet?

Low intensity exercise such as walking because extreme physical activity can make the pain worse

What type of exercise should we recommend for patients with fibromyalgia?

Back of the neck, upper chest, trunk, low back, and extremities

Where are the trigger points of fibromyalgia?

Their brain doesn't process pain very well

Why do patients with fibromyalgia have an inability to tolerate pain?

Patients with systemic sclerosis have extreme raynaud's so the coldness makes their arterioles constrict causing extreme pain

Why do we need to keep a patients room at a consistent temperature when they have systemic sclerosis?

Primary gout

The most common type of gout and results from one of several inborn errors of purine metabolism

Fibromyalgia

A chronic pain syndrome, not an inflammatory disease

Systemic lupus erythematosus (SLE)

A chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail

Rheumatoid arthritis

A chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints

2. Administer corticosteroids as prescribed for inflammation.

A client is diagnosed with systemic sclerosis (Scleroderma). Which intervention should the nurse anticipate? 1. Maintain bed rest as mush as possible. 2. Administer corticosteroids as prescribed for inflammation. 3. Advise the client to remain supine for 1 to 2 hours after meals. 4. Keep the room temperature warm during the day and cool at night.

Lyme disease

A reportable systemic infectious disease caused by the spirochete Borrelia burgdorferi and results from the bite of an infected deer tick, also known as the black-legged tick

Gout

A systemic disease in which urate crystals deposit in the joints and other body tissues, causing inflammation

Plasmapheresis

An in-hospital procedure prescribed by a health care provider in which the patient's plasma is treated to remove the antibodies causing the disease

Limited systemic sclerosis

CREST syndrome: Calcinosis Raynaud's phenomenon Esophageal dysmotility Sclerodactyly Talengiectasia

Exacerbations

Flare-ups

Scleroderma

Hardening of the skin

Drink plenty of fluids

How can the patient prevent urinary stones?

Diagnosis is based on symptoms and EEA blood test

How can we test someone for lyme disease?

Antibodies attack healthy normal cells and tissues. For reasons that are unclear, the immune system does not recognize body cells as self and therefore triggers an immune response.

How do antibodies react in autoimmune diseases?

- Immunosuppressants may be given in combination with steroids - If that doesn't work, then we can give glucocorticoids, cyclophosphamide, and plasmapheresis x3 days - Last resort would be kidney transplant

How do we treat lupus in the presence of severe renal impairment? (dont worry about memorizing just be aware)

Antibiotics for 14-21 days if diagnosed early

How do we treat lyme disease?

The patient's response to drug therapy

How does the physician differentiate between lupus and systemic sclerosis?

Knawing, burning sensation that increases in response to stress, increased activity, and weather conditions

How would you describe fibromyalgia pain?

Arthralgia

Joint pain

Ultrasound

Noninvasive visualization of the joint structures and it also allows for a quick visualization of both joints

Discoid lupus erythematosus

Only affects the skin and seen in only a small percentage of patients (Shellye saw this one time and it looked like he had 2nd degree burns everywhere)

Diffuse systemic sclerosis

Rapidly progressives and involves more systemic

True

T or F: Autoimmune diseases are difficult to diagnose, because their symptoms are so similar.

True!

T or F: Systemic sclerosis is less common than SLE, but it is associated with a higher mortality rate.

True

T or F: The early joint changes are similar to those seen in rheumatoid arthritis (RA).

CBC, high titers of some of these antibodies, kidney function, serum electrolytes, cardiac and liver enzymes, and clotting factors (remember systemic can affect pretty much any organ in our body)

The labs for SLE are similar to those of RA, but what are some lab tests specific to SLE?