DMARDs for Rheumatoid Arthritis

A nurse is caring for a client who has a new prescription for etanercept. Which of the following actions should the nurse take? 1. Administer a tuberculin skin test prior to starting the medication 2. teach the client that fevers are common while taking this medication 3. determine if the client has chronic HTN 4. mix the medication with methotrexate prior to administration

1. Administer a TB skin test prior to starting the medication Etanercept is contraindicated for clients who have a history of exposure to tuberculosis.

Which of the following is an adverse reaction to etanercept? 1. Skin rash 2. Tinnitus 3. Diarrhea 4. Dysphagia

1. Skin rash

A nurse is teaching about self-administering methotrexate to a client who has rheumatoid arthritis. Which of the following statements should be include? 1. Use an NSAID to reduce toxicity 2. If you miss a dose, take it with the next scheduled dose 3. Drink a minimum of 2 liters of water per day to promote excretion 4. Take it in the morning to prevent insomnia.

3. Drink a minimum of 2 liters of water per day to promote excretion Methotrexate can cause kidney damage. Clients can also take sodium bicarbonate tablets to increase urine alkalinity and reduce the drug precipitation.

Which of the following would likely be prescribed in conjunction with methotrexate during the initial treatment for rheumatoid arthritis? 1. Aspirin 2. Salicylates 3. Sulfonylureas 4. Ibuprofen

4. Ibuprofen NSAIDs are often prescribed with methotrexate during the initial course of treatment because it can take weeks for DMARDs to reach therapeutic levels. Aspirin, salicylates, and sulfonylureas can cause methotrexate toxicity.

A nurse is caring for a client who is taking etanercept for rheumatoid arthritis. The nurse should monitor the client for which of the following indications of a serious adverse reaction to the drug? 1. Excessive salivation 2. Increased thirst 3. Blood in the urine 4. Shortness of breath

4. Shortness of breath Etanercept can cause heart failure which manifest as SOB, cough, elevated blood pressure and heart rate, and pink-tinged sputum. Etanercept is likely to cause blood in stools, not urine, r/t GI hemorrhage.

Biologic DMARDs - Etanercept (Enbrel) Contraindications

- Active infection - Hematologic disease (anemia, hemophilia, blood clots, leukemia) - Malignancy (Presence of cancerous cells that have de ability to spread to other sites in the body)

Biologic DMARDs - Etanercept (Enbrel) Administration

- Administer by subcutaneous injection. - Give once weekly - Monitor site for redness, pain, and swelling after administration.

Biologic DMARDs - Etanercept (Enbrel) Interactions

- Administration with chemotherapeutic drugs may cause bone marrow suppression. - Should not be given with anakinra (Kineret) due to increased risk of infections. - Live vaccines

Biologic DMARDs - Etanercept (Enbrel) Interventions

- Assess for infection prior to each injection. - Monitor for signs and symptoms of infection during therapy. - Monitor for skin reactions. - Monitor for redness, warmth, and itching at the injection site. - Monitor clients for signs and symptoms of heart failure (cough, SOB, elevated BP and heart rate, pink sputum). - Administer TB test prior to starting therapy

Biologic DMARDs - Etanercept (Enbrel) Precautions

- Autoimmune diseases - Live vaccines: Measles, mumps, rubella (MMR) Rotavirus. Smallpox. Chickenpox. - Yellow fever. - Heart failure

Nonbiologic (Traditional) DMARDs - Methotrexate Adverse drug reactions:

- Bone marrow suppression (decreased platelets, RBC and WBC) - Increased risk of infection - Liver damage - Gastrointestinal ulceration - Pulmonary fibrosis - Dizziness and headache - Nausea and vomiting

Nonbiologic (Traditional) DMARDs - Methotrexate Interactions

- Concurrent use of methotrexate and digoxin may reduce digoxin level - Concurrent use of methotrexate and NSAIDs, salicylates, and sulfonamides may cause toxicity. - NSAIDS can be administered during the initial period until methotrexate has exhibited its therapeutic effect. Then they must be discontinued. - Caffeine may reduce the effectiveness of methotrexate - Concurrent use of warfarin may increase the risk for bleeding - Alcohol use may increase risk of hepatotoxicity.

Nonbiologic (Traditional) DMARDs - Methotrexate Administrations

- Give methotrexate once a week via route prescribed (oral, subcutaneous, or intramuscular). - Folic acid supplement may be prescribed to decrease risk of toxicity.

Biologic DMARDs - Etanercept (Enbrel) Adverse drug reactions:

- Increased susceptibility to infections - Dizziness - Abdominal pain - Pharyngitis - Psoriasis - Upper Respiratory Infections - Rare occurrence of severe allergic reactions such as Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and erythema multiforme - Local injection site reaction - Heart failure - Reactivation of latent tuberculosis (TB)

Nonbiologic (Traditional) DMARDs - Methotrexate Interventions:

- Monitor for decreased platelets, red and white blood cell counts. - Monitor for signs and symptoms of infection. - Monitor liver function tests and observe for jaundice. - Monitor for gastrointestinal bleeding (with methotrexate). - Monitor for respiratory distress and decreased oxygenation - Monitor for abdominal pain, diarrhea, nausea and vomiting

Nonbiologic (Traditional) DMARDs - Methotrexate Precautions

- Peptic ulcer or ulcerative colitis - Active bacterial or viral infections

Biologic DMARDs - Etanercept (Enbrel) Client Instructions

- Report signs and symptoms of infection immediately. - Avoid immunizations, especially those that contain live vaccines. - Report skin rashes immediately. - Advise clients to report reactions that do not subside within a few days. - Report signs and symptoms of heart failure (cough, SOB, elevated BP and heart rate, pink sputum) immediately. - Report SOB or new production of sputum (phlegm)

Nonbiologic (Traditional) DMARDs - Methotrexate Contraindications

- Teratogenic - Liver insufficiency or hepatitis - Renal insufficiency

Nonbiologic (Traditional) DMARDs - Methotrexate Therapeutic use and Drug classification

Decrease joint inflammation and subsequently joint damage. "Antineoplastic"

Biologic DMARDs - Etanercept (Enbrel) Therapeutic use and Drug classification

Decrease joint inflammation and subsequently joint damage. "Antirheumatic" Biologic DMARD drugs are tumor necrosis factor antagonists—drugs that bind with naturally occurring tumor necrosis factor, preventing it from attaching to cells on the surface of synovial tissue in the joints.

Nonbiologic (Traditional) DMARDs - Methotrexate Clients Instructions

Report abnormal bleeding, bruising, or petechiae (pinpoint areas of blood under the skin). Report ulcerations of the mouth or tongue. Report signs and symptoms of infection immediately. Avoid ingesting alcohol. Report yellowing of the skin and eyes immediately. Report blood in vomitus or stools. Report difficulty breathing or shortness of breath. Drink adequate amounts (2L) of water daily to ensure excretion of drug. Follow advice of Healthcare provider regarding contraception for men and women of child bearing age. Avoid breastfeeding while on this drug.

A nurse is teaching a client about adverse effects of etanercept. Which of the following statements by the client indicates understanding of the teaching? a. "I will need to get my blood drawn periodically while on this medication." b. "I may lose part or all of my hair." c. "I may wake up with a very dry mouth." d. "I will leave the needle cap off during the time the medication comes to room temperature."

a. "I will need to get my blood drawn periodically while on this medication." Etanercept places the client at risk for systemic fungal infections and other opportunistic infections. Therefore, the client will need to have their CBC monitored periodically while on this medication.

A nurse is teaching a client about methotrexate therapy for rheumatoid arthritis. Which of the following statements by the client indicates an understanding of the teaching? a. "I will take a birth control pill every day." b. "Methotrexate decreases my chances of developing an infection." c. "I take methotrexate every day with breakfast." d. "I will aim to drink five 8-ounce glasses of water per day."

a. "I will take a birth control pill every day." Methotrexate is teratogenic to a fetus and is contraindicated during pregnancy. Therefore, a client of childbearing age should use birth control while on this medication.

A nurse is teaching a client about methotrexate therapy for rheumatoid arthritis. Which of the following information should the nurse include?Select all that apply a. Avoid being near people who are sick with a communicable illness. b. Periodic laboratory tests are required. c. The drug's effects are immediate. d. Report bruising or petechiae. c. Avoid drinking alcohol.

a. Avoid being near people who are sick with a communicable illness. b. Periodic laboratory tests are required. d. Report bruising or petechiae. c. Avoid drinking alcohol.

A nurse is planning care for a client who has a new prescription of methotrexate. The nurse should plan to monitor the client for which of the following adverse effects? a. Bone marrow depression b. Thrombocythemia c. Double vision d. Constipation

a. Bone marrow depression The nurse should monitor the client for bone marrow depression, which is an adverse effect of folic acid analogs such as methotrexate.

A nurse is caring for a client who has a prescription for etanecept. The nurse should identify that etanercept treats rheumatoid arthritis by which of the following actions? a. Inactivation of tumor necrosis factor b. Inhibition of osteoclast activity c. Decreasing the reuptake of serotonin d. Interference with the production of lymphocytes

a. Inactivation of tumor necrosis factor Etanercept directly binds to the tumor necrosis factor (TNF), preventing the attachment of TNF onto the cell's surface. This prevents the autoimmune response and subsequent inflammation of the joints.

A nurse is teaching a client who is taking etanercept for rheumatoid arthritis. The nurse should instruct the client to monitor which of the following indications of an adverse reaction to this drug? a. Skin rash b. Tinnitus c. Diarrhea d. Dysphagia

a. Skin rash Etanercept can cause serious skin infections. Clients should immediately report any skin rashes or blisters, because an infection can cause a serious reaction, such as Stevens-Johnson syndrome or toxic epidermal necrolysis.

The health care provider plans to prescribe methotrexate to a patient with newly diagnosed rheumatoid arthritis (RA). The patient tells the nurse, "That drug has too many side effects; I would rather wait until my joint problems are worse before beginning any drugs." The most appropriate response by the nurse is a. "You should tell the doctor how you feel so the two of you can make a decision together." b. "It is important to start methotrexate early in order to decrease the joint damage." c. "Methotrexate is not expensive and will be cheaper to take than other possible drugs." d. "Methotrexate is very effective and has no more side effects than the other available drugs."

b. "It is important to start methotrexate early in order to decrease the joint damage." Rationale: Disease-modifying anti-rheumatic drugs (DMARDs) are prescribed early to prevent the joint degeneration that occurs as soon as the first year with RA. The other statements are accurate, but the most important point for the patient to understand is that it is important to start DMARDs as quickly as possible.

A nurse is teaching a client who has a new prescription for etancercept. Which of the following statements should the nurse make? a. "You will inject this medication once a week in your thigh muscle." b. "You should report signs of infection to your provider immediately." c. "You will need to avoid taking ibuprofen while on this medication." d. "You will need to receive a MMR vaccine 1 month after starting this medication."

b. "You should report signs of infection to your provider immediately." The nurse should teach the client that they are susceptible to infections when taking DMARD II medications such as etanercept. The client should report symptoms of infection, such as fever, cough, malaise, weight loss, and dyspnea, to the provider immediately to prevent further complications.

A nurse should identify that a client who has diabetes mellitus and is taking etanercept is at an increased risk for which of the following adverse effects? a. Kidney toxicity b. Infection c. Gout d. Deep-vein thrombosis

b. Infection Etanercept increases the risk of developing a serious infection. Providers should not prescribe etanercept for clients who have an existing infection and should use it cautiously with clients who have diabetes mellitus because the disease itself already causes an increased risk for infection.

When the nurse is reviewing laboratory data for a patient who is taking methotrexate, which information is most important to communicate to the health care provider? a. The platelet count is 130,000/μl. b. The white blood cell count (WBC) is 1500/μl. c. The blood glucose is 130 mg/dl. d. The potassium is 5.2 mEq/L.

b. The white blood cell count (WBC) is 1500/μl. Rationale: Bone marrow suppression is a possible side effect of methotrexate, and the patient's low WBC count places the patient at high risk for infection. The other laboratory values are also abnormal but are not far from normal values and would not have any immediate serious consequences.

A nurse is caring for a client who is currently taking methotrexate for rheumatoid arthritis. The nurse should identify that which of the following is an adverse effect of this medication? a. Hypertension b. Thrombocytopenia c. Glaucoma d. Edema

b. Thrombocytopenia Methotrexate has many adverse effects that affect the central nervous, respiratory, dermatologic, and hematology systems, such as anemia, leukopenia, and thrombocytopenia.

The health care provider prescribes methotrexate for a 28-year-old woman with stage II moderate rheumatoid arthritis (RA). When obtaining a health history from the patient, the most important information for the nurse to communicate to the health care provider is that the patient has a. A history of infectious mononucleosis as a teenager. b. A family history of age-related macular degeneration of the retina. c. Been trying to have a baby before her disease becomes more severe. d. Been using large doses of vitamins and health foods to treat the RA.

c. Been trying to have a baby before her disease becomes more severe. Rationale: Methotrexate is teratogenic, and the patient should be taking contraceptives during methotrexate therapy. The other information will not impact the choice of methotrexate as therapy.

A nurse is teaching a client about methotrexate. The nurse should inform the client to monitor for which of the following as an adverse effect of this drug? a. Muscle pain b. Peripheral edema c. Black, tarry stools d. Redness in the calf

c. Black, tarry stools Methotrexate can cause gastric intestinal ulceration, which can lead to perforation and bleeding. The client should monitor for blood in stools or emesis and report either to the provider immediately.