An Essay Submitted in Partial Fulfillment for the diploma degree In Hospital and clinical pharmacy

1. ‫م‬‫م‬‫م‬‫م‬‫م‬‫م‬‫م‬‫م‬‫م‬‫م‬‫م‬‫م‬‫م‬‫م‬‫م‬‫م‬‫م‬‫م‬‫م‬

2. Mansoura University
Faculty of Pharmacy
Department of Pharmaceutics
Clinical management of rheumatoid arthritis in peptic and
duodenal ulcer patients
By
Mohamed Fathi Mahmoud Eissa
Under the supervision of
Prof Dr.
THANAA M. BORG
Pharmaceutics department
Faculty of Pharmacy
An Essay
Submitted in Partial Fulfillment for the diploma degree
In Hospital and clinical pharmacy
2015

3. Rheumatoid Arthritis
“A chronic autoimmune disease characterized by the inflammation of the synovial joints”
Has a symmetrical bilateral effect on joints
Results in joint deformity and immobilization
Multiple factors increase one’s risk
(The Arthritis Society, 2012; Gulanick & Myers, 2011; Firth, 2011)

4. Symptoms
•Morning stiffness lasting
more than half an hour
•Simultaneous symmetrical
joint swelling
•Not relieved by rest
•Fever
•Weight loss
•Fatigue
•Anemia
•Lymph node enlargement
•Nodules
(The Arthritis Society, 2012; Firth, 2011; Oliver, 2010; Day et al., 2010)

5. Diagnosis
• CBC
• Radiographs of involved joints
• CT/MRI scans
• Direct arthroscopy
• Synovial/Fluid aspirate
• Synovial membrane biopsy
• Arthrocentesis
(National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2012)
No single test is specific to Rheumatoid Arthritis

6. Antibody Tests:
Rheumatoid Factor Test
Other blood tests check for the presence of
antibodies that are not normally present in
the human body
(National Rheumatoid Arthritis Society, 2012; Day et al., 2010)

7. Synovial/Fluid aspirate
Synovial membrane biopsy
Arthrocentesis
Athrocentesis: synovial fluid is aspirated and analysed for inflammatory components
(Day et al., 2010)
Abnormal synovial fluid: cloudy, milky, or dark yellow containing leukocytes

8. X-Ray CT/MRI scans
(Gulanick & Myers, 2011; Day et al., 2010)
X-rays are an important diagnostic
test for monitoring the disease
progression
Patients may reveal NO
changes on an X-ray in the
early stages
Used for better visualization of
soft tissue
MRI is particularly sensitive for the early
and subtle features of RA
Can detect changes of Rheumatoid
Arthritis prior to an X-Ray
(Radiopaedia, 2010; Dat et al., 2010)

9. Peptic ulcer
A break in superficial epithelial cells penetrating down to
muscularis mucosa

10. Protective factorsProtective factors vs.vs. hostile factorshostile factors
PathogenesisPathogenesis ::

11.  EndoscopyEndoscopy
 Biopsy – bacteria & malignancyBiopsy – bacteria & malignancy
 H.Pylori:H.Pylori:
 Endoscopy cytologyEndoscopy cytology
 Biopsy – Special stainsBiopsy – Special stains
 Culture - difficultCulture - difficult
 Urease Breath test.Urease Breath test.
DiagnosisDiagnosis

12.  Bleeding – Chronic, Acute, MassiveBleeding – Chronic, Acute, Massive
 Fibrosis, Stricture obstruction – pyloric stenosis.Fibrosis, Stricture obstruction – pyloric stenosis.
 Perforation – Peritonitis- emergency.Perforation – Peritonitis- emergency.
 Gastric carcinoma. (not duodenal carcinoma)Gastric carcinoma. (not duodenal carcinoma)
Complications

13. Non-pharmacological Treatment of
Peptic ulcer
1-Avoid spicy food.
2-Avoid xanthin containing beverges.
3-Avoid Alcohol.
4-Avoid Smoking.
5-Avoid heavy meals.
6-Encourage small frequent low caloric
meals.
7-Avoid ulcerating drugs e.g. NSAIDs,
corticosteroids, xanthines and
parasympathomimetics

14. Triple therapy for 14 days is considered the treatment of choice.
– Proton Pump Inhibitor + clarithromycin and amoxicillin
• Omeprazole (Prilosec): 20 mg PO bid for 14 d or
Lansoprazole (Prevacid): 30 mg PO bid for 14 d or
Rabeprazole (Aciphex): 20 mg PO bid for 14 d or
Esomeprazole (Nexium): 40 mg PO qd for 14 d plus
Clarithromycin (Biaxin): 500 mg PO bid for 14 and
Amoxicillin (Amoxil): 1 g PO bid for 14 d
• Can substitute Flagyl 500 mg PO bid for 14 d if allergic to Penicillin.
– In the setting of an active ulcer, continue on proton pump inhibitor therapy for
additional 2 weeks.
Treatment

15. Clinical management of rheumatoid arthritis in peptic
and duodenal ulcer patients

16. COX-2 Non-steroidal anti-inflammatory drugs (NSAIDs)
Examples General Use Side Effects pharmacist patient
counselling
Celecoxib (Celebrex®).
Rofecoxib (Vioxx®) and
Valdecoxib (Bextra®)
•It is simply a safer
alternative for those
patients with an
increased risk of
stomach ulcers and/or
bleeding.
• anti-
inflammatory:
Used in the
management
inflammatory
conditions
•Analgesic:
Control mild to
moderate pain
•The general
dose For
rheumatoid
arthritis is 200
mg up to twice a
day (McCormack,
2011).
Both rofecoxib
(Vioxx®) and
valdecoxib (Bextra®)
have been removed
from the market
because of concerns
of an increased risk
of heart attacks or
stroke.
•insomnia,
•abdominal pain,
•flatulence (gas),
•headache,
•nausea, and
•diarrhea.
•NSAIDs may
decrease response to
diuretics or
antihypertensive
therapy
•can raise blood
pressure in some
people
(The Arthritis Society, 2011; Day et al., 2010)

17. Corticosteroids
Examples General Use Side Effects pharmacist patient
counselling
Cortisone,
Hydrocortisone,
Prednisone,
Betamethasone ,
Dexa-methasone
• Used in the
management
inflammatory
conditions
•When NSAIDS
may be
contraindicated
•Promptly
improve
symptoms of
RA
•Increased
appetite
•Weight gain
•Water/salt
retention
•Increased blood
pressure
•Thinning of skin
•Depression
•Mood swings
•Muscle weakness
•Osteoporosis
•Delayed wound
healing
•Onset/worsening
of diabetes
•Take medications
as directed
(adrenal
suppression)
•Used with caution
in diabetic patients
•Encourage diet
high in protein,
calcium, potassium
and low in sodium
and carbohydrates
•Discuss body
image
•Discuss risk for
infection
(The Arthritis Society, 2011; Day et al., 2010)

18. Disease-modifying anti-rheumatic drugs(DMARDS)
Examples General Use Side Effects pharmacist patient
counselling
Methotrexate
(the gold
standard)
, gold salts,
cyclosporine,
sulfasalazine,
azathioprine
•immunosuppressive
activity
•Reduce
inflammation of
rheumatoid arthritis
•Slows down joint
destruction
•Preserves joint
function
•Dizziness,
drowsiness,
headache
•Pulmonary fibrosis
•Nausea
•Hepatotoxicity
•Infertility
•Alopecia
•Skin ulceration
•Aplastic anemia
•Thrombocytopenia
•Leukopenia
•Nephropathy
•May take several
weeks to months
before they
become effective
•Discuss
teratogenicity,
should be taken off
drug several
months prior to
conception
•Discuss body
image
(The Arthritis Society, 2011; Day et al., 2010)

19. Biologic Response Modifiers (“Bioligics”)
Examples General Use Side Effects pharmacist patient
counselling
Leufunomide (Avara ) ,
Etanercept (Enbrel )
Adalimumab ( Humira)
Tocilizumab (Actemra )
• Used in the
management
inflammatory
conditions
•When NSAIDS
may be
contraindicated
•Promptly
improve
symptoms of
RA
•Increase risk of
infection
•Leufunomide
(Avara is generally
avoided in women
who might become
pregnant.
•Take medications
as directed
•Discuss body
image
•Discuss risk for
infection
(The Arthritis Society, 2011; Day et al., 2010)

20. • In severe cases of rheumatoid arthritis,
surgery may be needed to reduce pain and
improve joint function. Some surgeries include
joint replacement, fusion of joints
(arthrodesis), tendon reconstruction, and
removal of inflamed tissues (synovectomy).
Surgery

21. Alternative Medicine
Olive leaf extract
Aloe Vera
Green Tea
Omega 3
Ginger Root Extract
Cats Claw
Omega 3 interferes with blood clotting drugs!
(American College of Rheumatology, 2012)

22. Exercise
Being overweight strains joints and leads to further inflammation
(Arthritis Foundation, 2012)
4 times a week for
30 minutes
•Walking
•Light jogging
•Water aerobics
•Cycling
•Yoga
•Tai chi
•stretching

23. Nutrition
(Johns Hopkins Arthritis Center, 2012)
The most commonly observed vitamin and
mineral deficiencies in patients with RA are:
o folic acid
o vitamin C
o vitamin D
o vitamin B6
o vitamin B12
o vitamin E
o calcium
o magnesium
o zinc
o selenium

24. Conclusion
• Rheumatoid Arthritis
• “A chronic autoimmune disease characterized by the inflammation of the synovial joints”
• Has a symmetrical bilateral effect on joints , Results in joint deformity and immobilization
• Peptic ulcer
• A break in superficial epithelial cells penetrating down to muscularis mucosa .
• Triple therapy for 14 days is considered the treatment of choice.
Clinical management of rheumatoid arthritis in peptic and duodenal ulcer patients .
• COX-2 Non-steroidal anti-inflammatory drugs (NSAIDs)
• Corticosteroids
• Disease-modifying anti-rheumatic drugs(DMARDS)
• Biologic Response Modifiers (“Bioligics”)
• Alternative Medicine Olive leaf extract ,Aloe Vera , Omega 3
• Exercise
• Nutrition

25. THANK YOU