Non-biologic disease-modifying antirheumatic drug (DMARD) therapy: Nursing pharmacology

Non biologic disease, modifying anti rheumatic drugs or dmards for short are a group of medications primarily used to treat rheumatoid arthritis.

The most commonly used ones are methotrexate, sulfaSALAzine, leflunomide and hydroxychloroquine. Now, in addition to rheumatoid arthritis, most of these medications have other indications.

So, methotrexate can be used to treat psoriasis and certain cancers. SulfaSALAzine is also indicated for ulcerative colitis.

Finally, hydroxychloroquine can be used to treat malaria and systemic lupus erythematosus. Now, nonbiologic dmards can be administered orally, subcutaneously, intramuscularly and intravenously once administered, they mainly work by inhibiting the immune response and suppressing inflammation.

However, nonbiologic dmards can cause some notable side effects such as bone marrow suppression, which can lead to conditions like anemia and leukopenia as well as severe skin reactions and stomatitis or painful mouth sores.

Other general side effects include gastrointestinal disturbances such as anorexia, nausea, vomiting, and diarrhea. In addition, the immunosuppressive effects of these medications can lead to an increased risk of developing infections and certain cancers.

More specifically methotrexate can lead to pulmonary fibrosis, hepatotoxicity and nephrotoxicity. Next, sulfaSALAzine can result in hypersensitivity reactions like anaphylaxis and orange discoloration of the urine.

While important side effects of leflunomide include heart palpitations, hepatotoxicity and interstitial lung disease. Finally, hydroxychloroquine s most common side effects are vision problems due to corneal or retinal damage.

In addition, some clients may also experience neurological side effects such as seizures as well as cardiovascular side effects like heart failure, qt prolongation and torsades de pointes as far as contraindications go.

These medications should not be used during pregnancy. Methotrexate has some important boxed warnings including its toxic effects on liver kidneys and lungs.

On top of that methotrexate should not be combined with nsaids or proton pump inhibitors. Since these medications can decrease the clearance of methotrexate from the body, potentially leading to elevated levels of methotrexate.

Lastly, methotrexate can decrease the effects of digoxin and folic acid. Now, sulfaSALAzine is contraindicated for use in clients with hypersensitivity to sulfonamides or salicylates.

It also decreases the absorption of both folic acid and iron and it can increase the hypoglycemic effect of oral hypoglycemics and increase the anticoagulant effect of oral anticoagulants.

On the other hand, leflunomide has a boxed warning due to its hepatotoxic effects and it can increase the anticoagulant effects of warfarin hydroxychloroquine is contraindicated in clients with conditions that affect their visual field such as macular degeneration and it can increase digoxin levels potentially leading to digoxin toxicity.

Finally, keep in mind that because of the depressive effects of dmards on the immune system, these medications can decrease the effectiveness of inactivated vaccines.

While administration of live attenuated vaccines may result in illness due to uninhibited growth of the live attenuated virus.

Now, when your client with rheumatoid arthritis is prescribed a nonbiologic dmard agent like methotrexate. First, perform a focused baseline musculoskeletal assessment, checking for joint pain, stiffness, swelling and range of motion.

Then review their most recent laboratory test results including renal and hepatic function. CBC rheumatoid factor C RP and E SR and be sure to confirm a negative pregnancy test for clients of childbearing age.

Lastly. Review diagnostic test results including x rays and ultrasound.

Next, explain to your client how their medication will help to decrease their joint pain and inflammation as well as increase their day to day functionality.

Instruct them to take their medication exactly as prescribed once each week, on the same day of the week. If your client is taking the medication as an oral solution, be sure to demonstrate how to measure the correct dose using a calibrated oral syringe.

On the other hand, if they will be administering the medication subcutaneously, demonstrate the proper use of the single use autoinjector confirm they are able to self inject the medication into their thigh or abdomen two inches away from their navel.

And if they understand how to rotate the injection sites, remind them to inspect the area for bruising, broken skin or tenderness before administration and make sure they know how to dispose of equipment properly.

Also, if they miss a dose, prompt them to contact their health care provider for directions. Lastly, caution your biological female clients of childbearing age to use a reliable form of birth control while taking this medication.

And to let their healthcare provider know right away. If they become pregnant, then discuss important lifestyle modifications your client should make while taking methotrexate, encourage them to increase their fluid intake up to 2 L per day.

And to avoid consuming alcohol also stress the importance of including in their diet foods high in folic acid such as spinach romaine lettuce, broccoli, peanuts, oranges and whole grains and to take the prescribed folic acid supplement daily.

Next, explain to your client that they may be at a higher risk for infection while taking methotrexate and review with them proper hand hygiene techniques to prevent infections.

In addition, let them know they should avoid large crowds and people with infections and talk to their healthcare provider before getting live virus vaccines.

Next, be sure to review how to recognize important side effects that should be reported to their healthcare provider right away.

This includes infections of the respiratory tract which could cause fever, chills, sore throat cough, or the production of large amounts of sputum as well as a dry nonproductive cough or shortness of breath gastrointestinal problems that could manifest as fatigue, anorexia, upper right abdominal pain, dark urine or yellowing of the skin or eyes, impaired renal function, which can present with decreased urine output blood in the urine or a significant weight gain bleeding problems that could manifest as dark tarry stools, coughing up blood or emesis that looks like coffee grounds bleeding gums, nosebleeds or minor cuts that take an unusually long time to stop bleeding.

And lastly, the development of a rash that could look like blisters, peeling skin as well as sores in the mouth, nose or eyes.

Finally, during treatment with nonbiologic dmards like methotrexate, closely monitor your client's laboratory test results and keep an eye out for the development of side effects.

Last but not least, evaluate for the desired therapeutic effects of a decrease in joint inflammation and pain associated with rheumatoid arthritis along with increased functionality.

All right, as a quick recap, nonbiologic dmard medications are used to treat rheumatoid arthritis as well as other diseases like psoriasis and malaria.

These medications include methotrexate, sulfaSALAzine, leflunomide and hydroxychloroquine. Common side effects include gastrointestinal disturbances, severe skin reactions, stomatitis, bone marrow suppression and an increased risk of developing infections when caring for clients taking a nonbiologic dmard.

Nursing considerations include performing a baseline assessment as well as monitoring for side effects and the therapeutic effect.

Client teaching is focused on safe self administration and learning to recognize side effects that need to be reported to their healthcare provider