REVIEW
NURSING CARE OF PATIENTS WITH RHEUMATOID ARTHRITIS
Vickie Ensor Bands, BSN, MSA*
ABSTRACT
Patients diagnosed with rheumatoid arthritis
face a lifelong condition that can be physically and
emotionally debilitating. Moreover, the medica-
tions required for treatment can have serious and
even life-threatening side effects. The role of nurs-
es caring for patients with rheumatoid arthritis is to
provide support through education about the dis-
ease process, treatment regimens, and identifying
treatment response. A major goal for nurses must
be assisting patients in forming a self-management
plan. Patients should learn the difference between
pharmacological and nonpharmacological treat-
ment options, understand that rheumatoid arthritis
is a lifelong, chronic illness that will need continu-
al reassessment, and partner with their healthcare
team to receive optimal benefit. Regularly docu-
menting patients medications, pain scores, and
ability to perform activities of daily living are only
small parts of the nurses role. Counseling, case
management, identification of psychosocial issues,
and assisting patients with selecting appropriate
complementary therapies and alternative treat-
ment options are significant responsibilities of
rheumatology nurses. Patients with rheumatoid
arthritis require careful screening and laboratory
testing prior to initiating drug therapy and while
treatment continues. The advent of biologics has
dramatically changed the prognosis for rheuma-
toid arthritis patients; however, these drugs come
with significant risks.
(Adv Stud Nurs. 2007;5(1):23-31)
*Director of Community Outreach and Occupational
Health, Upper Chesapeake Health, Havre De Grace,
Maryland.
Address correspondence to: Vickie Ensor Bands, BSN,
MSA, Director of Community Outreach and Occupational
Health, Upper Chesapeake Health, 501 S. Union Avenue,
Havre De Grace, MD 21078. E-mail: Veb.01@ex.uchs.org.
Johns Hopkins Advanced Studies in Nursing
INTRODUCTION
The significance of joint damage in rheumatoid
arthritis (RA) lies in its impact on function. Even with
treatment, within a relatively short time, patients may
become unable to perform activities of daily living.
According to a study conducted before the introduc-
tion of biologic therapy, approximately 25% of US
patients are unable to work within 6 years of disease
onset, and up to 50% are disabled within 21 years.1 It
is estimated that RA costs the average patient up to
$8500 annually because of loss of employment and
medical costs.2
Quality of life in patients with RA is also com-
monly affected by pain, feelings of dependence on oth-
ers, fatigue, and sleep disturbance.3-5 In a survey
conducted in 2004 by the Arthritis Foundation, more
than two thirds of 500 patients with RA reported that
despite treatment with disease-modifying anti-
rheumatic drugs (DMARDs), they experience pain,
stiffness, and fatigue daily.6 One half reported that
they continue to modify their daily household activi-
ties as a result of their arthritis.
This article discusses how nurses can help patients
understand and manage RA as a chronic, life-altering
disease. It also reviews how nurses can prevent and
identify adverse effects of drug therapy.
GOALS OF NURSING CARE IN RHEUMATOID ARTHRITIS
Ac c o rding to the American College of
Rheumatology (ACR), a physicians goals during RA
management should be to prevent or control joint
damage, prevent loss of function, and decrease pain.7
Table 1 lists a number of relevant nursing goals.
For patients newly diagnosed with RA referral to a
physical therapist, occupational therapist, and/or vo c a-
tional counselor should be considered early on.7 Some
23

patients may also benefit from consultation with an
o rthopedic surgeon, podiatrist, social work e r, health
educator, or health psychologist. The nurse and other
members of the multidisciplinary team need to share
information about patients pro g ress.
Evaluation of RA is a repetitive process. Nurses
should participate in periodically reassessing patients
for evidence of disease activity or progression, and for
toxic effects of the drug regimen. They should also reg-
ularly document patients medications, pain scores,
and ability to perform activities of daily living. For the
latter, the Health Assessment Questionnaire is becom-
ing commonly used in clinical practice (Table 2).8,9
HELPING PATIENTS LIVE WITH
RHEUMATOID ARTHRITIS
PATIENT EDUCATION
The ACR recommends that patients with
RA participate in developing a long-term tre a t-
ment plan that addresses their prognosis and
t reatment options.7 Educational sessions with a
nurse should precede and follow the deve l o p-
ment of this plan. Nurses can help patients
understand their pharmaceutical and nonphar-
maceutical options, evaluate later whether
t reatment needs to be adjusted, and begin to
accept RA as a chronic disease that can be treat-
ed but not cured. Two systematic reviews have
determined that, at least in the short term,
patient education in RA improves measures
such as disability, the number of tender joints,
patients assessments of their condition, psy-
chological status, and depre s s i o n .10,11 The
Arthritis Foundation offers a wide range of
materials and programs that can be helpful,
including an online discussion group for
patients with RA.12
PROMOTING ADHERENCE TO THERAPY
Adherence to treatment by patients with RA
is often suboptimal. Among adults part i c i p a t-
ing in RA studies, adherence rates range fro m
16% to 84% for pharmaceutical regimens and
f rom 25% to 65% for nonpharmaceutical
treatments.13 Patients who are asymptomatic or
in remission, and conversely, those with persis-
tent symptoms, may see little reason to contin-
ue following recommendations.
24
REVIEW
In addition to educating patients early and
often, nurses can take the following steps to promote
adherence13:
Remind patients to hang in there; some
medications need time to start working.
Routinely ask patients about their adherence, in
a nonjudgmental way, and discuss how they
might overcome barriers. One suggestion may be
to recommend the use of alarms (eg, on watches
or cell phones) as reminders to take their
medications.
Make sure patients have the skills and knowledge
they need for managing their RA.
Refer patients to mental health professionals if
needed.
Patients with chronic illness tend to accept tre a t-
ment recommendations best when they are able to par-
Table 1. Nursing Goals in Rheumatoid Arthritis
Upon Diagnosis Educate patients about rheumatoid arthritis, medications, and
self-care, especially community resources for exercise and
physical activity.
In collaboration with the physician, screen patients for
contraindications to drug therapy and order baseline
laboratory tests.
Arrange services of other healthcare professionals as needed.
Regularly During
Follow-up Verify the medication list (agent and dosage).
Assess patient compliance with drug therapy.
Assess and document activities of daily living and pain scores.
Update the log on laboratory toxicity monitoring, if needed.
Provide psychological support and reminders about self-care.
Share information about the patients progress with other
healthcare professionals.
In collaboration with the physician:
Monitor the incidence and severity of drug side effects.
Counsel the patient about preventing complications such
as infection, osteoporosis, and cardiovascular disease.
Monitor progression of rheumatoid arthritis, which may be
signaled by such signs as joint deformity or development
of extra-articular manifestations, including rheumatoid
nodules.
Encourage maintenance of mobility and protection of
unaffected joints through exercise, rehabilitation, and use
of supports/splinting.
Vol. 5, No. 1 April 2007
 REVIEW

ticipate in the decision-making process about their

care.14-16 An interv i ew study of 17 younger women with
RA, ages 26 to 40, found that these patients wanted
their doctors and nurses to be educators, partners, and
supporters.17 The patients said they wanted to be able
to negotiate about their treatment and to be included
in treatment plans without fear of disapproval.
COUNSELING ABOUT NONPHARMACOLOGICAL
INTERVENTIONS
EXERCISE AND PHYSICAL ACTIVITY
Of all physical modalities for arthritis pain relief,
exercise appears to be the most consistently effective.18
Many patients with RA fear that exercise will cause
pain or aggravate their existing level of pain. But, as
shown in the Figure, reduced activity can actually cre-
ate a vicious circle in which deconditioning leads to
increased functional impairment, in turn leading to
increased fatigue and accompanying problems such as
increased pain.19 To minimize restrictions in work and
leisure activities, exercise should be a key component
of RA management from the start.20
Nurses can help patients avoid pain exacerbation
by encouraging them to20:
Accept delayed-onset muscle soreness as a
normal consequence of starting an exercise
program.
Use heat or cold before and after exercise, along
with warm-up and cool-down periods.
Plan short periods of rest or nonwe i g h t -
bearing activity.
Move at a slower pace when needed.
Use medications for pain management as
appropriate.
Use prescribed assistive devices or orthoses
during exercise.
Table 2. The Health Assessment Questionnaire
Possible answers are: without any difficulty, with some difficulty,
with much difficulty, or unable to do.
Are you able to dress yourself?
Are you able to shampoo your hair?
Are you able to stand up from a straight chair?
Are you able to get in and out of bed?
Are you able to cut your meat?
Are you able to lift a full cup or glass to your mouth?
Are you able to open a new milk carton?
Are you able to walk outdoors on flat ground?
Are you able to climb up 5 steps?
Are you able to take a bath in the tub?
Are you able to get on and off the toilet?
Are you able to reach and get down a 5-lb object from just
above your head?
Are you able to bend down to pick up clothing from the floor?
Are you able to open car doors?
Are you able to open jars that have been previously opened?
Are you able to turn faucets on and off?
Are you able to able to run errands and shop?
Are you able to get in and out of a car?
Are you able to do chores such as vacuuming or yardwork?
Reprinted with permission from Ruderman. Curr Pharm Des. 2005;
11:671-684.9
Figure. The Chronic Illness Symptom Cycle

PHYSICAL THERAPY AND OCCUPATIONAL THERAPY

Physical therapy and occupational therapy are well
established as being beneficial in the treatment of RA.
Physical therapy most commonly involves supervision
in aerobic, range of motion, and strengthening exer-
cises; hydrotherapy; thermotherapy; and electrical
stimulation. Services of occupational therapists
include advice about joint protection and fatigue man-
agement, assessment of activities of daily living, envi-
Reprinted with permission from the Arthritis Foundation. Arthritis Foundation
ronmental modification and assistive devices, hand Aquatic Program Instructors Guide. Atlanta, Ga: Arthritis Foundation; 2005.19
and wrist splinting, and job rehabilitation.21

Johns Hopkins Advanced Studies in Nursing 25

 REVIEW
COMPLEMENTARY AND ALTERNATIVE MEDICINE
The use of complementary and alternative medicine
(CAM) by patients with rheumatic diseases is extre m e-
ly common.21 Most patients use CAM as a supplement
to standard medical care, rather than a replacement,
often because they want more complete pain relief.22,23
When discussing medications and treatment
adherence, nurses should always ask in a nonjudgmen-
tal way whether the patient uses CAM and, if so, what
types. According to well-designed studies or systemat-
ic reviews of multiple studies, promising CAM inter-
ventions for RA include Chinese thunder god vine
(Tripterygium wilfordii),24 gamma-linolenic acid (bor-
age seed oil, evening primrose oil, blackcurrant seed
oil),25 omega-3 fatty acids (fish oil),26 spa therapy,27 Tai
Chi,28 and vitamin E supplementation.29
Nurses should inform patients that although herbs
a re natural, they are not necessarily safe in all cases. The
US Food and Drug Administration does not regulate
supplements or herbal preparations. Tripterygium wil-
fordii is commonly associated with gastrointestinal side
effects and amenorrhea,24 and its use has been associat-
ed with death caused by myocardial damage, renal fail-
u re, and hypotension related to seve re gastrointestinal
effects.30 Some of the herbs used by patients with RA,
including feverf ew and devils claw, increase the risk of
bleeding if used along with antiplatelet or anticoagu-
lant therapy. Others, including willow bark and echi-
nacea, should not be used with immunosuppre s s i ve
d rugs such as methotrexate. Many patients expect clin-
icians to warn them about side effects of herbal re m e-
dies, but the long-term effects of these preparations
h a ve not been well studied.30
SUPPORTING SEXUAL INTIMACY
More than 50% of patients with RA re p o rt problems
with sexual relationships.31,32 Symptoms such as fatigue,
pain, and reduced joint function are the chief limita-
tions, but medication side effects, depression, altered
body image, and the effects of a partners assumption of
the caregiver role can also have an impact.33
For most people, sexual activity is an integral part of
life that contributes to their sense of well-being. Nurses
can support patients sexual health by integrating re l e-
vant questions into routine care. To decrease embar-
rassment, it helps to open with a statement such as:
Many people with arthritis mention changes in their
intimate physical re l a t i o n s h i p. Some questions that
can open lines of communication are: (1) Has art h r i t i s
26
put a strain on your relationship? (2) Ha ve you had any
difficulty with pain affecting your sexual relationship?33
Table 3 lists suggestions for patients who want to
improve their sexual function.33 Also, the Arthritis
Foundation offers a Guide to Intimacy with Arthritis,
available at its Web site or by calling 800-568-4045.12
COUNSELING ABOUT CARDIOVASCULAR DISEASE
Cardiovascular disease accounts for most of the
excess mortality associated with rheumatoid diseases.34
Atherosclerosis is now thought to be an inflammatory
disorder, and recent studies suggest that the systemic
inflammation in RA is linked to heart disease and an
Table 3. A Rheumatoid Arthritis Patients Guide to
Improving Sexual Function
1. Open communication between partners
Be honest with your partner about feelings, desires,
and sexual needs.
Address each others fears of physical harm.
Discuss each others willingness to redefine intimacy
through new positions, sexual aids, different techniques.
2. Use tactile communication
Kissing, caressing, petting, or massage may help restore
lost intimacy and assist in helping both partners relax.
Some couples may want to try using the hands or
mouth to help achieve orgasm.
3. Environmental factors
Plan blocks of time within your regular schedule when
both of you are relaxed and comfortable.
Make sure that you get rest ahead of time.
Avoid cold temperatures by taking a warm bath or
shower before sex.
Warm the bed by replacing cotton sheets with flannel
sheets or turn on an electric blanket for a few minutes
before getting into bed.
4. Medications
Take pain medication at least 30 minutes before sexual
activity.
Discuss any possible sexual side effects of medications
with a healthcare professional.
Water-based lubricants may be helpful in the presence
of vaginal dryness.
Adapted with permission from Ruffing. Sexual intimacy. In: Bartlett SJ,
Bingham CO, Maricic MM, Iversen MD, Ruffing V, eds. Clinical Care in the
Rheumatic Diseases. 3rd ed. Atlanta, Ga: Association of Rheumatology
Health Professionals; 2006.33
Vol. 5, No. 1 April 2007
 REVIEW

increased risk of early death.35-38 Other research has
shown that the mere presence of inflammation does
not cause atherosclerosis; cardiovascular risk factors
must also be present.39 Nurses can do a great service to
patients with RA by helping them identify and aggres-
sively lower their risk factors for cardiovascular disease,
such as hypertension, hypercholesterolemia, smoking,
and use of corticosteroids.
COUNSELING ABOUT PREGNANCY AND LACTATION
Methotrexate and leflunomide are potent terato-
gens. Nurses should periodically check that women of
childbearing potential who use these medications are
using reliable birth control.40,41 If a patient (male or
female) taking leflunomide decides to conceive, the
following drug washout protocol is necessary: oral
cholestyramine, 8 g three times daily, for 11 days.
Complete elimination of the drug can take as long as
2 years, so simply discontinuing it is insufficient.
Before conception is attempted, the plasma level of the
drug should be below 0.02 mg/L on 2 separate tests
performed at least 14 days apart.42
Some experts advise that sulfasalazine and hydroxy-
chloroquine can be maintained during pregnancy and
lactation.41 The safety of biologic DMARDs in this

Table 4. Monitoring Drug Toxicity in Rheumatoid Arthritis

Drug/Class Baseline Evaluation Monitoring

NSAIDs CBC, creatinine, LFTs CBC yearly, LFTs

Corticosteroids Blood pressure, blood chemistries panel, bone Urinalysis for glucose yearly; bone densitometry at regu-
densitometry lar intervals
Hydroxychloroquine None, except ophthalmologic exam if patient is over Yearly ophthalmologic exam
age 40 or has had previous eye disease
Sulfasalazine CBC and LFTs in patients at risk, G6PDH CBC every 24 weeks for the first 3 months, then every
3 months thereafter
Methotrexate CBC, creatinine, LFTs, alkaline phosphatase, chest radi- CBC, creatinine, LFTs monthly for the first 6 months;
ograph within previous year, hepatitis B and C serology every 12 months thereafter*
in high-risk patients
Leflunomide Hepatitis B and C serology in high-risk patients, CBC, CBC, creatinine, LFTs monthly for the first 6 months;
creatinine, LFTs every 12 months thereafter.* Patients also taking MTX
should have LFTs at least monthly.
TNF inhibitors CBC and ALT; assess for TB, other infections, risk fac- CBC and ALT monthly until dose is stable; may continue
(etanercept, infliximab, tors for infections, history of malignant disease or heart every 23 months thereafter
adalimumab) failure
Anakinra CBC; assess for TB, other infections, risk factors for CBC monthly for 3 months and every 3 months there-
infections after
Rituximab Assess for TB, other infections, risk factors for infections, CBC and platelet counts at regular intervals
especially hepatitis B.
Abatacept Assess for TB, other infections, risk factors for infections, Monitor COPD patients for worsening of respiratory
history of COPD. disease.
CBC = complete blood cell count (hematocrit, hemoglobin, white blood cell count, including white blood cell differential and platelet counts); COPD = chronic obstruc-
tive pulmonary disease; G6PDH = glucose-6-phosphate dehydrogenase; LFTs = liver function tests (aspartate aminotransferase [AST], alanine aminotransferase [ALT],
albumin); MTX = methotrexate; NSAIDs = nonsteroidal anti-inflammatory drugs; TB = tuberculosis; TNF = tumor necrosis factor; and ULN = upper limit of normal.
*For minor elevations in AST or ALT (< twofold ULN), repeat testing in 24 weeks. For moderate elevations in AST or ALT (> twofold but < threefold ULN),
closely monitor, with LFTs every 24 weeks and dosage reduction or drug discontinuation as necessary.
For persistent elevations in AST or ALT (> twofold or threefold ULN), discontinue MTX and perform liver biopsy as necessary.
For persistent elevations in AST or ALT (> twofold or threefold ULN), discontinue leflunomide and eliminate with cholestyramine therapy; perform liver biopsy as necessary.
Adapted with permission from American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines. Arthritis Rheum. 2002;46:328-346.7 Additional data
from Furst et al43; Rituxan (rituximab) prescribing information44; Leff45; Olsen et al.48

Johns Hopkins Advanced Studies in Nursing 27

 REVIEW
regard has not been established.43 Patients should talk
with their physician while planning a pregnancy or
immediately upon discovering they are pregnant.
PREVENTING DRUG-RELATED TOXICITIES
Patients with RA require careful screening before
receiving drug therapy, and most need laboratory test-
ing while treatment continues. Nurses have a responsi-
bility to work closely with physicians to ensure that
safety remains a foremost concern. When care is
s h a red between a primary care physician and a
rheumatologist, there should be a written plan about
how the task of monitoring drug toxicity will be divid-
ed.7 Table 4 gives basic monitoring guidelines for com-
monly used drugs.44,45
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
The major side effects of nonsteroidal anti-inflam-
matory drugs (NSAIDs) are renal toxicity and gas-
trointestinal toxicity, especially ulcers, perforation, and
hemorrhage. Creatinine and potassium levels should
be monitored in patients with pre-existing renal dis-
ease or diminished effective renal blood volume.
Hemoglobin should be assessed periodically in
patients on long-term NSAID therapy, to check for
occult bleeding.46
CORTICOSTEROIDS
Side effects of corticosteroids, even at low doses,
can include osteoporosis, hypertension, weight gain,
fluid retention, hyperglycemia, cataracts, and skin
fragility, in addition to increased risk of infection and
premature atherosclerosis. These risks need to be care-
fully explained to patients before therapy is initiated.
According to the ACR, all patients receiving cortico-
steroids should receive supplemental calcium (1500
mg/day) and vitamin D (400800 IU/day). Physicians
also consider bisphosphonate therapy, as well as hor-
m o n e - replacement therapy for postmenopausal
women who have no contraindications. Bone densito-
metry to assess fracture risk should be performed at
regular intervals, even in patients with no risk factors
for osteoporosis.7
SYNTHETIC DISEASE-MODIFYING
ANTIRHEUMATIC DRUGS
Safe administration of synthetic DMARDs
requires especially careful laboratory monitoring. In
28
patients receiving methotrexate or leflunomide, the
principal concern is liver dysfunction, especially if the
2 drugs are given together.47
BIOLOGIC DISEASE-MODIFYING ANTIRHEUMATIC DRUGS
INJECTION-SITE/INFUSION REACTIONS
Minor redness and itching at the injection site, last-
ing a few days, is common among patients using etan-
ercept and adalimumab. Ap p roximately 20% of
patients develop symptoms during infusion of inflix-
imab, most commonly headache and nausea, which
appear to be controllable by using antihistamines or
slowing the infusion rate.48 Anakinra is associated with
a dose-dependent incidence of injection-site reactions,
affecting 70% of patients. These normally do not
require treatment, and with continued use, they seem
to moderate in some patients. Infusion reactions are
the most common adverse event with rituximab,
occurring with approximately 35% of first infusions
and approximately 10% of second infusions.
Intravenous corticosteroids are recommended to
reduce the incidence and severity of infusion-site reac-
tions with rituximab.43 In clinical trials of abatacept,
only 1% of patients discontinued the drug because of
an acute infusion-related event.49 Nurses involved in
administering biologics should be prepared to treat
acute hypersensitivity reactions.
TUBERCULOSIS
All biologic DMARDs are thought to incre a s e
patients susceptibility to tuberculosis, including re a c-
t i vation of latent tuberculosis. The standard of care is
for patients to be pre s c reened with tuberculosis skin
testing and a history that evaluates the risk of latent
infection (prior exposure, prior or active drug addic-
tion, HIV infection, history of living in a region of
high tuberculosis pre valence, and history of work i n g
in a high-risk setting such as a jail, homeless shelter,
or drug rehabilitation center).43,50 Some practitioners
choose to perform a chest X ray along with a skin test;
others choose to perform a chest X ray only after a
p o s i t i ve skin test. Patients who react positively are
started on a 6-month course of isoniazid. After 2
months of isoniazid therapy, patients with RA may
begin biologic therapy. Because isoniazid is also hepa-
totoxic, monitoring liver functions will be crucial dur-
ing treatment, especially if methotrexate is continued
concurrently.
Vol. 5, No. 1 April 2007
 REVIEW
OTHER INFECTIONS
Serious infections including sepsis have been
described in association with all biologic DMARDs.43
These drugs should not be started in the presence of
serious infection. At all follow-up visits, question
patients receiving a biologic about symptoms of infec-
tion, and remind them to report symptoms of infec-
tion immediately so the drug can be discontinued if
necessary.51
RA itself doubles the risk of infection, compared
with the risk in age-matched controls.52 All patients
with RA should have yearly influenza vaccinations and
should receive the pneumococcal vaccine at appropri-
ate intervals.47 In patients receiving an immunosup-
pressant drug (notably methotrexate or any of the
biologics), it is best to vaccinate before DMARD ther-
apy starts and to avoid live vaccines.43,47
CANCER
One of the current controversies in rheumatol-
ogy is whether the use of tumor necrosis factor
(TNF) inhibitors increases the risk of cancer.
Ac c o rding to a recent systematic review, the use of
infliximab or adalimumab triples the risk of lym-
phoma and solid tumors. 53 ( Et a n e rcept was exc l u d-
ed because it inhibits TNF slightly differently than
infliximab and adalimumab.) Howe ve r, even before
TNF inhibitors we re introduced, the incidence of
lymphoma was increased among patients with
RA.54,55 Analyses of Swedish and UK databases have
shown no increased risk of solid cancer with TNF
inhibitors.56,57 Until more is known, patients being
c o n s i d e red for a biologic DMARD should be
screened for a history of malignant disease, so the
physician can decide whether to use the drug cau-
tiously or even avoid it.51
CONGESTIVE HEART FAILURE
Another controversy is whether TNF inhibitors
increase the risk of new-onset congestive heart failure
(CHF), worsening of existing CHF, and mortality.
There is conflicting evidence,58,59 and adding to the
uncertainty, RA itself increases the risk of CHF.38 An
international expert panel has concluded that to date,
only high-dose infliximab (10 mg/kg) seems to be
risky in this regard.43 Still, some experts recommend
that all TNF inhibitors be used cautiously, if ever,
when mild heart failure is present and be avoided
when heart failure is severe.51
Johns Hopkins Advanced Studies in Nursing
CONCLUSIONS
A patient diagnosed with RA faces a lifelong condi-
tion that can be physically and emotionally debilitating.
Su p p o rt and counsel from a knowledgeable nurse can
help patients improve their quality of life, in addition to
preventing or controlling joint damage, pre venting loss
of function, and decreasing pain. Nurses advocate for
patients by educating them about the disease, helping
them choose among their pharmaceutical and non-
pharmaceutical treatment options, promoting adher-
ence to treatment, and counseling them about how to
reduce the risk of complications such as infection,
osteoporosis, and cardiovascular disease. Most patients
with RA re q u i re drug therapy that has the potential for
serious or even life-threatening side effects; therefore,
nurses should know how to screen patients for con-
traindications and monitor laboratory results. By con-
tinually evaluating patients responses to therapy, nurses
play a pivotal role in improving RA outcomes.
REFERENCES
1. Wolfe F, Hawley DJ. The longterm outcomes of rheumatoid
arthritis: work disability--a prospective 18 year study of 823
patients. J Rheumatol. 1998;25:2108-2117.
2. Yelin E, Wanke LA. An assessment of the annual and long-
term direct costs of rheumatoid arthritis: the impact of poor
function and functional decline. Arthritis Rheum.
1999;42:1209-1218.
3. Jakobsson U, Hallberg IR. Pain and quality of life among
older people with rheumatoid arthritis and/or osteoarthritis:
a literature review. J Clin Nurs. 2002;11:430-443.
4. Melanson PM, Downe-Wamboldt B. Confronting life with
rheumatoid arthritis. J Adv Nurs. 2003;42:125-133.
5. Wolfe F, Michaud K. Fatigue, rheumatoid arthritis, and anti-
tumor necrosis factor therapy: an investigation in 24,831
patients. J Rheumatol. 2004;31:2115-2120.
6. New survey shows 70 percent of rheumatoid arthritis patients
receiving treatment are still impaired every day [press
release]. Atlanta: Arthritis Foundation; October 5, 2004.
7. American College of Rheumatology Subcommittee on
Rheumatoid Arthritis Guidelines. Guidelines for the manage-
ment of rheumatoid arthritis: 2002 update. Arthritis Rheum.
2002;46:328-346.
8. Fries JF, Spitz PW, Young DY. The dimensions of health out-
comes: the Health Assessment Questionnaire, disability and
pain scales. J Rheumatol. 1982;9:789-793.
9. R u d e rman EM. Current and future pharmaceutical therapy for
rheumatoid arthritis. Curr Pharm Des. 2005;11:671-684.
10. Niedermann K, Fransen J, Knols R, Uebelhart D. Gap
between short- and long-term effects of patient education in
rheumatoid arthritis patients: a systematic review. Arthritis
Rheum. 2004;51:388-398.
29
 REVIEW
11. Riemsma RP, Kirwan JR, Taal E, Rasker JJ. Patient education
for adults with rheumatoid arthritis. Cochrane Database Syst
Rev. 2003:CD003688.
12. Arthritis Foundation Web site. Available at:
http://www.arthritis.org. Accessed March 13, 2007.
13. Rapoff MA, Bartlett SJ. Adherence in children and adults.
In: Bartlett SJ, Bingham CO, Maricic MM, Iversen MD,
Ruffing V, eds. Clinical Care in the Rheumatic Diseases.
Atlanta, Ga: Association of Rheumatology Health
Professionals; 2006.
14. Thorne SE, Paterson BL. Two decades of insider research:
what we know and don't know about chronic illness experi-
ence. Annu Rev Nurs Res. 2000;18:3-25.
15. Coulter A. Patient-centered decision making: empowering
women to make informed choices. Womens Health Issues.
2001;11:325-330.
16. Gallant MH, Beaulieu MC, Carnevale FA. Partnership: an
analysis of the concept within the nurse-client relationship. J
Adv Nurs. 2002;40:149-157.
17. Fair BS. Contrasts in patients' and providers' explanations of
rheumatoid arthritis. J Nurs Scholarsh. 2003;35:339-344.
18. Minor MA, Sanford MK. The role of physical therapy and
physical modalities in pain management. Rheum Dis Clin
North Am. 1999;25:233-248, viii.
19. Arthritis Foundation. Arthritis Foundation Aquatic Program
Instructors Guide. Atlanta, Ga: Arthritis Foundation; 2005.
20. Westby MD, Minor MA. Exercise and physical activity. In:
Bartlett SJ, Bingham CO, Maricic MM, Iversen MD, Ruffing
V, eds. Clinical Care in the Rheumatic Diseases. Atlanta, Ga:
Association of Rheumatology Health Professionals; 2006.
21. Hammond A. Rehabilitation in rheumatoid arthritis: a critical
review. Musculoskeletal Care. 2004;2:135-151.
22. American College of Rheumatology Committee on
Rheumatologic Care. American College of Rheumatology
position statement: complementary and alternative medicine
for rheumatic diseases. Available at: http://www.rheuma-
tology.org/publications/position/complementary.asp.
Accessed February 1, 2007.
23. Kolasinski SL. Complementary and alternative therapies for rheu-
matic disease. Hosp Pract (Minneap). 2001;36:31-36, 39.
24. Tao X, Younger J, Fan FZ, et al. Benefit of an extract of
Tripterygium Wilfordii Hook F in patients with rheumatoid
arthritis: a double-blind, placebo-controlled study. Arthritis
Rheum. 2002;46:1735-1743.
25. Soeken KL, Miller SA, Ernst E. Herbal medicines for the
treatment of rheumatoid arthritis: a systematic review.
Rheumatology (Oxford). 2003;42:652-659.
26. Stamp LK, James MJ, Cleland LG. Diet and rheumatoid
arthritis: a review of the literature. Semin Arthritis Rheum.
2005;35:77-94.
27. Verhagen AP, Bierma-Zeinstra SM, Cardoso JR, et al.
Balneotherapy for rheumatoid arthritis. Cochrane Database
Syst Rev. 2003:CD000518.
28. Han A, Robinson V, Judd M, et al. Tai chi for treating
rheumatoid arthritis. Cochrane Database Syst Rev.
2004:CD004849.
29. Edmonds SE, Winyard PG, Guo R, et al. Putative analgesic
activity of repeated oral doses of vitamin E in the treatment of
rheumatoid arthritis: results of a prospective placebo controlled
double blind trial. Ann Rheum Dis. 1997;56:649-655.
30
30. Kolasinski SL. Therapies from complementary and alterna-
tive medicine. In: Bartlett SJ, Bingham CO, Maricic MM,
Iversen MD, Ruffing V, eds. Clinical Care in the Rheumatic
Diseases. Atlanta, Ga: Association of Rheumatology Health
Professionals; 2006.
31. Kraaimaat FW, Bakker AH, Janssen E, Bijlsma JW.
Intrusiveness of rheumatoid arthritis on sexuality in male and
female patients living with a spouse. Arthritis Care Res.
1996;9:120-125.
32. Hill J. The impact of rheumatoid arthritis on patients' sex
lives. Nurs Times. 2004;100:34-35.
33. Ruffing V. Sexual intimacy. In: Bartlett SJ, Bingham CO,
Maricic MM, Iversen MD, Ruffing V, eds. Clinical Care in
the Rheumatic Diseases. 3rd ed. Atlanta, Ga: Association
of Rheumatology Health Professionals; 2006.
34. Van Doornum S, McColl G, Wicks IP. Accelerated athero-
sclerosis: an extraarticular feature of rheumatoid arthritis?
Arthritis Rheum. 2002;46:862-873.
35. Solomon DH, Curhan GC, Rimm EB, et al. Cardiovascular
risk factors in women with and without rheumatoid arthritis.
Arthritis Rheum. 2004;50:3444-3449.
36. Kremers HM, Nicola PJ, Crowson CS, et al. Prognostic
importance of low body mass index in relation to cardio-
vascular mortality in rheumatoid arthritis. Arthritis Rheum.
2004;50:3450-3457.
37. Maradit-Kremers H, Nicola PJ, Crowson CS, et al.
Cardiovascular death in rheumatoid arthritis: a population-
based study. Arthritis Rheum. 2005;52:722-732.
38. Nicola PJ, Maradit-Kremers H, Roger VL, et al. The risk of con-
gestive heart failure in rheumatoid arthritis: a population-based
study over 46 years. Arthritis Rheum. 2005;52:412-420.
39. del Rincon I, Freeman GL, Haas RW, et al. Relative contri-
bution of cardiovascular risk factors and rheumatoid arthritis
clinical manifestations to atherosclerosis. Arthritis Rheum.
2005;52:3413-3423.
40. Nelson JL, Ostensen M. Pregnancy and rheumatoid arthritis.
Rheum Dis Clin North Am. 1997;23:195-212.
41. Janssen NM, Genta MS. The effects of immunosuppressive
and anti-inflammatory medications on fertility, pregnancy,
and lactation. Arch Intern Med. 2000;160:610-619.
42. US Food and Drug Administration. Detailed view: safety
labeling changes approved by FDA Center for Drug
Evaluation and Research October 2005. Arava tablets
(leflunomide) prescribing information. Available at:
http://www.fda.gov/medwatch/SAFETY/2005/Oct_PI/
Arava_PI.pdf. Accessed March 13, 2007.
43. Furst DE, Breedveld FC, Kalden JR, et al. Updated consensus
statement on biological agents for the treatment of rheumatic
diseases, 2006. Ann Rheum Dis. 2006;65(suppl 3):iii2-iii15.
44. US Food and Drug Administration. Rituxan (rituximab) pre-
scribing information. Available at: http://www.fda.gov/
cder/drug/infopage/rituximab/default.htm. Accessed
March 13, 2007.
45. L e ff L. Emerging new therapies in rheumatoid arthritis: what's
next for the patient? J Infus Nurs. 2006;29:326-337.
46. Turkiewicz AM, Moreland LW. Rheumatoid arthritis. In:
Bartlett SJ, Bingham CO, Maricic MM, Iversen MD, Ruffing
V, eds. Clinical Care in the Rheumatic Diseases. 3rd ed.
Atlanta, Ga: Association of Rheumatology Health
Professionals; 2006.
Vol. 5, No. 1 April 2007
 REVIEW
47. O'Dell JR. Therapeutic strategies for rheumatoid arthritis. N
Engl J Med. 2004;350:2591-2602.
48. Olsen NJ, Stein CM. New drugs for rheumatoid arthritis. N
Engl J Med. 2004;350:2167-2179.
49. Orencia (abatacept) prescribing information. New York,
NY: Bristol-Myers Squibb; 2007. Available at:
http://www.orencia.com. Accessed January 29, 2007.
50. Bieber J, Kavanaugh A. Consideration of the risk and treat-
ment of tuberculosis in patients who have rheumatoid arthri-
tis and receive biologic treatments. Rheum Dis Clin North
Am. 2004;30:257-270, v.
51. Scott DL, Kingsley GH. Tumor necrosis factor inhibitors for
rheumatoid arthritis. N Engl J Med. 2006;355:704-712.
52. Doran MF, Crowson CS, Pond GR, et al. Frequency of
infection in patients with rheumatoid arthritis compared with
controls: a population-based study. Arthritis Rheum.
2002;46:2287-2293.
53. Bongartz T, Sutton AJ, Sweeting MJ, et al. Anti-TNF anti-
body therapy in rheumatoid arthritis and the risk of serious
infections and malignancies: systematic review and meta-
analysis of rare harmful effects in randomized controlled tri-
als. JAMA. 2006;295:2275-2285.
Johns Hopkins Advanced Studies in Nursing
54. Baecklund E, Ekbom A, Sparen P, et al. Disease activity
and risk of lymphoma in patients with rheumatoid arthritis:
nested case-control study. BMJ. 1998;317:180-181.
55. Ekstrom K, Hjalgrim H, Brandt L, et al. Risk of malignant
lymphomas in patients with rheumatoid arthritis and in their
first-degree relatives. Arthritis Rheum. 2003;48:963-970.
56. Askling J, Fored CM, Brandt L, et al. Risks of solid cancers
in patients with rheumatoid arthritis and after treatment with
tumour necrosis factor antagonists. Ann Rheum Dis.
2005;64:1421-1426.
57. Watson KD, Dixon WG, Hyrich KL, et al. Influence on anti-
TNF therapy and previous malignancy on cancer incidence
in patients with rheumatoid arthritis (RA): results from the BSR
Biologics Register (BSRBR) [abstract]. Rheumatology
(Oxford). 2006;45:i10-i12.
58. Kwon HJ, Cote TR, Cuffe MS, et al. Case reports of heart
failure after therapy with a tumor necrosis factor antagonist.
Ann Intern Med. 2003;138:807-811.
59. Cole J, Busti A, Kazi S. The incidence of new onset conges-
tive heart failure and heart failure exacerbation in Veteran's
Affairs patients receiving tumor necrosis factor alpha antag-
onists. Rheumatol Int. 2007;27:369-373.
31