Arthritis: Rheumatoid Arthritis, Osteoarthritis and Gout

Author: Alene Burke RN, MSN
6 Contact Hours
Alene Burke & Associates is approved as a provider of Continuing Education by the Florida Board of Nursing, Provider # 50-2502


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DESCRIPTION:

Arthritis is an inflammatory disease of the bone joints that is marked with a limitation of movement, swelling and pain. In our country, it is the number one chronic disorder that leads to disability among people 15 years of age and older. In 2005, it was estimated that 66 million people, that is, one out of every 3 adults in our nation is affected by arthritis. Additionally, it affects about 300,000 children and it is estimated that it costs the United States in excess of $86.2 billion every year.

OBJECTIVES:

At the conclusion of this course, the learner will be able to:
  1. List several types of arthritis.
  2. Briefly describe rheumatoid arthritis and gout.
  3. Detail rheumatoid arthritis, osteoarthritis and gout in terms of their etiology, prevalence, pathophysiology, signs and symptoms, complications, diagnosis, prevention and treatment, including pharmacological interventions and the latest research about hormone replacement therapy and the cardiovascular side effects of the COX-2 inhibitors and the effect of this research on the withdrawal some medications from the market and stronger warnings.
  4. Describe some arthritis resources and associations and the services that they provide.

INTRODUCTION

Arthritis is an inflammatory disease of the bone joints that is marked with a limitation of movement, swelling and pain. It can be caused by an infection in the joint, a buildup of uric acid or simply with the degeneration of a joint or joints as an individual grows older and perhaps, genetics.

Arthritis is the number one chronic disorder that leads to disability in our country among people 15 years of age and older. In 2005, it was estimated that 66 million people, that is, one out of every 3 adults in our nation is affected by arthritis. Additionally, it affects about 300,000 children and it is estimated that it costs the United States in excess of $86.2 billion every year. Women are more affected than males. (Arthritis Foundation, 2004)

TYPES OF ARTHRITIS

There are more than 100 different types of arthritis. Some of these types include the below.

OSTEOARTHRITIS, RHEUMATOID ARTHRITIS AND GOUT

Osteoarthritis, known as degenerative joint disease, is the most commonly seen form of arthritis among the elderly population. Osteoarthritis results from the wearing out or deterioration of the smooth cartilage lining of the joint. This loss of cartilage makes the joints rougher than they had been when the cartilage was in place. Although it can also affect the hands, degenerative osteoarthritis is most often seen in the knees, spine and hips- the weight bearing joints of the body. This form of arthritis cannot be cured but those that suffer from it rarely become bedridden or crippled as a result of it. Post menopausal osteoarthritis is the result of the depletion of hormonal estrogen after menopause. It is a variation of the larger diagnosis of osteoarthritis from other causes.

Rheumatoid arthritis also involves painful swelling of the joints but it is usually associated with the smaller, non weight bearing joints of the body. Also, it is not usually associated with old age onset, but instead, it primarily begins in the young adult from ages 30 to 50 from unknown causes. It can also develop in young child. This form of rheumatoid arthritis is referred to as Still's disease or juvenile rheumatoid arthritis. Unlike osteoarthritis, rheumatoid arthritis is associated with more profound physical deformities and crippling.

Gout is quite different from osteoarthritis and rheumatoid arthritis. Gout is a disease or disorder that occurs when the body cannot excrete the uric acid it produces because the body is overproducing it or the kidneys have a diminished ability to filter it out and excrete it. When uric acid builds up in the body the joints, as well as soft tissues, become affected by it. The buildup of uric acid in gout causes very painful attacks of arthritis and it is accompanied with a high concentration of uric acid in the bloodstream and the formation of uric acid crystals in the affected joints.

RHEUMATOID ARTHRITIS

Sadly, rheumatoid arthritis is a destructive and chronic inflammation of the joints that affects young adults and children, most commonly occurring in females. It is marked with symmetrical swelling in the smaller joints of the body such as the ankle, hand and wrist. The onset of the deforming and crippling disease can be sudden and unexpected but most often it is somewhat gradual. This disorder is progressive and often without a hoped for remission despite treatment.

About 6.5 million people in the United States are affected with rheumatoid arthritis. Women are affected up to three times more than men. Although the onset can occur at any age, the onset is most frequent among those between 25 and 50 years of age.

Although the cause of this form of arthritis is largely unknown, there appears to be a genetic basis among the white race in that pentapeptide in the HLA-DR and locus of class II histocompatibility genes have been identified. (Langford & Thompson, 2000; Merck & Co., 2005)


Pathophysiology

This disease progresses from joint inflammation to edema and congestion in the joint's capsule and the synovial membrane. Later, granulation tissue develops and destroys the capsule and cartilage. This fibrous granulation leads to the deformity and immobilization of the affected joint(s). This degenerative process can also affect major bodily organs such as the kidneys, eyes, lungs and the heart. (Langford & Thompson, 2000; Merck & Co., 2005)

Signs and Symptoms

Some of the early signs may include: The middle stage signs and symptoms are: The late signs and symptoms of rheumatoid arthritis are:

Diagnosis

The American Rheumatoid Association (ARA) has established diagnostic criteria. They are as follows:
  1. morning stiffness in and around joints lasting at least 1 hour before maximal improvement;
  2. soft tissue swelling (arthritis) of 3 or more joint areas observed by a physician;
  3. swelling (arthritis) of the proximal interphalangeal, metacarpophalangeal, or wrist joints;
  4. symmetric swelling (arthritis);
  5. rheumatoid nodules;
  6. the presence of rheumatoid factor; and
  7. radiographic erosions and/or periarticular osteopenia in hand and/or wrist joints.
Criteria 1 through 4 must have been present for at least 6 weeks. Rheumatoid arthritis is defined by the presence of 4 or more criteria, and no further qualifications (classic, definite, or probable) or list of exclusions are required." (Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS, Healey LA, Kaplan SR, Liang MH, Luthra HS, et al., 1988)

In addition to a complete physical exam and medical history, the following diagnostic tests can be done to facilitate the diagnosis of rheumatoid arthritis.

Treatment

The goals of treatment for rheumatoid arthritis aim to control the inflammatory process and to relieve the troublesome and painful symptoms. Currently, there is no treatment available to repair any existing damage to the joints.

Treatment consists of one or more of the following modalities, as based on the unique needs of the patient.

RECENT NEWS ABOUT COX-2 INHIBITORS AND NSAIDS

In 2005, research indicated that some popularly used and intensely marketed COX-2 inhibitors, used for arthritis, increased the risk of cardiovascular events. On April 7, 2004 the U.S. Food and Drug Administration (FDA) asked Pfizer Inc. to voluntarily take Bextra off the market and to place strong warnings on Celebrex as a result of this research. This advice news lead to the withdrawal of Bextra (valdecoxib) from the market and to the strong warning that Celebrex (celecoxib), too, is associated with cardiovascular complications. Vioxx (rofecoxib) had been previously taken off the market by Merck because of its cardiovascular disease risk as well.

The FDA has also asked the numerous manufacturers of over the counter NSAIDs, other than aspirin and acetaminophen, to include additional information about the potential for gastrointestinal and cardiovascular side effects and risks.

At the current time it appears that the cardiovascular side effects are dose dependent, therefore, decisions about whether or not to take available NSAIDs and Celebrex should be up to the patient and their physician. Additionally, if the decision is to use or continue to use one of these medication, the dosage should be the lowest possible to achieve the desired effect. (Arthritis Foundation, 2005)

OSTEOPOROSIS

Osteoporosis is a "generalized, progressive diminution of bone density (bone mass per unit volume), causing skeletal weakness, although the ratio of mineral to organic elements is unchanged." (Merck, 2005)

There are three types of osteoporosis:

Type 1 primary osteoporosis is six times more prevalent in women than in men. This type typically appears between the ages of 51 and 75 years of age. It is associated with distal radius fractures (Colles' fractures) and vertebral crush fractures.

Type 2 primary osteoporosis is twice as common in women than men and its onset is generally after 60 years of age. This type is a part of the normal aging process in that it results from decreasing numbers and activity levels of osteoblasts, rather than an increase of osteoclast activity. It is associated with femoral neck fractures, fractures of the pelvis, humerus, vertebrae and tibia. Some people, particularly women, can have type 1 primary osteoporosis and type 2 primary osteoporosis simultaneously.

Secondary osteoporosis can be caused by a number of diseases, medications, and other conditions, such as prolonged space flight weightlessness. It accounts for about 5% of all osteoporosis cases. (Langford & Thompson, 2000; Merck & Co., 2005)


ETIOLOGY AND PREVALENCE

The cause of primary osteoporosis is not known. The possible causes of secondary osteoporosis and osteoarthritis are: Women are affected with osteoporosis more than men. About 50% of postmenopausal women have osteoporosis. Of these women, 33% will have an osteoporotic fracture during their lifetime. (Langford & Thompson, 2000; Merck & Co., 2005)

Some of the risk factors associated with primary osteoporosis include:

Pathophysiology

The resorption of bone exceeds the rate of bone formation when osteoporosis occurs. The bone mass declines, cortical thickness diminishes and the size and number of trabeculae decline. (Merck & Co., 2005)

Signs and Symptoms

Individuals are typically asymptomatic early in the disease. The first symptom is usually a dull, aching, constant pain in the bones, particularly the back and chest. The pain may radiate down the leg, and muscle spasms may be present. Later in the disease, the back pain may become chronic, unrelenting, dull and aching. As the spinal column mass diminishes, dorsal kyphosis and cervical lordosis (dowager's hump) increase, which can lead to one or more compression fractures of the spine and a reduction in height. The most common affected vertebrae are those at the T-8 level and below. Other fractures may also occur with minimal or no trauma, particularly the hip and the wrist in an attempt to break a fall.

Other early signs and symptoms are: Some of the middle stage signs and symptoms include lessening joint motion as well as joint: The late signs and symptoms are:

THE COMPLICATIONS OF OSOSTEOPOROSIS

The complications of osteoporosis include:

DIAGNOSIS

Osteoporosis is diagnosed with a clinical assessment, the presence of bone and/or joint pain, laboratory findings, x-ray, photon absorptiometry and CT scans.

Laboratory findings X-Ray Photon absorptiometry and CT scans

PREVENTION

Some of the things that can be done to prevent osteoporosis and osteoarthritis include:

TREATMENT

Exercise

A regular exercise routine, as approved by the physician, as well as the following is recommended to strengthen the muscles, maintain joint mobility, and to decrease the rate of calcium loss. Physical Therapy Interventions

These treatment interventions aim to prevent deformity, increase joint mobility, decrease pain, restore lost function, in some cases, and to maximize the patient's ability to perform their activities of daily living. Some patient's can also benefit from assistive devices, such as a grasper. Most of these interventions can be independently done in the home without the services of a physical therapist. Nutrition

A regular, nutritious diet that is high in protein is recommended. Women should take or consume 1500 mg of calcium a day and men should take or consume 1,000 to 3,500 mg of calcium a day if they are not absorbing calcium in a normal manner.

Vitamin D should be taken concurrent with calcium. The dosage can range from 400 or 800 IU per day and up to 50,000 IU once or twice a week, as based on the patient's 25 hydroxy vitamin D and 1,25 dihydroxy vitamin D level. Serum and urinary calcium levels should be monitored when high doses are given since hypercalcemia, hypercalciuria, and renal failure can occur. (Langford & Thompson, 2000; Merck & Co., 2005)

Medications

Hormone Replacement Therapy

Estrogen supplements can be considered for postmenopausal women without a uterus and estrogen-progesterone combinations can be considered for postmenopausal women with an intact uterus. Testosterone replacement therapy is an option for older men at risk for primary osteoporosis type 2.

Raloxifene, an estrogen-like drug, can also be considered. (Merck & Co., 2005)

Salicylates and nonsteroidal anti-inflammatory medications (NSAIDs).
These medications were detailed above

Bisphosphonates

Bisphosphonates inhibit bone resorption. Fosamax (alendronate ) is a bisphosphonate that is used for osteoarthritis among postmenopausal women as well as for those with Paget's disease. The dosage for postmenopausal women is 10 mg every day orally. This medication must be taken with a full glass of water on an empty stomach. Additionally, the patient should be instructed to remain upright for at least 30 minutes after taking dose in order to prevent esophageal irritation.

Some of the side effects associated with bisphosphonate medications include: It is contraindicated with hypocalcemia and hypersensitivity. It can be used with caution among children and those that are lactating or pregnant. Cautious use is also recommended if the patient has ulcers, gastritis and/or esophageal disease. Electrolytes and renal function must be assessed throughout the course of therapy. (Merck, 2005; Skidmore-Roth, 2004)

Selective estrogen receptor modulator (Evista)

Evista decreases the resorption of bone and decreases bone turnover. The dosage is 60 mg a day. Some of the side effects include nausea, vomiting, anorexia, diarrhea, hot flashes, depression, migraine headaches, insomnia, vaginitis, weight gain, peripheral edema, leg cramps, sinusitis, pharyngitis, laryngitis, and others.

It is contraindicated during pregnancy and lactation as well as for those with a hypersensitivity to it. Cautious use is necessary if the patient is affected with hepatic disease and/or venous thrombosis. It is recommended that daily weights, blood pressure and hepatic function tests be monitored throughout the course of therapy. (Skidmore-Roth, 2004)

Salmon calcitonin

Salmon calcitonin can be an alternative when estrogen therapy is contraindicated or refused. It is available in 2 forms, that is, nasally and parenterally. The nasal dosage is one spray (200 U) per day in alternating nostrils. The parenteral dose is 100 IU subcutaneously daily or every other day. Both forms should be taken concurrently with calcium and vitamin D supplementation. (Merck, 2005)

Sodium fluoride

Sodium fluoride, with a dosage of 50 mg per day, concurrent with 1g or more of calcium appears to increase bone mass, but because it decreases bone density and makes bones more fragile, it is not a drug of choice. (Merck, 2005)

Androgen

Short term therapy, of less than 3 months, is sometimes considered when the patient is plagued with uncontrollable fractures. Because androgenic anabolic steroids (stanozolol and nandrolone) have the risk of hepatotoxicity and can lower the concentrations of lipoproteins, their use is limited despite the fact that they do increase bone density in women. Men also take androgens for replacement treatment when there is an androgen deficiency. (Merck, 2005)

GOUT

ETIOLOGY AND PREVALENCE

The cause of gout is unknown but a number of things appear to lead to the under secretion and the over production of uric acid, those things that lead to and characterize this form of arthritis.

Some of these factors include: The more developed nations of the world have a greater incidence of gout than undeveloped nations and men are affected with gout more than women. It is rare in women prior to menopause and its appearance in women after menopause appears to be associated with the use of diuretics. More severe symptoms are found among those that have had a bout of gout before the age of 30. (Langford & Thompson, 2000; Merck & Co., 2005)

PATHOPHYSIOLOGY

An overproduction of uric acid and an undersecretion of uric acid lead to gout. Crystals of monosodium urate form when uric acid builds up in the system. When these crystals are deposited into tissues surrounding peripheral joints, such as tendons, cartilage and ligaments and in other tissue, such as the ear, the person is affected by gout. These crystals are then periodically released from time to time, for some unknown reason, during an acute attack of inflammation. Over time, the monosodium urate crystals can also be deposited in organs, such as the kidney, and in larger joints. (Langford & Thompson, 2000; Merck & Co., 2005)

SIGNS AND SYMPTOMS

An acute attack of gout can occur at any time without any warning but it sometimes follows a stressor (physical or emotional), surgery, an overabundance of foods high in purines, alcohol, an infection and fatigue.

The first sign is usually nocturnal pain in one or more peripheral joints. The great toe is affected most often, however, it can also affect the knee, ankle, instep, wrist, and elbow.

Other signs and symptoms include:

THE COMPLICATIONS OF GOUT

Acute attacks of gout can occur several times a year unless prophylactic treatment is given. Eventually, without treatment, chronic arthritis, chronic joint pain, erosive, permanent joint deformity, and limitations of joint mobility and function can occur.

The joints that are most often affected are those of the feet and hands, however, the shoulder, cervical spine, sacroiliac, hip and sternoclavicular joints can also be affected with gout. Cyclosporine induced gout typically begins in the larger central joints, like the sacroiliac, hands and hip. It can also damage the renal tubules.

Urolithiasis (uric acid or calcium oxalate stones) occurs in approximately 20% of people with gout. Obstruction, infection, renal dysfunction can follow. (Langford & Thompson, 2000; Merck & Co., 2005)

DIAGNOSIS

The diagnosis of gout is based on the following data:

PREVENTION

Daily prophylactic doses of colchicine and allopurinol are used to prevent recurring attacks of gout when the patient is affected with chronic gout. (Langford & Thompson, 2000; Merck & Co., 2005)

TREATMENT

The goals of treatment include: Coexisting conditions, such as hyperlipidemia, diabetes, obesity and hypertension must be controlled and managed.

Surgery

At times, large crystal deposits, referred to as tophi, are surgically removed. (Merck & Co., 2005)

Medications

Colchicine

Colchicine is a uricosuric medication used for both acute attacks of gouty arthritis and chronic gout that is accompanied by recurrent and frequent acute attacks. Its mechanisms of action lower serum uric acid levels by inhibiting the reabsorption of uric acid.

When used for the treatment of acute gout attacks, the response to colchicine is typically quite dramatic in terms of its effect. Joint pain usually subsides after only 12 hours of treatment and the joint pain may disappear completely in 48 hours or less. Although colchicine does not retard the progressive joint damage of gout that is produced by tophi, it can prevent it by lowering and maintaining the serum urate concentration at or near its normal level.

Colchicine is contraindicated with a hypersensitivity to it. It is also contraindicated with high dose aspirin therapy and among patients that have severe gastrointestinal, hepatic or renal impairment. It should be used with caution when a patient has a blood dyscrasia, is pregnant or lactating and among the elderly and pediatric populations. The elderly may be adversely affected with electrolyte imbalances if they experience vomiting as a result of the colchicine therapy.

Some of the side effects and adverse drug reactions associated with colchicines are: The usual adult dosage of colchicine is 0.5 mg to 1.2 mg (usually 1 mg) by mouth every 2 hours for acute attacks of gout until the therapeutic response is obtained or diarrhea or vomiting occur. The maximum dosage is 7 mg over 48 hours. The prophylactic dosage is 0.5 to 1.8 mg every day for long term therapy.

This medication should be taken on an empty stomach to enhance absorption. Intravenous colchicine can be given when the patient's gastrointestinal tract is not tolerating po colchicine. (Merck & Co., 2005; Skidmore-Roth, Linda, 2004)

Probenecid

Probenecid (Benemid) another uric acid lowering medication, is used for the prevention of hyperuricemia and gouty arthritis. Specifically, it lowers the reabsorption of uric acid, therefore and reduces serum uric acid levels by promoting its excretion.

This medication is contraindicated with renal and hepatic disease, hypersensitivity and among patients who have uric acid calculi. It must be used cautiously during pregnancy.

Some of the side effects and adverse effects of probenecid are: More serious side effects and adverse reactions include hepatic necrosis, nephrotic syndrome and apnea.

The usual adult dosage of probenecid for hyperuricemia is 250 mg two times a day for one week which can be increased by 250 mg to 500 mg a day or bid until the uric acid level normalizes. The maximum daily dosage is 2 g. The maintenance dose is 500 mg per day.

Patients taking probenecid should be instructed to drink plenty of fluids (2 to 3 liters per day) to decrease their risk of uric acid stones. They should also be advised to take the medication with food or milk and to take an antacid to decrease the risk of gastrointestinal side effects.

When a patient is taking probenecid, the following have to be monitored and assessed. An overdosage can be signaled with confusion, hyperreflexia, twitching and headache. (Skidmore-Roth, Linda, 2004)

Allopurinol

Allopurinol is another uricosuric agent used for the treatment of chronic gout, calcium oxalate calculi, and Chagas' disease. Its mechanism of action decreases the amount of uric acid that is synthesized. It is used to prevent an attack of gout and to treat hyperuricemia.

It is contraindicated in patients who have had a prior severe allergic reaction to it. It should be used cautiously with pregnancy, lactation and among children. Cautious use is also advised when the patient has had a prior mild prior allergic reaction to it and for those with renal insufficiency or hepatic disease. Baseline and ongoing liver function studies should be done because this medication is hepatotoxic.

Some of the adverse reactions associated with allopurinol are GI irritation, neuritis, fever, drowsiness, pruritic rash, leukocytosis, thrombocytopenia, eosinophilia, leukocytosis, bone marrow suppression, hepatitis, cataracts and renal impairment.

The adult dosage of allopurinol for gout may range from 200 to 600 mg/day in divided doses to inhibit uric acid synthesis and to control serum urate concentration. The maximum daily dosage is 800 mg a day. (Skidmore-Roth, Linda, 2004)

Sulfinpyrazone

Sulfinpyrazone, another medication used for gout, increases the excretion of uric acid by inhibiting the reabsorption of urates in the tubules. The recommended adult dosage for gout is 100 to 200 mg bid for a week and then 200 mg to 400 mg twice a day but not to exceed 800 mg per day

Sulfinpyrazone is contraindicated for patients with GI inflammation, active peptic ulcers, blood dyscrasias, hypersensitivity and a creatinine clearance of <50 mL/min. It must be used with caution during pregnancy.

Some of the side effects of sulfinpyrazone are rash, flushing, headache, dizziness, tinnitus, polyuria, anemia, increased bleeding time, renal calculi and leukopenia. More serious adverse reactions include apnea, hepatic necrosis, GI bleeding, agranulocytosis and coma. (Skidmore-Roth, Linda, 2004)

Salicylates and nonsteroidal anti-inflammatory medications NSAIDs)

These medications serve as both anti-inflammatory agents and analgesics. Examples are aspirin, ibuprofen, diclofenac, fenoprofen, flurbiprofen, indomethacin, ketoprofen, meclofenamate, nabumetone, naproxen, oxaproxen, piroxicam, sulindac and tolmetin.

Some of the side effects and adverse drug reactions to the NSAIDs are GI irritation, cardiovascular complications, blood dyscrasias, nephrotoxicity (oliguria, azotemia, hematuria and dysuria), abdominal pain, cholestatic hepatitis, anorexia, dizziness and drowsiness. Antacids, H2 blockers and sucralfate can be given between meals for mild GI side effects of aspirin. 100 to 200 µg bid to qid of misoprostrol or a proton pump inhibitor can be used with aspirin and other NSAIDs to reduce the risk of GI bleeding among high risk patients.

The NSAIDS are contraindicated among patients with asthma, severe liver and/or renal disease, and hypersensitivity. They can be used with caution among the elderly and children, during lactation and pregnancy and for patients with GI, cardiac and/or bleeding disorders.

The patient's blood, renal and hepatic function must be monitored when NSAIDS are used. Baseline hearing and eye exams are also recommended so that changes can be identified. Toxicity may be signaled with tinnitus and/or blurred vision. Current concerns about COX-2 inhibitors and NSAIDS are described below.

Analgesics

In addition to the NSAIDs, other analgesics, such as codeine 30 mg to 60 mg may be used to manage the pain. (Merck & Co., 2005)

Sodium Bicarbonate

Sodium bicarbonate is used to alkalize urine for patients that have calculi formation. The usual adult dosage is 325 mg to 2 g four times a day or 48 mEq (4g) followed by 12 to 24 mEq q4h. (Skidmore-Roth, Linda, 2004)

Diet

People that have gout should: Other Interventions

The patient should lose weight, as indicated, to avoid additional stress on the joints. At times, splinting the inflamed joint may be beneficial in reducing the pain and decreasing the risk of deformity. (Merck & Co., 2005)

Joint Aspiration

Some gout attacks are treated with the aspiration of affected joints after which corticosteroid esters are instilled. Depending on the size of the joint, prednisolone tebutate from 10 mg to 50 mg is used. (Merck & Co., 2005)

Exercise and Rest

During the acute phase of a gout attack, the joint should be rested. After that, normal exercise and rest is recommended. (Merck & Co., 2005)

SUMMARY

The implications of arthritis involve the entire health care team. The treatment of arthritis often involves multiple interventions such as medications, pain relief, physical and/or occupational therapy, applications of heat or cold and patient/family education. A team approach involving a number of professional disciplines and a thorough knowledge of arthritis are the keys to success in the management of this widespread and often chronic disease.

Copyright © 2005 Alene Burke & Associates

Care has been taken to confirm the accuracy of the information presented in this course and to describe generally accepted practices and drug information. However, the author and publisher are not responsible for errors or omissions or for any consequences from application of the information and make no warranty, express or implied, with respect to the contents of the publication.


REFERENCES

American College of Rheumatology (2004). "About the American College of Rheumatology." http://www.rheumatology.org/about/index.asp?aud=mem

Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS, Healey LA, Kaplan SR, Liang MH, Luthra HS, et al.(1988). "The American Rheumatism Association 1987 Revised Criteria for the Classification of Rheumatoid Arthritis". Arthritis Rheum. 1988 Mar;31(3):315-24 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve &db=PubMed&list_uids=3358796&dopt=Abstract

Arthritis Foundation (2004). "The Facts About Arthritis". http://www.arthritis.org/resources/gettingstarted/default.asp

Arthritis Foundation (2005). "Straight Talk About Selective COX-2 Inhibitors and NSAIDs". http://www.arthritis.org/conditions/NSAIDS/Straight_Talk_FAQ.asp

Langford, Rae W. and June D. Thompson (2000). Mosby's Handbook of Diseases, 2nd Edition. Mosby Inc.

MDchoice, Inc. (2005)."Fungal Arthritis." http://www.drkoop.com/ency/93/000444.html

MDchoice, Inc. (2005). "Non-gonococcal (septic) Bacterial Arthritis" http://www.drkoop.com/ency/93/000430.html

MDchoice, Inc. (2005). "Psoritic Arthrits" http://www.drkoop.com/ency/93/000413.html

Merck & Co., Inc. (2005) Beers, Mark H. and Robert Berkow. Merck Manual of Diagnosis and Therapy: Seventeenth Edition. "Gout" Section 5 Chapter 55. 2005. http://www.merck.com/mrkshared/mmanual/section5/chapter55/55a.jsp

Merck & Co. Inc. (2005) Beers, Mark H. and Robert Berkow. Merck Manual of Diagnosis and Therapy: Seventeenth Edition. "Osteoporosis" Section 5 Chapter 57. http://www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section5/chapter57/57a.jsp%3Fregion%3 Dmerckcom&word=osteoporosis&domain=www.merck.com#hl_anchor

Merck & Co., Inc. (2005) Beers, Mark H. and Robert Berkow. Merck Manual of Diagnosis and Therapy: Seventeenth Edition. "Rheumatoid Arthritis" Section 5, Chapter 50. http://www.merck.com/mrkshared/mmanual/section5/chapter50/50a.jsp

Skidmore-Roth, Linda (2004). Mosby's Rapid Reference Library: Nursing Drug Reference. CD-ROM

Contact Hours: 6
Price: $34.50
Course Title: Arthritis: Rheumatoid Arthritis, Osteoarthritis and Gout
Course Number: 20-72489

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