2. a case study on hypertension with rheumatoid arthritis and erosive gastritis

- Ajita Sadhukhan
- Pharm D. 3rd year
- Roll No. : 1
- Enrolment No. : 150821207001

 HYPERTENSION: It is defined as the persistent increase in blood
pressure above 140/90 mm Hg.
 RHEUMATOID ARTHRITIS: It is a chronic systemic autoimmune disorder
causing a symmetrical polyarthritis.
 EROSIVE GASTRITIS: It is gastric mucosal erosion caused by damage to
mucosal defenses.

Age : 50 years IPD No.:170883096
Weight : 102 kg Department: Female Medicine Ward
Sex: Female Unit: II

 C/O Anxiety and breathlessness since 7-8 days
 C/O Decreased appetite
 C/O Acidity
PMHx : K/C/O RA since 8 years(metacarpal joints) steroid dependent &
K/C/O HTN since 10 years and stroke in 2005
Family Hx : NS
ALLERGIES : NKA

PHYSICAL EXAMINATION:
 GENERAL: -
 CVS: S1 S2 +, no murmur
 RS: NAD
 CNS: Conscious, oriented
 BP: 120/80 mm Hg
 PR: 116/min
 TEMP: 101 F
 PA: Soft

LABORATORY PARAMETERS OBSERVED VALUE NORMAL RANGE UNIT
Hb 9.9 11.5-18 g%
WBC 8180 4000-11000 Cells/cu mm
Neutrophils 66 40-70 %
Eosinophils 14 1-6 /cu mm
Lymphocytes 16 20-40 /cu mm
Monocytes 04 2-10 /cu mm
Basophils 00 0-1 /cu mm
RBC 3.42*10^12 3.8-5.8*10^12 /cu mm
ESR 60 1-20 mm/hr
PCV 31.5 40-54 %
MCHC 31.4 33-36 g/dL
Se. Urea 22 10- 45 Mg/dL
Se. Uric Acid 2.5 2.4-7.0 Mg/dL
Se. Creatinine 0.6 <1.5 Mg/dL
RF (Rheumatoid Factor) IgM Titre 64 <10 IU/mL

 A 50 year old female patient was admitted to Med. ward-2 with
complaints of anxiety with breathlessness since 7-8 days,
decreased appetite and acidity.
 Based on lab report, patient’s Hb, RBC count, ESR, PCV, MCHC
and RF levels are abnormally decreased. Hence, patient was
diagnosed with Rheumatoid Arthritis.
8

RA with HTN with Erosive Gastritis
9

For Rheumatoid Arthritis:
 It is an incurable disease so focus to stop inflammation (put disease in
remission).
 Relieve symptoms.
 Prevent joint and organ damage.
For HTN:
 Maintain appropriate blood pressure to 120/80 mmHg and lipid values to
reduction of cardiovascular and renal morbidity and mortality.
 Use and maximize non-pharmacologic therapies in combination with
pharmacotherapy.
 Maintain a flexible and normal lifestyle.
For Erosive Gastritis:
 The goal of treatment is to reduce gastric inflammation, relieve symptoms,
and eliminate the underlying cause.

TIME GC Temp. BP PR SPO2 PA URINE/STOOL
3:00 p.m. Stable 101 F 120/80mmHg 116/min 97% soft Passed
9:00 p.m. Stable 100 F 120/70mmHg 112/min 97% soft Passed
CVS : S1 S2 + , No Murmur
RS : NAD
CNS : conscious, oriented
ADV: Gastroenterologist opinion on Tuesday, plan for GI scopy
Rx: As per chart

DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. Pantoprazole 40mg IV 8 hourly Erosive esophagitis
Inj. Ondansetron 2ml IV 8 hourly Nausea and vomiting
Tab. Paracetamol +
Chlorpheniramine +
Phenylephrine + Caffeine
500mg+4mg+10mg+100mg P.O. 1-0-1 Painkiller
Tab. Methylprednisolone 5mg P.O. 1-0-0 breathlessness
Inj. Multivitamin 1 amp Vit C 150mg/1.5 ml
2 amp Vit B12 0.7 mg
Niacinamide 12 mg/1 ml
IV Once daily Vitamin B & C supplement
Tab. Hydroxychloroquine 200mg P.O. 1-0-1 Rheumatoid Arthritis
Tab. Losartan Potassium 25mg P.O. 1-0-0 Antihypertensive
Tab. Methotrexate 7.5mg P.O. Once weekly Rheumatoid Arthritis
Tab. Folic Acid 5mg P.O. 1-0-1 Folic acid supplement

TIME GC TEMP. BP PR SPO2 PA URINE/STOOL
7:00 a.m. Stable 100 F 130/80 mmHg 98/min 98% Soft Passed
10:30 a.m.
6:00 p.m.
Stable
Stable
99 F
98.7 F
160/100
mmHg
140/90 mmHg
92/min
88/min
93%
98%
Soft
Soft
Passed
Passed
• Patient feels better appetite.
• C/O: Pain in whole left leg starting from left hip & goes downwards to toe
• ADV: Orthosurgeon appointment → B/L TKR
• Rx: As per chart

Inj. Pantoprazole 40mg IV 8 hourly Erosive esophagitis
Inj. Ondansetron 2ml IV 8 hourly Nausea and vomiting
Tab. Paracetamol +
Chlorpheniramine +
Tab. Methylprednisolone 5mg P.O. 1-0-0 Rheumatoid Arthritis
Inj. Multivitamin 1 amp Vit C 150mg/1.5 ml
2 amp Vit B12 0.7 mg
Niacinamide 12 mg/1 ml
IV Once daily Vitamin B & C supplement

5:00 a.m. Stable Normal 130/80mmHg 101/min 98% soft Not passed
7:30 a.m. Stable Normal 160/100mmHg 90/min 98% soft Not passed
 CVS : S1 S2 + , No Murmur
 RS : NAD
 CNS : conscious, oriented
 ADV: Gastroenterologist opinion, plan for upper GI scopy
 Rx: As per chart

Inj. Pantoprazole 40mg IV 1-0-0 Erosive esophagitis
Inj. Ondansetron 2mg IV 1-0-1 Nausea and vomiting
Tab. Paracetamol +
Chlorpheniramine +
Tab. Calcium Carbonate +
Colecalciferol
500mg P.O. 1-0-1 Calcium Supplement
Syp. Tramadol + Aceclofenac 2 tsf P.O. TDS Painkiller, osteoarthritis

9:30 a.m. Stable Normal 140/90mmHg 96/min 99% soft Passed
4:00 p.m. Stable Normal 140/90mmHg 89/min 98% soft Not passed
5:30 p.m. Stable Normal 146/90mmHg 94/min 97% soft -
7:30 p.m. Stable 100 F 124/80mmHg - 98% soft -
9:00 p.m. Stable 100 F 160/90mmHg - - soft -
 RS : NAD
 ADV: Gastroenterologist opinion

Inj. Pantoprazole 40mg IV TDS Erosive esophagitis
Inj. Ondansetron 2mg IV TDS Nausea and vomiting
Tab. Paracetamol +
Chlorpheniramine +
Colecalciferol

7:00 a.m. Stable Normal 130/80mmHg - 95% Soft Passed
10:00 a.m.
7:00 p.m.
9:00 p.m.
Stable
Stable
Stable
-
-
-
110/70mmHg
120/80mmHg
130/80mmHg
116/min
104/min
97/min
98%
95%
98%
Soft
Soft
Soft
Passed
-
-
 RS : NAD
 C/O: Difficulty in swallowing and decreased appetite
 ADV: Gastrologist opinion → SOS endoscopy

Inj. Ondansetron 2mg IV SOS Nausea and vomiting
Tab. Paracetamol +
Chlorpheniramine +
Colecalciferol

TIME GC TEMP. BP SPO2 PA URINE/STOOL
7:00 a.m. Stable Normal 130/80mHg 98% Soft -
9:00 a.m. Stable Normal 130/80mmHg 98% Soft Urine – passed
Stool – not
passed
 RS : NAD
 No fresh complaints

Inj. Ondansetron 2mg IV SOS Nausea and vomiting
Tab. Paracetamol +
Chlorpheniramine + Phenylephrine
+ Caffeine
Colecalciferol
Tab. Esomeprazole + Domperidone 20mg P.O. 1-0-1 Erosive oesophagitis, epigastric pain
Tab. Pantoprazole 40mg P.O. 0-0-1 Antacid
Tab. Simethicone + magaldrate 20mg/5ml P.O. TDS Hyperacidity, gastritis

Tab. Paracetamol +
Chlorpheniramine + Phenylephrine
+ Caffeine
500mg+4mg+10mg+100mg P.O. 1-0-1 Erosive esophagitis
Colecalciferol
Tab. Esomeprazole + Domperidone 20mg P.O. 1-0-1 Erosive oesophagitis, epigastric pain
Tab. Pantoprazole 40mg P.O. 0-0-1 Antacid
Syp. Dried aluminium hydroxide gel
+ Magnesium hydroxide +
Simethicone
2tsf P.O. TDS Antacid

 For Rheumatoid Arthritis:
❖ Non-pharmacological treatment:
➢ Physiotherapy
➢ Swimming
➢ Free hand exercise
➢ Avoid cold
❖ Pharmacological therapy:
➢ There are three general classes of drugs commonly used in
the treatment of rheumatoid arthritis: non-steroidal anti-inflammatory
agents (NSAIDs), corticosteroids, and disease modifying anti-rheumatic
drugs (DMARDs).

 For HTN:
❖ Non Pharmacological treatment
➢ Fat free and salt restricted diet (Take K+ rich diet, Avoid red meat)
➢ Avoid smoking & Moderation or stop alcohol
➢ Walking (20-30 min per day) if possible
➢ Relaxation or Meditation (If Stress)
❖ Pharmacological Treatment :
➢ ACE inhibitors- Enalapril, captopril, Ramipril
➢ ARBs – Telmisartan, Olmesartan, Losartan
➢ CCB – Nicardipine, Amlodipine

 For Erosive Gastritis:
❖ Non-pharmacological Therapy:
➢ Avoid spicy and fried food
➢ Intake of food in small quantity and in small interval (2-3 hrs)
➢ Avoid hot drinks
➢ Avoid alcohol and caffeine
➢ Avoid smoking
➢ Meditation (if stress)
❖ Pharmacological Therapy:
➢ removing pain symptoms (no-spa, analgin, platifilin, papaverine);
➢ antibiotics (amoxicillin, tetracycline, clarithromycin);
➢ anti-inflammatory drugs (ranitidine, de-nol, omez);
➢ drugs, normalizing the acidity (enterogel, Almagel, Aluminium phosphate
gel, Rennie, Maalox);
➢ enzymes (pancreatin, mezim, Festal, Creon);
➢ drugs, contributing to the restoration of the affected tissues (trental, aloe
extract, B vitamins, ascorbic acid).

 CRP(C-reactive protein): NOT DONE
 Lipid Profile: NOT DONE
 Blood sugar fasting : NOT DONE
 MONITOR CLOSELY:
➢ Hydroxychloroquine + Methotrexate: Hydroxychloroquine decreases levels of Methotrexate
by reducing its renal clearance.
➢ Vitamin D + Aluminum Hydroxide: Avoid co-administration as chronic use of aluminum
containing antacids in conjugation with vitamin D can lead to aluminum retention and
possible toxicity.
➢ Chlorpheniramine + Phenylepinephrine: Chlopheniramine increases and phenylephrine
decreases sedation.
➢ Chlorpheniramine + Caffeine: Chlopheniramine increases and caffeine decreases sedation.
➢ Esomeprazole + Methotrexate: Esomeprazole increases levels of Methotrexate by reducing
its renal clearance.
➢ Caffeine + Methotrexate: Caffeine increases the effects of Methotrexate by
pharmacodynamic antagonism.
➢ Caffeine + Phenylephrine: Both decrease sedation.

HTN:
 It is an incurable but controllable disease.
 It is a silent killer.
RA:
 It is an incurable but controllable disease.
Erosive Gastritis:
 It can be cured with medications.

 Dose of drugs
 Frequency of dose
 Route of administrations such as I.V, I.M., t/d, s/c, P.O., S/L.
 Counselling regarding overdose (may cause toxicity), underdose
(submaximal or no response) and missing of dose of medication. E.G. If
a dose is missed, then the patient is to be advised to go for the next
dose, otherwise toxicity of drug may occur.
 Contraindications
 Drug interactions (drug-drug, drug-food)
31

 Exercise (Walking and Swimming)
 Diet Control
 Low salt Intake
 Balanced diet
 Avoid red meat
 Reduce Weight
 Avoid Cold

2. a case study on hypertension with rheumatoid arthritis and erosive gastritis

2. a case study on hypertension with rheumatoid arthritis and erosive gastritis

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