A 50-year-old female presented with joint pain, hypertension, and HIV. She has a history of rheumatoid arthritis, hypertension, and HIV managed with antiretrovirals. Current medications included methotrexate, folic acid, prednisolone, enalapril, and antiretrovirals. Laboratory tests showed elevated inflammatory markers. A treatment plan was developed to add omeprazole, continue medications, monitor symptoms and labs, and counsel on lifestyle modifications. The goals were to control symptoms, prevent complications, and maintain viral suppression.

1. Case presentation on
RHEUMATOID ARTHRITIS PLUS HTN +
STAGE T1 RVI
From ambulatory Ward
By : Mohammed ahmed
5/22/2023
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2. Patient Identification
 N.A is a 50 Years old Female Patient with a
weight of 60Kg and come to DRH ambulatory
ward on December 06/04/2011 with card
No.601273 from Desise
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3. Case Summary
Subjective Information
C/C: joint pain of 01 month duration
HPI: this is a 50 years old female patient she is a known HTN
patient on medication past 6 month and known RVI patient for
the past 2 years on TDF+3TC+EFV with baseline CD4 count of
450 and current CD4 count is 562 and she claims to be adherent
for her medications currently she presented with aching joint
pain which is simultaneously involving both the right and left
hands and fingers which is
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4. Cont.…
Worsened in the morning and improves with
Movement.
 she has no hx of fever, redness in the affected
joint
 she has no hx of chronic cough, night sweating,
loss of appetite or weight lose
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5. Cont.….
 She has no hx of trauma
 Allergy : NKDA
 SH: she is no smoking ,chewing chat & drinking
alcohol.
 PMH: HTN plus RVI
 PMnH: HAART and HCT 25 mg po/day and enalpril 5
mg po/d
 FHx: FHx of DM and HTN with fathers
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6. Objective Information
Physical Examination:
GA- chronic sick looking
HEENT PC and NIS
Chest : clear and resonant
CVS : S1 and s2 well heard
No murmur No gallop
MSS: edema
tenderness in the joint
INT: no palmar pallor
CNS: conscious and oriented
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7. Cont.….
ABD: flat moves with respiration
no organomegally
LGS: no significant LAP
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8. Objective Information cont’d
Vital Signs
Date BP PR RR T0
06/04/11 140/90 88 20 T0:36.90c
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Cr 0.8 0.5-1.3
Urea 26 18-53
BUN 12 6-25
FBS 109 70 - 110
Serum chemistry test

9. Laboratory results
Tests and reference range
X-ray-bony erosions seen
- widening of the joints space with decalcification seen
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10. Cont.….
CBC with differential
Name result reference
WBC 6.4. 4.00-11.00
Neutrophil 5.0 2.00-7.00
lymphocyte 2.28 0.80-4.00
Hgb 14.8 11.0-18.0
Hct 40.3 33.0-54.0
MCV 30.4 27.0-34.0
Platelet 250 100-450
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11. Assessment
 RA + HTN+ Stage T1 RVI
 Plan; CBC, OFT, RF, ANA, X-RAY of the
hand(Both)
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12. Current Medications
 Methotrexate 7.5mg po/week for 01 month
 Folic acid 5mg po/week for 01 month
 Prednisolone 40mg Daily
 HCT 25 mg po/day for 01 month
 Enalapril 5mg po bid for 01 month
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13. Drug therapy problem
Drug-related
Needs
Drug Therapy
Problem
Recommendati
on
INDICATION DRUG Interaction Prednisolone 40 mg
po daily should be
added and
parecetamol added to
pain relief
INDICATION Needs Additional Drug
Therapy
Omeprazole 20 mg po
Bid should be added.
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14. Background information
 Rheumatoid Arthritis(RA)-is a chronic systemic autoimmune
inflammatory disease characterized mainly by symmetrical
inflammation of the synovial tissue of joints resulting in
destruction of the joints and peri-articular tissues.it occurs
more commonly in young and middle-aged women.
 It is the most common form of chronic inflammatory
arthritis and often results in joint damage and physical
disability.
 Female : male ratio 3:1
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15. Causes of RA
 Polyarticular
 autoimmune disease
 symmetrical and mainly peripheral RA(additive)
 Rheumatic fever(migratory)
 SLE
 Trauma: can cause intrarticular fracture,
 sub laxation/dislocation, hemarthrosis
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16. Clinical feature of RA
 Stiffness that worse in the morning and improves during the
day; the stiffness may recur especially after strenuous activity.
 The usual joints affected by RA are the metacarpophalangeal
joints, the pip joints, the wrists, knees, ankles and toes.
 Low grade fever, anorexia, weight loss, fatigue and weakness
can occur
 After months to years, deformities can occur
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17. Cont.….
 dryness of the eyes, mouth and other mucus
membranes is found, especially in advanced disease.
 INVESTIGATIONS
ESR/CRP
rheumatoid factor
 ANA(antinuclear antibody)
 X-ray of involved joints
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18. Cont.….
 Criteria for the dx of Rheumatoid Arthritis
At least four of the following
 morning stiffness > 1hour
 synovitis in three joints simultaneously
 synovitis in wrist or hand MCP or PIP joints
 symmetrical arthritis(some joint areas on both sides of the body)
 Rheumatoid nodules
 serum rheumatoid factor
 Radiographic changes typical of RA
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19. Treatment
Non pharmacologic
 rest of affected joints during acute flares
 physiotherapy
 exercise
 weight loss if obese
PHARMACOLOGIC
 DMARDs are the mainstay of RA treatment because they
modify the disease process and prevent or reduce joint
damage. In addition to relying on safety and efficacy data
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20. Cont.….
 First line methotrexate, 7.5mg p.o once per week Increase
dose gradually to a maximum of 25mg per week
 plus folic acid, 5mg p.o per week with methotrexate at
least 24 hours after the methotrexate dose. AND/OR
 Chloroquine phosphate, 150mg p.o(as base) daily for 5 days
of each week for 2-3 months. Then reduce dose if possible
and administer 5 days
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21. cont.…
a week with an annual medicine holiday for 1 month.
 Do ophthalmic examination annually to monitor for Ocular
damage. AND/OR
 Sulfasalazine, 500mg p.o, bid. Gradually increase over one
month from 500mg to 1g bid. Liver function and CBCs
monthly for first 3 months then Every 3-6 months.
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22. Cont.…
 Oral corticosteroids indication: as bridging therapy while waiting for
DMARDs to take effect.
 the elderly if threatened by functional dependence and intolerant
to NSAIDs.
 extra-articular manifestations, e.g. pleural effusion, scleritis.
 acute flare
 Prednisolone, 40mg p.o daily for 2 wks. during acute flares.
Thereafter gradually reduce the dose To <7.5mg daily.
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23. Cont.….
Joint pain management -NSAIDs
 Use for active inflammation with pain. NSAIDs are used for
symptomatic control only, as they have no long-term disease
modifying effects.
 NSAIDs dose Should be reduced and then stopped once the DMARDs
have taken effect.
 Ibuprofen, 800mg, p.o TID with meal. If not tolerated 400mg TID. OR
 Diclofenac 150-200mg/day p.o in 2-4 divided doses. Rectal
suppository, insert 50mg or 100mg rectally.
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24. Cont.….
 Indomethacin, 25-50mg p.o BID to TID; max
dose: 200mg/day.
 Rectal suppository, insert 100mg, BID or once,
at bed time.
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25. HTN
HTN: IS Persistent elevation of systemic ABP above the normal
limits or defined as a blood pressure ≥140/≥90 mmHg
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26. Etiology
primary hypertension it is unkown cause
 environmental factor
 genetic and childhood factors
Secondary hypertension. Known cause
• CKD and Cushing syndrome and other glucocorticoid excess states
• Pheochromocytoma
• Primary aldosteronism and other mineralocorticoid excess states
• Renovascular hypertension
• Sleep apnea
• Thyroid or parathyroid disease 5/22/2023
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27. HTN crisis
• Hypertensive crises: are clinical situations where BP values are
very elevated, typically greater than 180/120 mm Hg.
They are categorized as either a hypertensive emergency or
hypertensive urgency.
Hypertensive emergencies: are extreme elevations in BP
that are accompanied by acute or progressing target-organ
damage.
Hypertensive urgencies: are high elevations in BP without
acute or progressing target-organ injury.5/22/2023
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28. Clinical presentation
 Most patients are asymptomatic and are identified only in the
course of a physical examination and by measuring BP.
Desired Outcomes
 The goal of BP management is to reduce the risk of CVD and target
organ damage such as MI, HF, stroke, and kidney disease associated
morbidity and mortality.
 Targeting a specific BP is actually a surrogate goal that has been
associated with reductions in CVD and target organ damage.
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29. Non pharmacologic treatment
 Weight reduction (body mass index: 18.5–24.9 kg/m2
 Adopt DASH eating plan Consume a diet rich in fruits, vegetables, and
low-fat dairy products with a reduced content of saturated and total fat
 Dietary sodium restriction no more than 100 mmol/day (2.4 g sodium
or 6 g sodium chloride)
 Physical activity Engage in regular aerobic physical activity such as brisk
walking (at least 30 min/day, most days of the week)
 Moderation of alcohol consumption Limit consumption to no more
than two standard drinks per day 5/22/2023
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30. Pharmacologic treatment
Drug Selection in Hypertensive Patients only
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Patient Type First Choice Drug Add Second Drug If
Needed to Achieve a
BP < 140/90 mm Hg
If Third Drug Is
Needed to Achieve a
BP < 140/90 mm Hg
Black patients all ages CCB or thiazide
diuretic
ARB or ACE-I (if
unavailable can add
alternative first choice
drugs)
Combination of CCB +
ACE-I or ARB +
thiazide diuretic
White and other non-
black patients:
Younger than 60
ARB or ACE-I CCB or thiazide
diuretic
Combination of CCB
+ ACE-I or ARB +
thiazide diuretic
White and other non-
black patients: 60 and
older
CCB or thiazide
diuretic (although
ACE-Is or ARBs are
also usually effective)
ARB or ACE-I (or
CCB or thiazide if
ACE-I or ARB used
first)
Combination of CCB +
ACE-I or ARB +
thiazide diuretic

31. cont.….
When hypertension is associated with other condition
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Patient Type First Choice Drug Add Second Drug If
Needed to Achieve a
BP < 140/90 mm Hg
If Third Drug Is
Needed to Achieve a
BP < 140/90 mm Hg
HTN and DM ARB or ACE-I; Note: in
black patients, it is
acceptable to start
with CCB or thiazide
CCB or thiazide
diuretic; Note: in
black patients, if
starting with a CCB or
thiazide, add an ARB
or ACE-I
Alternative second
drug (thiazide or
CCB)
HTN and CKD ARB or ACE-I; Note: in
black patients, good
evidence for renal
protective effects of
ACE-Is
CCB or thiazide
diuretic
Alternative second
drug (thiazide or
CCB)

32. cont.…
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Hypertension
and clinical
coronary
artery
diseased
β-blocker
plus ARB or
ACE-I
CCB or
thiazide
diuretics
Alternative second
step drug (thiazide or
CCB)
Hypertension
and stroke
history
ACE-I or ARB CCB or
thiazide
diuretics
Alternative second
drug (CCB or thiazide
Hypertension
and heart
failure
Patients with symptomatic heart failure should usually
receive an ARB or ACE-I + β-blocker + diuretic +
spironolactone regardless of blood pressure. A
dihydropyridine CCB can be added if needed for BP
control

33. HIV/AIDS
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 AIDS is a chronic infectious disease caused by the human immuno-
deficiency virus type 1 and 2
 It is essentially a disease of the immune system, which results in
progressive immunodeficiency state
WHO staging of HIV/AIDS
 stage 1-asymptomatic
 stage 2-mild disease
 stage 3 –moderate disease
 stage 4 –advanced immunocompromised

34. Classfication of ARV Drugs
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 Currently available drugs for the treatment of HIV infection:
 Viral reverse transcriptase enzyme inhibitors (NRTIs , NNRTIs)
 Viral protease enzyme inhibitors (PIs),
 Viral integrase enzyme inhibitor, e.g. Raltegravir
 Those that interfere with viral entry e.g. Enfuvirtide, Maraviroc

35. first-line ART regimens for adults, adolescents, pregnant
and breastfeeding women
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36. Preferred second line ART regimens for Adults and
adolescents
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37. Pharmaceutical care plan
Goal of therapy
 reduce pain, swelling and stiffness
 delay disease progression and onset of long term complications
 achieve goal and reduce CVD complication and target organ damage
 prevent deformities
 increase CD4 count and reduce viral load to undetectable levels
 improving quality of life
 reduce HIV related mortality
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38. Intervention
 DTP –omeprazole 20mg BID
 Added prednisolone and DC ibuprofen
Counseling
 Reduce salt intake coffee
 physical activity
 Reduce alcohol consumption
 Smoking cessation
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39. Follow up evaluation
 Vital sign BP, PR ,RR
 Revise physical examination
 CBC
 OFT ( Scr, ALT and AST)
 CD4 and Viral load
 Fundscophy and visual field examination
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40. References
1. Pharmacotherapy practice and principle 4th edition
2.STG For General Hospitals Third Edition, 2014
3.UPTODATE 21.6 version
4.ART guideline 2017
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41. THANK YOU FOR
YOUR ATTENTION !!!
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42. ANY COMMENTS
& QUESTION ? YOU ARE
WELL COME !
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