This case presentation describes a 58-year-old male patient who presented with multiple joint swelling and pain in both lower limbs for 3 weeks. Diagnostic tests showed positive RF IgM and the patient was diagnosed with undifferentiated arthritis. The patient was treated with intravenous methylprednisolone as a bridging therapy along with hydroxychloroquine and sulfasalazine as DMARD therapy. The patient's symptoms resolved and he was discharged on a tapering steroid regimen along with sulfasalazine and hydroxychloroquine for ongoing treatment of undifferentiated arthritis.

1. Case presentation on
Undifferentiated Arthritis
R.Anusha,
PharmD Intern,
170514882007.
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2. • Patient Name:Mr.SA
• Gender:Male
• Age:58 years
• IP No:315133
• DOA:23/8/19
• DOD:28/8/19
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3. SUBJECTIVE
• Chief complaints: Multiple joint swelling and pain
in both lower limbs.
• Present illness history: Complaints of multiple
joint swelling and pain in both lower limbs since 3
weeks.
• Past medical history: K/C/O HYPOTHYROIDISM
HTN,DM,CAD.
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4. • Medication reconciliation:
T.MET XL 50 mg PO OD
T.ONDERO 5 mg PO OD
T.VOLIBO M 500mg/0.2 mg PO OD
Cap.CLAVILIP 10 mg PO OD
T.THYRONORM 100 mcg PO OD
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5. OBJECTIVE
PHYSICALAPPERANCE
• Height:159cms
• Weight:65kgs
• BMI:25.71kg/m2
VITALS
• Pulse rate:98 beats/min
• Blood pressure:130/80 mm
Hg
• Respiratory rate:18
breaths/min
• Temperature: Afebrile
• Pain score:2/10
(Dull, Aching and continuous)
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6. Diagnostic tests:
TSH: 2.46
Creatinine: 0.73
HbA1c: 8.1
RF IgM: +Ve (associated with more severe disease)
HLA B27(?Reactive Arthritis) : Negative
Anti cyclic citrullinated peptides(CCP) : Negative
Final diagnosis: undifferentiated arthritis
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7. DRUG CHART
Drug Generic Dose ROA Freq. Indication
Inj.SOLUMEDROL Methyl
prednisolone
125 mg
in 100
ml NS
IV Over 1 hour
(stopped on
26/8/19)
Undifferentiated
Arthritis
T.HQTOR Hydroxy
chloroquine
200 mg PO OD after
dinner
Undifferentiated
Arthritis
T.SAAZ Sulfasalazine 500 mg PO BD(after
breakfast-
after dinner)
Undifferentiated
Arthritis
Inj.PERFALGAN Paracetamol 500 mg IV TID for 2
days
Pain
T.THYRONORM Levothyroxine 100
mcg
PO BBF Hypo
thyroidism
T.ONDERO Linagliptin 5 mg PO OD DM
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8. • Generic
• Dose
• ROA
• Freq.
• Indication
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Drug Generic Dose ROA Freq. Indication
T.VOLIBO M Metformin
Voglibose
500mg/
0.2mg
PO OD DM
Cap.CLAVILIP Atorvastatin
Clopidogrel
10 mg PO OD Dyslipidemia
T.MET XL Metoprolol 50 mg PO OD Hypertension
T.TAYO 60 K Cholecalciferol 1 tab PO Once a
week after
breakfast
Vit D
supplement
Cap.GEMCAL
PLUS
Calcium
carbonate,
Calcitriol
1 cap PO OD after
dinner
Calcium
supplement
Inj.SOLUMEDROL Methyl
prednisolone
40 mg
in 100
ml NS
IV BD
6AM-
6PM(start
ed on
26/8/19)
Undifferentiated
Arthritis

9. GOALS OF THE TREATMENT
• To control the symptoms.
• To stop the progression of the UA(Undifferentiated Arthritis)
to RA(Rheumatoid Arthritis).
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10. ASSESSMENT
• Based on subjective and objective evidence patient was
diagnosed with Undifferentiated Arthritis.
• Undifferentiated arthritis (UA) encompasses signs and
symptoms consistent with inflammatory arthritis that do not
meet the classification criteria for a specific rheumatic
disease, and can have diverse presentations.
• Treating undifferentiated arthritis before it progresses to
RA is important.
• Patients with polyarthritis may be treated with methotrexate
or leflunomide, and a patient with oligo arthritis may be
treated with sulfasalazine or hydroxychloroquine.
• Administration of single injection of 120 mg of
methylprednisolone has been suggested as a useful approach
as a ‘bridging therapy’ to induce remission in this patients.
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11. • Inj.SOLUMEDROL(Methyl prednisolone) 125 mg in 100 ml
NS over 1 hour was given as a ‘bridging therapy” for control
of symptoms.
• T.HQTOR(Hydroxychloroquine) 200 mg OD and
T.SAAZ(Sulfasalazine) 500 mg BD are given as DMARD
therapy.
• Inj.PERFALGAN(Paracetamol) 500 mg IV TID was given
for pain relief.
• On Day-4, Inj.SOLUMEDROL(Methyl prednisolone) dose
was decreased to 40 mg in 100 ml NS over 1 hour.
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12. • As per medication reconciliation,
T.MET XL 50 mg PO OD
T.ONDERO 5 mg PO OD
T.VOLIBO M 500mg/0.2 mg PO OD were continued
Cap.CLAVILIP 10 mg PO OD
T.THYRONORM 100 mcg PO OD
• Cap.GEMCAL PLUS(Calcium carbonate, Calcitriol),1 cap,
PO,OD after dinner given as a Calcium supplement.
• T.TAYO 60 K (Cholecalciferol)1 tab, PO, Once a week after
breakfast, given as a Vit D supplement.
• Patient was symptom free and hemodynamically stable and
hence planned for discharge.
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13. MONITORING PARAMETERS
If DMARD therapy given for longer period then,
• Sulfasalazine: CBC and liver enzymes should be checked
regularly.
• Hydroxychloroquine: Check visual acuity at least once
every year.
• Corticosteriods: May induce steroid induced osteoporosis
and hyperglycemia (Monitor blood sugar levels).
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14. PATIENT COUNSELLING
• Undifferentiated arthritis is a common inflammatory form of
arthritis involving joint swelling, pain, and stiffness that
cannot be classified as a rheumatalogic disorder.
• There is lower joint count and less hand involvement.
• An estimated 45% - 55% of patients will achieve
spontaneous remission, whereas upto 32% go on to develop
rheumatoid arthritis(RA).
• Early treatment affords the best chance at preventing disease
progression, disability, and decreased quality of life among
those at risk of developing rheumatoid arthritis.
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15. • Physiotherapy can improve range of movements in joints.
• There is some evidence that a Mediterranean type diet rich in
fish, cooked vegetables and olive oil is beneficial for patients
with RA.
• Hypertension, Diabetes mellitus,Hypothyroidism should be
appropriately controlled.
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16. DISCHARGE MEDICATION
T.SAAZ DS (Sulfasalzine Delayed Release) 1 gm 1tab PO BD
After food till review for undifferentiated arthritis.
T.HQTOR(Hydroxychloroquine) 200 mg 1 tab PO OD at
bedtime for undifferentiated arthritis.
T.DEFACORT(Deflazacort)
30 mg 1 tab PO after breakfast for 10 days followed by
24 mg 1 tab PO after breakfast for 10 days followed by
18 mg 1 tab PO after breakfast for 10 days followed by
12 mg 1 tab PO after breakfast for 10 days followed by
6 mg 1 tab PO after breakfast for 10 days to continue
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17. • T.GEMCAL PLUS 1 tab PO OD after dinner till review
given as calcium supplement.
• T.TAYO 60K 1tab PO Once a week after breakfast on every
Sunday for 12 weeks given as vitamin D supplement.
• T.PANTOCID 40 mg 1 tab PO OD BBF till review given for
APD.
• T.MET-XL 50 mg 1 tab PO OD at 9 am till review at 8 AM to
continue for hypertension.
• T.THYRONORM 100 mcg 1 tab PO OD on empty stomach
at 8 AM to continue to hypothyroidism.
• Cap.CLAVILIP 10 mg 1 cap PO OD after dinner at bed time
at 9 PM to continue.
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18. • Inj. BASAGLAR(Insulin glargine)
S/C 22 IU after dinner
• Inj. ACTRAPID (Human Insulin)
S/C 15 IU Before breakfast Given for DM
15 IU before lunch
10 IU before dinner
Review in OPD in 10 days.
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