Henderson, Lynn
NGR6172
Assignment 8
Analysis of Complementary and Alternative Therapy Study
Rheumatoid arthritis (RA) is a chronic inflammatory disease that is the most common
autoimmune disease affecting the joints. It can be a challenging disorder to treat with symptoms
that include joint pain and swelling, morning stiffness of the joints, as well as fatigue (Buttgereit
et al., 2010).
Generalizability of the Study
A review by Cutolo (2012) examined chronobiology (study of biological rhythms) and its
implications on the treatment for RA. The findings of the reviews are applicable to patients with
RA, whether acute or chronic, with a focus on early morning symptom exacerbations (pain,
stiffness). The treatment suggestions would not be applicable to patients with a contraindication
to glucocorticoids or combination therapy with a disease-modifying anti-rheumatic drug
(DMARD) such as methotrexate (MTX) if contraindicated.
Main Outcome and Findings
Cutolo (2012) explained that the endocrine, nervous, and immune systems are
interconnected with the bodies 24 hour circadian rhythm. Due to the chronic stress RA puts on
the body, cortisol production during the night is either insufficient or is dysfunctionally released
to inhibit the immune and inflammatory effects of the disease and results in RA symptoms
showing their highest severity early in the morning.
Based on the concept of chronobiology, treatment for RA should use a nighttime
intervention on the immune/inflammatory response seen in both acute and chronic RA. The
review included studies that recommended low dose glucocorticoid chronotherapy with modified
release prednisone for long term treatment of RA. The author indicated that the most advanced
approach was a 3 a.m. release of prednisone to regulate inflammation significantly reducing
morning joint stiffness. Chronotherapy showed good results when applied to other drugs as well
that included methotrexate (Cutolo, 2012).
Impact on Occupational Health Nurse Practitioner Prescribing Practices
For workers with RA, the disease can often lead to impaired functioning at work if the
patient is receiving ineffective treatment by their providers outside of work. When job duties
exacerbate symptoms and restrict work abilities, it is the responsibility of the Occupational
Health Nurse Practitioner (OHNP) to create an optimal treatment plan in order to prevent
decreased work productivity, excessive absenteeism, as well as disability. This would include
light or restricted duties during acute exacerbation of symptoms and an ideal medication regimen
to manage the chronic condition.
In addition to the study review by Cutolo (2012), there have been several additional
studies on the efficacy of low-dose glucocorticoid chronotherapy for RA. A study by Buttgereit
et al. (2011) showed low-dose modified release (MR) prednisone added to disease-modifying
antirheumatic drug (DMARD) treatment significantly improved RA symptoms which lead to
improvements in physical and mental functioning. Another study by Buttgereit, Doering et al.
(2010) concluded that the MD prednisone chronotherapy was safe, well tolerated, and had
prolonged improvement and treatment outcomes.
Based on the literature, I would consider chronotherapy with low-dose glucocorticoid
chronotherapy. For newly diagnosed RA, MTX is recommended as an initial treatment approach
before glucocorticoids (Davis & Matteson, 2012). I’d continually monitor the patients’
improvement or lack of and refer them out to a rheumatologist for further evaluation and
treatment if needed.
References
Buttgereit, F., Doering, G., Schaeffler, A., Witte, S., Sierakowski, S., Gromnica-Ihle, E., Jeka, S.,
Krueger, K., Szechinski, J., & Alten, R. (2010). Targeting pathophysiologal rhythms:
Prednisone chronotherapy shows sustained efficacy in rheumatoid arthritis. Ann Rheum
(69), 1275-1280. doi: 10.1136/ard.2009.126888
Buttgereit, F., Mehta, D., Kirwan, J., Szechinski, J., Boers, M., Alten, R., Supronik, J., Szombati,
I., Romer, U., Witte, S., & Saag, K. (2013). Low-dose prednisone chronotherapy for
rheumatoid arthritis: a randomized clinical trial (CAPRA-2). Ann Rheum Dis, (72), 204210. doi: 10.1136/annrheumdis-2011-201067
Cutolo, M. (2012). Chronobiology and the treatment of rheumatoid arthritis. Curr Opin
Rheumatol, (24), 312-318. doi: 10.1097/BOR.0b013e3283521c78
Davis, J., & Matteson, E. (2012). My treatment approach to rheumatoid arthritis. Mayo Clinic
Proc, 87 (7), 659-673. http://dx.doi.org/10.1016/j.mayocp.2012.03.011