Case 1: A patient with RA, characterized as a chronic progressive disease, can experience acute episodes of pain and inflammation. Nonsteroidal anti-inflammatory drugs may provide symptomatic relief, but they do not change the course of the disease. DMARDs have the potential to prevent or reduce joint damage. According to the American College of Rheumatology (ACR) classification criteria, a person with the disease for greater than 6 months is classified as having established RA. If after 3 months of methotrexate monotherapy, a patient like JC with established RA deteriorates from low to moderate/high disease activity, then therapy modification is appropriate. Addition of another DMARD or switching to a different nonmethotrexate DMARD, such as hydroxychloroquine or leflunomide, is recommended. A dose increase of methotrexate is another option for JC; however, doses exceeding 20 mg a week carry increased risks of adverse effects such as elevation of liver enzyme levels and myelosuppression. Complete blood count with differential and liver function tests should be monitored at baseline, every 2 to 4 weeks for the initial 3 months of therapy, and every 12 months after 6 months of therapy for patients receiving methotrexate.
Case 2: SF is an obese woman who has complaints of recent pain and weakness in her legs. Many possibilities should be considered when determining the cause of these symptoms. The patient’s comorbidities, lifestyle changes, and medication profile as well as the timing of the onset of these symptoms need to be evaluated before making any recommendations. Although exercise can sometimes cause leg pain or muscle weakness, the patient complains of worsening symptoms in the past few weeks and has had the same exercise routine for 6 months. She recently switched from simvastatin to rosuvastatin 10 mg a day and is concurrently taking a fibric acid derivative, gemfibrozil. Coadministration of statins and fibrates increases the risk of myopathy. According to the prescribing information for rosuvastatin, gemfibrozil significantly increases rosuvastatin exposure, and consequently, combination therapy should be avoided. If the combination therapy is necessary to achieve lipid goals, the rosuvastatin dose should not exceed 10 mg a day. Risk factors that predispose this patient to myopathy with the combination statin-fibrate therapy include older age, female gender, diabetes, hypothyroidism, and exercise. The pharmacist should contact SF’s physician to report these symptoms/signs and discuss a possible change in the patient’s cholesterol medications.