Which patient with newly diagnosed Rheumatoid Arthritis (RA) should be thoroughly assessed for renal function status before initiating Disease-Modifying Antirheumatic Drug (DMARD) and Nonsteroidal Anti-Inflammatory Drug (NSAID) therapy?

From the Guidelines

The 65-year-old patient diagnosed with glaucoma should be thoroughly assessed for renal function status before the initiation of disease-modifying antirheumatic drug (DMARD) and nonsteroidal anti-inflammatory drug (NSAID) therapy. When considering the initiation of DMARD and NSAID therapy in patients with newly diagnosed rheumatoid arthritis (RA), it is crucial to assess renal function status, particularly in patients with certain characteristics that may increase their risk of renal complications.

Key Considerations

• Older adults, especially those over 65, are at a higher risk of renal impairment due to age-related decline in renal function 1.
• Patients with pre-existing kidney disease, hypertension, or diabetes are also at increased risk of renal complications when taking DMARDs and NSAIDs.
• Baseline assessment of renal function should include serum creatinine, estimated glomerular filtration rate (eGFR), urinalysis, and blood pressure measurement.
• Methotrexate, a common first-line DMARD, is renally excreted and may require dose adjustment or avoidance in renal impairment, as recommended by the 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis 1.
• NSAIDs can reduce renal blood flow and cause acute kidney injury, especially in vulnerable patients, highlighting the need for careful monitoring and dose adjustment as needed 1.

Patient-Specific Factors

• The 65-year-old patient with glaucoma may be at increased risk of renal complications due to age-related decline in renal function and potential use of medications that may affect renal function.
• The 26-year-old patient being treated for an eating disorder and the 35-year-old patient with obesity may not be at increased risk of renal complications based solely on the provided information.
• The 40-year-old patient who is an avid cyclist may not be at increased risk of renal complications based solely on the provided information.

Recommendations

• All patients with newly diagnosed RA should undergo thorough renal function assessment before starting DMARDs and NSAIDs, with particular attention to those with pre-existing kidney disease, older adults, patients with hypertension or diabetes, those taking other nephrotoxic medications, and patients with a history of kidney stones or urinary tract abnormalities.
• Regular follow-up assessments of renal function are recommended after initiating therapy, typically at 4-8 weeks initially and then periodically based on individual risk factors.

From the FDA Drug Label

Renal Methotrexate may cause renal damage that may lead to acute renal failure High doses of methotrexate used in the treatment of osteosarcoma may cause renal damage leading to acute renal failure. Nephrotoxicity is due primarily to the precipitation of methotrexate and 7-hydroxymethotrexate in the renal tubules Close attention to renal function including adequate hydration, urine alkalinization and measurement of serum methotrexate and creatinine levels are essential for safe administration Renal Effects Long-term administration of NSAIDs has resulted in renal papillary necrosis and other renal injury. Renal toxicity has also been seen in patients in whom renal prostaglandins have a compensatory role in the maintenance of renal perfusion In these patients, administration of a NSAID may cause a dose-dependent reduction in prostaglandin formation and, secondarily, in renal blood flow, which may precipitate overt renal decompensation. Patients at greatest risk of this reaction are those with impaired renal function, heart failure, liver dysfunction, those taking diuretics and ACE inhibitors, and the elderly

The patient who should be thoroughly assessed for renal function status before the initiation of disease-modifying antirheumatic drug (DMARD) and nonsteroidal anti-inflammatory drug (NSAID) therapy is the 40-year-old who is an avid cyclist is not the correct answer, the correct answer is not listed, however, a patient with a history of renal disease or a patient taking medications that may affect renal function would be at risk.

• Impaired renal function
• Heart failure
• Liver dysfunction
• Taking diuretics
• Taking ACE inhibitors
• Elderly 2 3

From the Research

Patient Assessment for Renal Function Status

When considering the initiation of disease-modifying antirheumatic drug (DMARD) and nonsteroidal anti-inflammatory drug (NSAID) therapy for patients newly diagnosed with rheumatoid arthritis (RA), it is essential to assess renal function status thoroughly in certain patients. The following characteristics may indicate a need for thorough assessment:

• Age and comorbidities: While age itself is a factor, comorbid conditions that may affect renal function are more critical.
• Medications and potential interactions: Patients on medications that may interact with DMARDs or NSAIDs, potentially affecting renal function, should be assessed.
• Pre-existing conditions that may impact renal function: Certain conditions can affect kidney function and should be considered when initiating DMARD and NSAID therapy.

Specific Patient Considerations

Given the options:

• a. 65-year-old diagnosed with glaucoma: Glaucoma itself does not directly impact renal function, but age can be a factor.
• b. 26-year-old being treated for an eating disorder: The treatment for eating disorders, as discussed in studies 4, 5, 6, 7, 8, may involve medications that could potentially interact with DMARDs or NSAIDs, affecting renal function.
• c. 35-year-old whose body mass index is categorized as obese: Obesity can be associated with various health issues, including those that may affect renal function, but it is not directly indicated as a primary concern for renal assessment in the context of initiating DMARD and NSAID therapy.
• d. 40-year-old who is an avid cyclist: Physical activity level, such as being an avid cyclist, does not directly indicate a need for thorough renal function assessment before initiating DMARD and NSAID therapy.

Recommendation

Based on the information provided and considering potential medication interactions and the impact of underlying conditions on renal function, the patient being treated for an eating disorder (option b) should be thoroughly assessed for renal function status before the initiation of DMARD and NSAID therapy, due to the potential for medication interactions as noted in studies 4, 5, 6, 7, 8.