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What is RA?

Chronic inflammatory disease of unknown etiology marked by SYMMETRIC, peripheral polyarthritis


What is the clinical presentation of RA?

Early morning stiffness > 1 hour and easing with physical activity. Pain and stiffness of more than 6 weeks duration. Usually symmetric. Typically occurs first with the small joints of the hands and feet


What is Flexor Tendon Tenosynovitis?

A frequent hallmark of RA and leads to decreased range of motion, reduced grip strength, and trigger fingers


What is Secondary Sjogren's Syndrome?

10% of RA patients get it. Atrophy of lacrimal duct. Atrophy of salivary glands


What is the lung involvement like for RA?

Nodules. Pulmonary effusions. Pulmonary fibrosis (increased w/ smoking)


What serology is looked at for RA diagnosis?

High-positive RF or high-positive anti-CCP antibodies (>3 times ULN)


What acute-phase reactants are looking at for RA?

Abnormal (increased) CRP or abnormal (increased) ESR


What is the goal of RA therapy?

Increased QOL (increased dexterity w/ decreased pain). Achieve remission (simplified disease activity score of 3.3)


What are the two classes of pharmacological treatment for RA?

Non-Biologic Disease Modifying Anti-Rheumatic Drugs (DMARDs). Biologic DMARDs


What are some of the common Non-Biological DMARDs?

MTX. Hydroxychloroquine. Cyclosporine. Minocycline. Sulfasalazine, etc.


What are some of the common Biologic DMARDs?

Etanercept. Infliximab. Rituximab. Abatacept. Tocilizumab, etc.


What vaccinations do you need BEFORE starting DMARD or biologic agents (they can still be done after DMARDs are started, but not recommended)?

Pneumococcal. Influenza IM. Hep B. Human Papillomavirus. Herpes Zoster


**What is DMARD Initiation like?

Onset: 6-12 weeks. Bridging with Glucocorticoids (rapid disease control, predisone 5-10mg daily, Provide osteoporosis prophylaxis if > 3 months. Can use with NSAIDs or Analgesics for symptomatic relief (no disease modifying benefit)


**What is the DOC for RA?



**What are some general comments about MTX use?

Folic acid supplementation does not compromise efficacy (MTX depletes folic acid levels). Give doses > 25mg parenterally. Keep hydrated!


**What are some common ADRs with MTX?

GI (N/V/D). Heme (decreased WBC and platelets). Increased LFTs (d/c if 2x ULN). Teratogenic (3 months contraception for men, 2 menstrual periods for women)


What are some general comments about Hydroxychloroquine?

Considered tx failure at 6 months w/o response. Lack of myelosuppressive, hepatic, and renal toxicity. Take w/ food or milk


What are some ADRs associated with Hydroxychloroquine?

GI (N/V/D). Ocular (blurred vision). Rash, alopecia. HA, vertigo, insomnia


How does Sulfasalazine work?

Sulfasalazine --> SULFAPYRIDINE (active component) + 5-aminosalicylic acid


What are some general comments about Sulfasalazine?

Start low, go slow. Antibiotics decrease bioavailability. Warfarin displacement. NOT a true DMARD. Take after meals and keep hydrated (renal stones), iron chelation, urine discoloration


**What is the timeline for early and established RA?

Early RA: < 6 months. Established RA > 6 months


**What is a poor prognosis for RA?

Presence of 1 or more of the following features: Functional limitation, Extraarticular, Positive rheumatoid factor or anti-cyclic citrullinated peptide antibodies, or Body erosions by radiograph


**What is the main medication that can be used in poor prognosis RA?

MTX or Leflunomide (these can be used with any RA duration or disease activity)


How do Biologic Agents work?

Inhibit pro-inflammatory cytokines (TNF, IL-1, IL-6). Deplete peripheral B cells. Prevent T cell activation


**What is TB screening like for RA?

Tuberculin skin test or interferon-gamma-release assays in all patients starting Biologic Agents (if positive --> CXR, if active --> sputum exam). Treatment with biologic agents can be initiated or resumed after 1 month of LTBI tx. Annual TB test for patients at risk


**What are some common TNF-Inhibitors used?

Infliximab. Etanercept. Adalimumab. Golimumab. Certrolizumab. Treatment in combo w/ MTX is better than either alone


**What is the BBW with TNF-Inhibitors?

Increased risk of infections, Lymphoma. Increased mortality with CHF (contraindicated with Stage IV)


Why are obese patients less likely to have good treatment outcomes with anti-TNF agents?

Obesity already puts the body in some sort of inflammatory state


What are some common ADRs with Infliximab?

Infusion reactions (fever, chills, etc). GI, Fatigue, increased infections. Loss of response over time


What should you use to pre-medicate a patient before Infliximab?

Antihistamines, APAP, Corticosteroids


What is Infliximab usually given with?



What are some general comments about Abatacept?

Live vaccines should not be given during and for 3 months after treatment


What is the BBW for Rituximab?

Fatal infusion reactions. JCV --> PML. Premed 30 minutes before (antihistamine, steroid, APAP)


What is Toclizumab?

IL-6 receptor inhibitor. All IL-inhibitors require more monitoring


What is combination therapy like for biologics?

Combination biologic DMARD therapy is not recommended because of the increased risk for infection


IL-inhibitors require a lot more monitoring, what needs to be monitored while on Tocilizumab?

AST/ALT, CBC w/ platelet, lipids Q4-8 weeks


IL-inhibitors require a lot more monitoring, what needs to be monitored while on Anakinra?

Neutrophil count monthly for 3 months then quarterly up to 1 year


What agent can potentially still be used in patients with Hepatitis C?



When can biologics be used with history of Malignancies?

If they were treated > 5 years ago. If less than 5 years you can still use Rituximab


What is biologic use like in CHF patients?

Recommends NOT using anti-TNF biologic in NYHA Class III or IV with EF < 50%


What is Osteoarthritis?

Common degenerative disorder of the articualr cartilage associated with hypertrophic bone changes


What type of OA is seen in men and women?

Men: more hip. Women: more hands, knee, foot


**What is the clinical presentation of OA?

Morning stiffness < 30 minutes. Pain worsens with activity. Joint locking or instability. ASYMMETRIC distribution


**What are the therapeutic recommendations for OA of the Hand?

At least 1 or more: Topical capsaicin, Topical NSAIDs, Oral NSAIDs, Tramadol


**What are the therapeutic recommendations for OA of the Knee?

Only 1 med: APAP, Oral NSAIDs, Topical NSAIDs, Tramadol, Intraarticular corticosteroid injections


**What are the therapeutic recommendations for OA of the Hip?

Only one: APAP, Oral NSAIDs, Tramadol, Intraarticular corticosteroid injections


What do you look for when radiographically (MRI > X-Ray) diagnose OA?

Presence of osteophytes. Joint space narrowing. Cysts. Deformity. Sclerosis


What injectable steroids can be used for OA?

Methylprednisolone ACETATE (needs to be acetate!). Betamethasone. Triamcinolone


What injectable Hyaluronic Acid can be used for OA?

Euflexxa, Hyalgan, Orthovisc, Supartz, Synvisc, Nuflexxa. Start with steroids first, if they fail then try these


What is Diacerein?

Disease modifying OA drug. Inhibits IL-1 synthesis, prevents remodeling, preliminary studies


**For step-wise therapy, what is done for increasing mild OA?

Start with APAP and continue until effective or step up to NSAID. Also, encourage regular exercise and consider physical therapy


**For step-wise therapy, what is done for increasing moderate OA?

Add combination glucosamine and chondroitin for moderate to severe knee OA; d/c if no change after 3 months


For step-wise therapy, what is done for increasing Severe OA?

Consider opioid therapy --> consider corticosteroid injection --> consider hyaluronic acid --> discuss total joint replacement