Rheumatoid Arthritis

Question 1

Prednisone counselling short term therapy

Answer 1

-insomnia take before 4pm
-stomach upset take w food
-monitor BP BG (inc both)

Question 2

Prednisone side effects with long term therapy

Answer 2

-weight gain, moon face
-osteoporosis
-acne
-pancreatitis
-adrenal suppression
-increased risk of infection
-cataracts
-hyperglycemia
-hypertension
-muscle atrophy
-truncal obesity
-increased risk of MI

Question 3

Arthrotec CI

Answer 3

Diclofenac/misoprostol
Abortifacient

Question 4

csDMARDs include

Answer 4

methotrexate - gold standard
sulfasalazine - if MTX CI
hydroxychloroquine - mild disease
leflunomide - inc s/e

Question 5

can csDMARDs be combined?

Answer 5

yes, tx can include MTX + adjunct sulfasalazine or hydroxychloroquine or leflunomide

Question 6

which csDMARD treatment combination has the best evidence to support its use?

Answer 6

methotrexate, hydroxychloroquine and sulfasalazine (“triple therapy”) - superior in efficacy to methotrexate alone as initial therapy and similar to combination therapy
with methotrexate and a biologic

Question 7

Improvement with csDMARDs may be
seen in ____ of therapy initiation and reach maximum effect in _____.

Answer 7

6–8 weeks
3–6 months
same for JAK inhibitors

Question 8

Methotrexate dosing

Answer 8

dose: 20-25mg weekly with folic acid 5mg given 8-12h after (typically given the day after, or may also be daily)
Metoject IM but more commonly used SC in thigh or abdomen bc its less painful, safer, more effective than IM

Question 9

Why give folic acid with Methotrexate?

Answer 9

reduces MTX toxicity - GI adverse effects, apthous ulcers, liver dysfunction

Question 10

Methotrexate lab monitoring

Answer 10

baseline and monthly bloodwork (should be done 1-2 days just prior to the weekly MTX dose)

Question 11

Methotrexate AE & DDI

Answer 11

side effects: Nausea/vomiting, diarrhea, mouth ulcers, flu-like aches, headache, pneumonitis (rare), sun sensitivity, hepatotoxicity
(elevated LFTs)
DDI: smoking may reduce efficacy, avoid alcohol at least within 24h of dose

Question 12

Hydroxychloroquine administration

Answer 12

take w food or at bedtime to minimize flatulence

Question 13

Hydroxychloroquine AE, DDI, monitoring

Answer 13

monitoring: eye exam at baseline then annually after 5 years for retinopathy
unique DDI: smoking may reduce efficacy
side effects: Nausea, abdominal cramping, diarrhea, flatulence, headache, skin rash, sun sensitivity, corneal and retinal deposition
with long term use at high dose

Question 14

Sulfasalazine administration

Answer 14

take with food

Question 15

Sulfasalazine AE

Answer 15

side effects: Dose related GI intolerance and headache. Hypersensitivity and sun sensitivity reactions (with or without fever),
diarrhea, can discolour urine (orange), oligospermia (reversible), bone marrow toxicity (rare), may affect fertility in men.

Question 16

Leflunomide AE, DDI, monitoring

Answer 16

monitoring: labwork at baseline then every 2-3 months
side effects: Nausea, diarrhea, weight loss, hypertension, alopecia/hair thinning, hepatotoxicity (elevated LFTs), headache,
pneumonitis (rare)
DDI: avoid alcohol
other: loading dose not recommended

Question 17

which csDMARDs require contraception?

Answer 17

MTX
leflunomide

Question 18

JAK inhibitors names, brand names, mechanism, place in therapy

Answer 18

Tofacitinib Xeljanz®
Baricitinib Olumiant®
Janus kinase (JAK) inhibitor blocks signaling for several cytokines
are considered after bDMARD therapy has failed

Question 19

JAK inhibitors counselling

Answer 19

Warning: TB screening required, Shingrix recommended prior, no live vaccines during, contraception recommended
Monitoring: regular labwork
Side effects: Headache, diarrhea, hepatotoxicity, bowel perforation, serious and opportunistic infections (including TB),
neutropenia, elevated lipids, malignancy, heart rate decrease and PR interval prolongation, interstitial lung disease,
liver enzymes elevation, increased CK, thrombosis risk
DDI: hold during antibiotic tx

Question 20

Biologic DMARD considerations eg target TNF (infliximab, golimumab, etanercept, certolizumab, adalimumab), target T-cells
(abatacept), target B-cells (rituximab), and interleukin (tocilizumab, sarilumab)

Answer 20

may not be filled at regular pharmacy (IV or SC injections)
no live vaccines
screen for TB prior
hold while on antibiotics
TNF - Contraindicated with lupus, heart failure, demyelinating disease
T-Cell - may worsen COPD

Question 21

considerations for vaccines while on DMARDs

Answer 21

There are no risks with killed vaccine. Vaccination should start when symptom burden and inflammatory
markers are low, ideally 2 weeks or more before DMARD initiation.
Live vaccines are safe for patients on methotrexate ≤25mg/week or glucocorticoids <20mg/day but not recommended while receiving Biologic DMARD therapy

Question 22

considerations for vaccines while on DMARDs

Answer 22

There are no risks with killed vaccine. Vaccination should start when symptom burden and inflammatory
markers are low, ideally 2 weeks or more before DMARD initiation.
Live vaccines are safe for patients on methotrexate ≤25mg/week or glucocorticoids <20mg/day but not recommended while receiving Biologic DMARD therapy

Question 23

NSAIDs role in therapy

Answer 23

NSAIDs have a role as an adjunct in relieving pain, but have no effect on underlying disease processes

Question 24

Corticosteroids role in therapy

Answer 24

Corticosteroids rapidly reduce inflammation and can provide significant benefit as a bridging agent early on in RA treatment.[

Question 25

Corticosteroids role in therapy

Answer 25

Corticosteroids rapidly reduce inflammation and can provide significant benefit as a bridging agent early on in RA treatment.

Question 26

Patients on prolonged corticosteroid therapy should take calcium (total intake of 1200 mg/day, preferably from diet) and vitamin D supplementation
800–2000 units/day.
[100

Question 27

Patients on prolonged corticosteroid therapy should take

Answer 27

-calcium (total intake of 1200 mg/day, preferably from diet) and vitamin D supplementation
800–2000 units/day.
-gastroprotective therapy, particularly with concomitant
NSAID use.

Question 28

Corticosteroid injections can cause dysglycemia for

Answer 28

up to 10 days