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Therapeutics > OA/RA > Flashcards

OA/RA Flashcards

1
Q

Osteoarthritis is a disease of the ?
What’s our goal?
Clinical presentation ?

A

Cartilage
Pain relief!

Joint pain in hips, knees, hands that resolves with motion, recurs with rest.
Usual duration < 30 mins
May be related to weather . Can have limited joint motion .

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2
Q

Non Pharm Tx
Highlight some Strongly recc therapies
Waht about conditionally recommended?

A

Exercise, self efficacy and self management programs

for knee and hip : Weight loss, tai chi, cane, Knee brace

Heat, therapeutic cooling, acupuncture, kinesiotaping, balance training

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3
Q

Pharm Tx

  1. What tx should u try to use first?
  2. Strongly recommended for hand, knee and hips ?
  3. Strongly rec for knee and hip and conditionally rec for hands?
  4. for all , the following drugs r conditionally recommended
A

Topical nsaids (knee and hand)

oral nsaids

Intra-articular steroids

Tylenol, tramadol, duloxetine

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4
Q

NSAIDS

If possible use which formulation over which?
Great for __
WHy do hips and hands have limitations?
-Initiate oral med of choice, regardless of ___ (Lowest and shortest dose possible)

What can you use to diffuse the GI and renal AE’s of NSAIDS?
-Note AE of Fluid retention +Incr BP

Cardiovasc risk –> Avoid in patients?

A

Topical > systemic

knees!

handwashing, depth of hip joint

location!

PPI’s,H2, COX2 selective agents

with known active ischemic disease, CVD, and moderate/severe CHF

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5
Q

NSAIDS DDI’s
(5) and
Likely less risk if u use a topical

Sulfa Allergy beware of?

A

Lithium, warfarin bleeding risk, oral hypoglycemics, ACEI, diuretics

Celecoxib (sulfonamide)

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6
Q

Other TX options ? (3)

A

Diclofenac Gel (AAA 4x daily)
Capsaicin (irritant )
Glucosamine/chondroitin (caution with shellfish allergy + no evidence it actually works)

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7
Q

Rheumatoid Arthritis : Autoimmune Disease
-Describe the inflammation

Sx’s : Joint pain/stiffness
Fatigue, weakness, loss of appetite
RF 60-70% , elevated ESR /CRP, warm tender and swollen
-Might have normocytic anemia

A

Chronic, systemic inflammation
progressive symmetrical joint damage

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8
Q

Difference between RA and OA

-Onset
-What happens
Develops over?
Pattern ?
Which joints
Morning stiffness?
Manifestations?
Gender?

A

RA : Onset 30-60 years
* Autoimmune joint
destruction
* Develops over
weeks/months
* Symmetrical
* Primarily small joints
* Morning stiffness (>1 hr)
* Extra-articular
manifestations
* More common in females

OA : Onset after age 40
* Biomechanical loss of
cartilage
* Develops over many years
* Unilateral or bilateral
* Primarily larger joints
* Minimal morning stiffness
* No extra-articular
manifestations
* Males = females

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9
Q

Goals of Tx
R___
Improve __ and __
Reduce ___
Slow __
Delay ___

A

remission/low disease activity
functional status, quality of life
sx’s
progression
disability

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10
Q

Non Pharm for RA
R,P,O,A,H,W,S,A

A

rest, PT, OT, assistive devices, heat or cold therapy, weight loss, surgical correction , anti inflamm diet

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11
Q

TX Strategy in General : Which 3 categories of drugs ?

A

csDMARD : Conventional synthetic disease modifying antirheumatic drug

Biologics : TNF/non TNF

tsDMARD : targeted synthetic DMARD

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12
Q

csDMARDS : 4
Biologics TNFI : 5
Biologics Non TNF : 5
Adjunctive therapy of nsaids and glucocorticoids name an example of each

A

MTX, Hydroxychloroquine, sulfasalazine, leflunomide

adalimumab, certolizumab, etanercept, golimumab, infliximab

Abatacept, rituximab, tocilizumab, sarilumab, anakinra

ASA
Cortisone

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13
Q

Glucocorticoids AE’s
P
R
E
D
N
I
S
O
N
E

A

psychiatric (mood change and jitters)
round face
eyes (glaucoma and cataracts)
diabetes
neutrophilia
immunosuppression, insomnia
stomach (GI upset and ulcer)
Osteoporosis
Na/H2O retention
Endocrine (HPA suppression)

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14
Q

MTX
-It is the ___ initial DMARD therapy for most pt’s with mod/high disease activity

Dosing ?
What can u do to reduce ae’s?

Titrate up gradually to optimal response

When can u see initial vs full effects?

What must be supplemented ?

A

PREFERRED

15 mg weekly; oral preferred

May divide dose to reduce side effects (daily); transition to subQ

May take 3-6 weeks to see initial effects, 12+ weeks for full effect

Folic acid : 1 mg daily or 5 mg weekly (Day after MTX) to reduce SE

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15
Q

MTX DDI
-ALbumin binding interactions with ? (5)
-Reduction of renal elimination of drug (with Acidic drugs such as? )

A

salicylates, phenytoin, SMZ/TMP, ciproflox, thiazide diuretics

Salicylates or vitamin C

For salicylates –> includes NSAIDS But u dont have to avoid NSAIDS. u can be cautious and use diclofenac or mobic

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16
Q

MTX : BBW
Never bake diet goods , humans only prefer sugar

A

Nephrotoxicity (Renally elim)
Bone marrow suppression
dermatologic rxns
GI (N/V/D)
Hepatotoxic
opportunistic infxn
pneumonitis
Secondary malig (lymphomas)

17
Q

MTX Monitoring parameters? 6

MTX and pregancy?

A

Scr, CBC, LFTS, baseline chest xray, if needed, hepB/c testing, liver biopsy

Preg category X. Abortifacient, teratogen
-Following tx, avoid preg for 3 months w/male patients, 1 ovulatory cycle for females

18
Q

Maintenance monitoring of MTX : CBC, LFT, Scr Frequency

If < 3 month therapy
if 3-6 months
if >6 months

A

2-4 weeks, 8-12 wks, 12 weeks

19
Q

Biologics : TNF Alpha Inhibitors

-Immune suppression, reduce inflammation

AE’s : I,M,A,H, I (I might actually hate it)

A

Infection Risk : Tb, must test before therapy.
Invasive fungal infxns
Atypical/opportun bact/viral infxns
reactivation HepB

Malignancy : lymphoma or skin cancer

Autoimmune conditions : Worsening or new onset, MS, drug induced lupus like syndromes

HF : Worsening or new onset

Immunologic rxns : ANA titer, Ab devel

20
Q

For each TNFAlphaI name the route

  1. Adalimumab (Humira)
  2. Certolizumab (cimzia)
  3. Etanercept (Enbrel)
  4. Golimumab (Simponi)
    (combo w/ MTX)
  5. Infliximab (Remicade)
    (combo w/ MTX
A

Subq
Subq
subq
IV / subq
IV

21
Q

Counseling for TNFAI
-Dont __, ___. before injecting, bring to ___
Don’t __
Pens and synringes are ___
What varies with product?

Which product has antigenic potential? (Infusion related rxns)
-Premedicate with __,__ and or __
Infusions less than ___ not recc first line

A

freeze, refridgerate. ROOM TEMP
Shake
Single use
Injection site! (thigh, lower abd, upper arm)

Infliximab
-Antihist, APAP, corticosteroids
2 hrs

22
Q

Biologics : NON TNF
Abatacept (Orencia) -> route?
Ae’s? (5)
-Competes w/CD80/CD86 binding to prevent costum signal required for T cell activation

Rituximab (Rituxan)
-Route?
AE’s?
BBW? (4)
-mab binds CD20 on B lymphocytes

A

IV, subq

Nausea, headache, antibody devel, infection, COPD exacerbations

IV
edema, HTN, fatigue, chills, neuropathy,
headache, insomnia, N/V/D, rash, itching, night sweats, hematologic, infection, antibody development, cough, epistaxis

Fatal infusion reactions – monitor closely!
* Severe mucocutaneous reactions
* HBV reactivation
* Progressive multifocal leukoencephalopathy (PML)

23
Q

Tocilizumab (ACtemra)
-Humanized IL6 receptor inhib

Route?

AE’s?

BBW?

A

IV or SubQ

HLD, infusion rxns
-Elevated liver enzymes. If AST/ALT>1.5 UNL, dont start. If 5xULN, discontinue
-Hematologic effects : Neutropenia, thrombocytopenia
Dont start if ANC< 2000 or Plt <100K
Discontinue if ANC <500 or Plt <50k

INFECTIONS + TB

24
Q

Sarilumab (Kevzara)
-IL6 maB
route?

AE’s ?
BBW?

A

Subq

HLD
-Elevated liver enzymes. If AST/ALT>1.5 UNL, dont start. If 5xULN, discontinue
-Neutropenia, Thrombocytopenia

Dont start if ANC< 2000 or Plt <150K
Discontinue if ANC <500 or Plt <50k

INFECTIONS + TB

25
Q

Anakinra (Kineret)
-IL1 receptor antag
Route?
AE’s ?

A

Subq

N/V/D, HA, Thrombocytopenia, and neutropenia

26
Q

Biologics Monitoring

Prior to Initiation ? (5)

Throughout therapy?

A

TB screening
* HBV screening
* Up-to-date vaccinations
* Risk assessment for cancer
* CBC, LFT

Sx improvement
* Assessment of physical
function
* S/sx of infection
* Agent specific concerns

27
Q

Targeted Synthetic DMARDS (JAKS)

Name the 3 drugs, dose? and route

What is it metabolized by? Need dose adj for?

A

Tofacitinib (xeljanz) IR 5 mg po bid, ER 11 mg po daily

Baricitinib (Olumiant) : 2 mg po daily

Upadacitinib (rinvoq) 15 mg po daily

CYP3A4 . CYP3a4 inhibs

28
Q

JAKS AE’s (4) ?
Monitoring Baseline+Periodically?
Dont initiate in pt’s with ??
Baseline in general ?

A

infection risk, hyperlipidemia, LFT
elevations, bone marrow suppression

CBC, LFT, lipids

Absolute lymphocyte count <500 cells/mm3
* ANC <1,000 cells/mm3
* Hb <8 g/dL.

screen for viral hepatitis, tuberculosis

29
Q

BBW for all RA JAKS
Incr risk of serious bact, fungal, viral and opport infxns leading to ?
-Higher rate of all cause __ including ___
Higher rate of __ and __
Higher rate of ___
Incr incidence of ___ venous and arterial thrombosis

A

hospitalization or death including Tb

mortality, sudden cardiovasc death

lymphomas, lung cancers
MACE
pulmonary embolism

30
Q

KIM : print out Special Pop
ALSO pt’s can receive any vaccine just not live ones

A

print out

Therapeutics (15 decks)

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