Rheumatoid Arthritis

Question 1

Process of RA development?

Answer 1

chronic inflammation –> growth of tissue (pannus) –> loss of bone and cartilage

Question 2

RA triggers?

Answer 2

genetics
stochastic event

Question 3

Consequences of inflammation?

Answer 3

loss of cartilage
formation of scar tissue
ligament laxity
tendon contractures

Question 4

Gender more common for RA?

Answer 4

women 3:1

Question 5

RA symptoms?

Answer 5

symmetrical joint pain and stiffness > 6 weeks
muscle pain
fatigue, weakness, low-grade fever, appetite decrease
joint tenderness and warmth ans swelling over affected joints
Rheumatoid nodule development

Question 6

WHat joints is does RA usually start in

Answer 6

peripheral joints

Question 7

Diagnosis for RA?

Answer 7

joint involvement
lab tests
- Rheumatoid factor in 60-70% pts
- elevated ESR and CRP
- anti-cyclic citrullinated pepide antibody
Duration of symptoms

Question 8

When to start DMARDs?

Answer 8

within first 3 months of diagnosis

Question 9

Non-pharm treatment?

Answer 9

Pts education
rest activity balance
reduce joint stress
diet
wt loss
surgery
occupational and physical therapy

Question 10

Main DMARD used?

Answer 10

Methotrexate

Question 11

MOA of Methotrexate?

Answer 11

anti-folate, less DNA synthesis, repair, cellular replication and immune response

Question 12

Onset of methotrexate?

Answer 12

1-2 months

Question 13

Methotrexate dosing?

Answer 13

7.5-25mg po weekly

Question 14

Methotrexate common AE’s?

Answer 14

N & V
Fatigue
stomatisis
skin itch, burining, rash
hair loss
photosensitivity

Question 15

Serious SE of methotrexate?

Answer 15

hepatotoxicity
hematologic abnormalities
pulmonary toxicity
reversible sterile in men
infection increase

Question 16

Unique SE of hydroxchloroquine?

Answer 16

ocular toxicity?

Question 17

DMARD drugs?

Answer 17

hydroxychloroquine
sulfasalazine
methotrexate
leflunomide

Question 18

CI w/ methotrexate?

Answer 18

pregnancy/breastfeeding
severe hepatic impairment
caution in lung dysfunction
Current hematological abnormalities

Question 19

DI w/ methotrexate?

Answer 19

TRIMETHOPRIM**

NSAIDs, PPI’s, Loops –> in doses 500-2000mg weekly

Question 20

Monitoring DMARDs?

Answer 20

disease activity q 1-3m
radiographs q 6-12m

Question 21

Saftey monitoring for methotrexate?

Answer 21

CBCs and LFTs
Creatinine
Initial chest x-ray

Question 22

Which DMARD can replace methotrexate if not tolerated?

Answer 22

leflunomide

Question 23

Biologic DMARDs?

Answer 23

TNF
Interleukins

Question 24

What do biologic DMARDs cause over time?

Answer 24

soft tissue and bone damage

Question 25

Common SEs of biologic DMARDs?

Answer 25

Nausea
headache
Diarrhea
Malaise

Question 26

Pre-treatment of biologic DMARDs?

Answer 26

acet + antihistamine + steroid 90 min prior

Question 27

When is Infection rate increase highest

Answer 27

early in therapy

Question 28

Cancer risks in biologic DMARDs?

Answer 28

skin
Lymphomas

Question 29

Which biologic DMARD does not have antibody development?

Answer 29

IL-6 inhibtors

Question 30

Antibody development more common in TNF or B/T cell treatment?

Answer 30

More in TNF

Question 31

Which biologic DMARDs are indicated in combo w/ methotrexate?

Answer 31

Infliximab
Golimumab

Question 32

CI of TNF?

Answer 32

active severe infection
HF

Question 33

unique concerns w/ TNF?

Answer 33

autoimmune diseases
Seizures

Question 34

Oneset of IL-1 or 6?

Answer 34

weeks, peak at 5-6 months

Question 35

WHich IL has a CI of active infections?

Answer 35

tocilizumab

Question 36

Anakinra dosing?

Answer 36

100mg SubQ daily

Question 37

Does anakinra cause GI issues/ perforation?

Answer 37

no

Question 38

Unique SE w/ sarilumab/tocilizumab?

Answer 38

dyslipidemia

Question 39

unique T cell SEs?

Answer 39

COPD exacerbations
HTN
BG increase

Question 40

T cell drug?

Answer 40

Abatacept

Question 41

B cell drug?

Answer 41

Rituximab

Question 42

What must B cell depletor be pre-treated w/?

Answer 42

methylprednisolone
Acet
diphenhydramine

Question 43

Dosing of Rituximab?

Answer 43

1g IV infusion, 2 doses spaced 2 weeks apart

Question 44

When can you retreat w/ rituximab?

Answer 44

when needed, usually 6 months

Question 45

What needs to be held prior to rituximab infusion?

Answer 45

HTN meds

Question 46

Serious AE of Rituximab?

Answer 46

SJS/TEN

Question 47

SE of rituximab?

Answer 47

HTN
GI perforation
BG increase

Question 48

Biologic DMARDs place in therapy?

Answer 48

after other options have been tried unless severe RA
1. TNF
2. IL-1 or 6
3. abatacept
4. Rituximab

Question 49

Janus kinase inhibitors?

Answer 49

Tofacitinib
Baricitinib
Upadacitinib

Question 50

Concern for antibody formation with janus kinas inhibitor?

Answer 50

NONE

Question 51

Janus kinase inhibitors CYP substrate?

Answer 51

3A4

Question 52

First line approach for DMARDs in low disease activity?

Answer 52

HCQ>SSZ>MTX>LEF

Question 53

First line approach for DMARDs in moderate to high disease activity?

Answer 53

MTX strongly recommended over HCQ and SSZ,
conditionally recommended over LEF

Question 54

Drugs safe in pregnancy?

Answer 54

HCQ and SSZ good options
Stop MTX 3 months prior to conception (male and female)
all biologics except rituximab have favourable saftey profiles