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PF3012 > Rheumatoid Arthritis > Flashcards

Rheumatoid Arthritis Flashcards

1
Q

3 lab tests to diagnose RA

A
  • rheumatoid factor
  • erythrocyte sedimentation rate
  • C reactive protein

(x rays of hands and feet)

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2
Q

Physical examination for RA

A
  • Swelling of 3 or more joints
  • Tenderness along the joint line
  • “Squeeze test”
  • Synovitis
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2
Q

Drug classes for pain relief in RA

A
  • COX 2 selective inhibitors
  • NSAIDs
  • Glucocorticoids can be used in flare ups
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3
Q

What is the protocol for treatment of newly diagnosed RA patients?

A

Pain relief - NSAIDs/COX-2
cDMARD (methotrexate, leflunomdie, sulfasalazine)
+/- short term glucocorticoids
When disease control not achieved with treatment with methotrexate and one of more other DMARD: introduce biological agent
Can prescribe biologic and methotrexate

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4
Q

List 9 adverse effects of Corticosteroids

A
  • Diabetes
  • Osteoporosis
  • Avascular necrosis of the femoral head
  • Muscle wasting
  • Peptic ulcer
  • Psychosis
  • Immunosuppression
  • Cushing syndrome
  • Ophthalmic effects
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5
Q

Patient information for Corticosteroid treatment

A
  • Carry steroid card (prescriber, dose, duration)
  • Take single daily dose in the morning
  • Do not stop taking abruptly - taper down dose if:
    Treatment > 3 weeks
    Prednisolone 40mg >7 days
    Possible adrenal suppression of another cause
    Repeated evening doses
    Repeated courses
    Short course within 1 year of stopping long term steroid treatment
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6
Q

First line treatment with DMARDs

A

Methotrexate + one or more other DMARDs (sulphasalazine, hydroxychloroquinine)
Once disease is controlled, can reduce dose
4-6 months to full response, 50% of patients on long term treatment

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7
Q

What is the dose of methotrexate?

A

7.5mg - 25mg once weekly orally or s/c
Parenteral methotrexate available if patient fails to respond or if extreme nausea on oral therapy

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8
Q

Methotrexate interactions

A
  • Excretion is affected - leads to toxicity
  • Avoid aspirin and NSAIDs (but can be used if monitored?)
  • Trimethoprim
  • Alcohol
  • Take folic acid on different day
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9
Q

Which methotrexate tablets should you keep in stock

A

2.5mg tablets

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10
Q

Name the 3 major methotrexate adverse effects and signs of them

A

Blood Disorders
- Sore throat/ Other infections (neutropenia sign)
- Fever/ chills (neutropenia sign)
- Mouth ulceration
- Easy bruising or bleeding

Liver toxicity
- Diarrhea
- Vomiting
- Unexplained rash

Respiratory Effects
- Breathlessness
- Dry persistent cough

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11
Q

When should blood tests, renal function, hepatic function be done on Methotrexate

A
  • Every 1-2 weeks until stable
  • Then monthly for one year
  • Then every 2-3 months
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12
Q

Contraception and Methotrexate

A
  • Men and women must use effective contraception during treatment and for 6 months after stopping
  • Cannot be used if you might be pregnant or wish to start a family
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13
Q

How long does it take to notice effects of Methotrexate?

A

up to 12 weeks

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14
Q

Dose of sulphasalazine

A
  • 500mg daily initially
  • increase in 500mg increments weekly, up to a max dose of 2g-3g daily in divided doses
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15
Q

7 adverse effects of sulphasalazine

A
  • blood disorders (leukopenia, thrombocytopenia, neutropenia)
  • taste disturbances
  • tinnitus
  • GI disturbances
  • staining of soft contact lenses
  • orange discolouration of skin/ urine/ bodily fluids
  • hepatotoxicity
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16
Q

Monitoring on sulfasalazine

A

full blood count and liver function initially, then once monthly for 3 months, then every 3 months
renal function

17
Q

Dosage of hydroxychloroquinine

A

200-400mg daily
increased to max dose of 6.5mg/kg/day

18
Q

4 adverse effects of hydroxychloroquine

A
  • ocular toxicity - v. important
  • GI disturbances
  • skin rash
  • discoloration of skin, nails, mucous membranes
19
Q

Monitoring on hydroxychloroquinine

A

ask patient re. visual impairment prior to commencing treatment
only start treatment if no eye abnormality is present
review annually during treatment

20
Q

Hydroxychloroquinine interaction

A

do not take antacids 4 hours before or 4 hours after hydroxychloroquinine

21
Q

Anti-TNF-α antibodies

A

Adalimumab, Infliximab

22
Q

TNF-α receptor fusion protein

A

Etanercept

23
Q

Newer TNF-α therapies

A

Certolizumab pegol
Golimumab

24
Q

Dose of adalimumab

A

40mg every 2 weeks by SC injection
Can be used in combination with methotrexate or as monotherapy

25
Q

MOA of adalimumab

A

Binds to TNF-α, neutralises it

26
Q

Dose of infliximab

A
  • 3mg/kg week 0, week2, week 6 and then every 8 weeks thereafter
  • IV infusion or SC injection at home
  • Has to be prescribed with methotrexate (MTX reduces the formation of antibodies to infliximab)
27
Q

Adverse effects of infliximab

A

mild infusion reactions eg. headache, urticaria

28
Q

MOA of infliximab

A

binds to TNF-α, neutralising its activity

29
Q

MOA of etanercept

A

TNF-α fusion protein, which binds to TNF-α receptors, preventing the interaction of TNF-α with its receptors

30
Q

dose of etanercept

A

25mg twice weekly or 50mg once weekly
SC injection
can be used in combination with methotrexate or as monotherapy

31
Q

MOA of rituximab

A

Causes depletion of peripheral B cells, which play a role in RA
Anti-CD20

32
Q

dosage regimen of rituximab

A

single treatment course of two IV infusions two weeks apart
each dose lasts 6-12 months
do not repeat within 6 months
requires methotrexate concomitant Rx

33
Q

Rituximab adverse effects

A

infusion related reactions e.g. hypotension, fever, rash

34
Q

Abatacept MOA

A

Blocks full activation of T cells, preventing the release of pro-inflammatory cytokines

35
Q

Dose of Abatacept

A

Loading dose by IV infusion every 2 weeks for 3 doses
Followed by IV infusion every 4 weeks or SC injection every week
Dose based on body weight

36
Q

What is anakinra

A

IL-1 inhibitor
Daily SC injection
Risk of neutropenia
Not approved by NICE

37
Q

What is Tocilizumab

A

IL-6 inhibitor
Monthly IV infusion or weekly SC injection

38
Q

What are the risks upon starting anti-TNF-α treatment?

A
  • risk of opportunistic infection
  • Potential for reactivation of hep B infection, Tuberculosis
  • Signs of blood disorders
  • Surgery
  • Concerns re. Lympho-malignancies, melanoma
  • Injection site reactions
  • Effective contraception required
39
Q

What are anti-TNF-α treatments C/I in?

A
  • Patients with heart failure NYHA III
  • caution in any heart failure
  • Pregnancy

PF3012 (10 decks)

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