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Therapeutics 1 > Rheumatoid Arthritis > Flashcards

Rheumatoid Arthritis Flashcards

1
Q

Describe the basic pathophysiology of RA.

A

infiltration of synovium by immune cells that release cytokines that proliferate damaging immune response in joint

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2
Q

Define pannus.

A

A pannus is a proliferating, inflamed joint that eventually invades/destroys cartilage and bone.

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3
Q

Diagnosis of RA is determined by a score of ___ points or more in what 4 diagnostic criteria?

A

6 points or more

1) joint involvement
(2) serology
(3) duration of symptoms
(4) acute phase reactants (CRP and ESR

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4
Q

5 most common joints affected by RA

A

hips, knees, ankles, elbows, shoulders

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5
Q

Name some extra-articular manifestations of RA.

A

(1) rheumatoid nodules
(2) ocular
(3) cardiac
(4) pulmonary
(5) vasculitis
(6) Felty’s syndrome (splenalomegaly)

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6
Q

Which two serologic measures are most specific to RA and are most often present in someone with the disease?

A

anti-CCP and RF

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7
Q

What is joint aspiration?

A

turbidity of synovial fluid

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8
Q

What kinds of characteristics generally indicate a poor prognosis in somebody with RA?

A

low socioeconomic status, poor education, psychosocial stress, extra-articular manifestations, elevated CRP/ESR, high RF titers, erosions observed in x-ray, present in >20 joints

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9
Q

Contrast RA from OA.

A

see table in notes: differentiating criteria include age of onset, disease distribution, ESR, inflammation level, morning stiffness, osteophyte/pannus presentation, swelling, and typical presentation

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10
Q

Identify non-pharmacological treatment options for RA.

A

(1) rest
(2) splints/prosthetics (for deformities)
(3) PT/OT
(4) emotional support
(5) weight reduction
(6) surgery
(7) pt. education

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11
Q

What is the role of NSAIDs/COX-2 inhibitors in RA pharmacotherapy?

A

adjunct therapy: only help with pain, but do not alter disease progression, therefore should not be used as monotherapy

use anti-inflammatory doses (generally 2x analgesic doses)

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12
Q

dosing of Celebrex (celecoxib)

A

100-200 mg PO BID

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13
Q

Patients with what allergy should be carefully monitored with Celebrex use?

A

those with a sulfa allergy

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14
Q

What are the 4 different ways that corticosteroids can be used in RA patients?

A

(1) burst therapy: to treat an acute flare-up
(2) bridge therapy: in combination with a DMARD while you wait for its onset
(3) long term low dose: for advanced disease
(4) for patients with extra-articular manifestations

note: NOT as monotherapy

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15
Q

Using prednisone as an example, what would be considered a short term, low dose regimen of oral CS?

A

< 10 mg QD for less than 3 months

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16
Q

What is the max recommendation of a high daily dose of prednisone?

A

60 mg QD

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17
Q

adverse effects of oral CS

A

(1) hyperglycemia
(2) irritability
(3) elevated BP
(4) gastritis

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18
Q

monitoring parameters for oral CS use

A

BP and glucose ever 3-6 months

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19
Q

Which class of drugs can be used as monotherapy in RA due to their ability to decrease and prevent joint damage and preserve joint integrity?

A

DMARDs

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20
Q

What is the DMARD of choice in RA patients? How is it dosed?

A

Rheumatrex (methotrexate)

initial dose is 7.5 mg weekly, but can be increased to 15 mg weekly

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21
Q

What supplementation is recommended with methotrexate use?

A

folic acid (MOA of drug is inhibition of dihydrofolic acid reductase, depleting folate)

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22
Q

Which two DMARDs cannot be used in pregnancy?

A

Sulfasalazine, Methotrexate

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23
Q

monitoring parameters for MTX use

A

CBC, SCr, LFT

frequency depends on duration of therapy:
<3 months: every 2-4 weeks
3-6 months: every 8-12 weeks
>6 months: every 12 weeks

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24
Q

adverse effects of methotrexate

A

hepatic issues, hematologic, gastrointestinal, dermatologic, ocular, teratogenic

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25
Q

contraindications to methotrexate therapy

A

pregnancy, immunodeficiency, pre-existing blood dyscrasia, chronic liver disease

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26
Q

leflunomide dosing

A

100 mg PO QD for 3 days, then 20 mg QD

can reduce to 10 mg QD if adverse effects

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27
Q

leflunomide time to onset

A

1 month

28
Q

Use caution with leflunomide if:

A

patient is also using methotrexate (increased risk of liver toxicity)

29
Q

leflunomide adverse effects

A

diarrhea, teratogenic, rash, alopecia, increased LFTs

30
Q

Which two DMARDs are prodrugs?

A

leflunomide and sulfsasalazine

31
Q

leflunomide monitoring parameters

A

CBC, SCr, LFTs every
< 3 months: every 2-4 weeks
3-6 months: every 8-12 weeks
> 6 months: every 12 weeks

32
Q

sulfasalazine dosing

A

500 mg PO QD up to 1 g 2-3x QD

33
Q

sulfasalazine time to onset

A

1-2 months

34
Q

sulfasalazine adverse effects

A

dermatologic, gastrointestinal, hematologic

35
Q

sulfasalazine monitoring

A

CBC, SCr, LFTs
< 3 months: every 2-4 weeks
3-6 months: every 8-12 weeks
> 6 months: every 12 weeks

36
Q

Use caution with sulfasalazine in patients who:

A

have a sulfa allergy

37
Q

Hydroxychloroquine (Plaquenil) dosing

A

200 mg PO BID

38
Q

Hydroxychloroquine time to onset

A

2-4 months

39
Q

Plaquenil adverse events

A

ocular, gastrointestinal, dermatologic

40
Q

Plaquenil monitoring

A

advantage: no extensive regular lab work required, just an ocular exam ever 6-12 months

41
Q

What are some of the risks associated with BRM therapy?

A

(1) can exacerbate existing heart failure
(2) increased susceptibility to infections, particularly TB
(3) demyelinating disorders
(4) malignancies
(5) no concurrent vaccine treatment

42
Q

adverse effects of BRM therapy

A

(1) injection site reactions
(2) headache and rash
(3) CHF exacerbations
(4) risk of malignancy and demyelinating disease

43
Q

Etanercept (Enbrel) dosing

A

50 mg SC weekly

44
Q

These anti TNFs do not require lab monitoring.

A

Enbrel, Remicade, Humira, Cimzia

45
Q

This anti TNF does require lab monitoring (which labs?)

A

Simponi (Golimumab)

CBC with platelets, LFTs

46
Q

Which anti TNF agents are only indicated for RA in combination with MTX?

A

Remicade, Golimumab

47
Q

What testing is recommended before initiation of an anti-TNF agent?

A

TB skin test

48
Q

Which anti-TNF agents can be used either alone or in combination with a non-BRM DMARD?

A

Enbrel, Humira, Cimzia

49
Q

Anakinra (Kineret) MOA

A

IL-1 receptor antagonist

50
Q

Anakinra (Kineret) indication

A

for patients with moderate to severe RA with an inadequate response to one or more DMARD

can be used alone or in combination with DMARDs other than BRMs

51
Q

Humira dosing

A

40 mg SC every other week

52
Q

Simponi dosing

A

50 mg SC monthly

53
Q

Infliximab dosing

A

3 mg/kg at 0, 2, 6 weeks, then every 8 weeks

54
Q

Certolizumab dosing

A

2 200 mg SC injections at 0, 2, and 4 weeks, then either:

(1) 200 mg SC every 2 weeks
(2) 400 mg SC every 4 weeks

55
Q

Anakinra dosing (normal and CrCl < 30 mL/min)

A

100 mg SC QD

if CrCl < 30 mL/min, 100 mg SC QOD

56
Q

Kineret should not be used with what other class of drugs?

A

anti-TNF or T-cell costimulation modifier (abatecept)

57
Q

How is Kineret dosed?

A

by weight, but all doses are given IV over 30 minutes

doses given at 0, 2, and 4 weeks, then every 4 weeks thereafter

58
Q

Anakinra adverse effects

A

HA, nausea, upper respiratory issues, infusion rxns, serious infection, malignancy

59
Q

Anakinra precautions/warnings

A

not for use with with TNF antagonist or IL-1 antagonist
increased risk for infections (caution in COPD patients)
no concurrent live vaccination administration

60
Q

Which BRM is an IL-6 receptor antagonist?

A

Tocilizumab (Actemra)

61
Q

Actemra dosing

A

4 mg/kg IV over 1 hour

62
Q

Actemra monitoring parameters

A

neutrophil count, platelet count, LFTs all every 4-8 weeks

lipid panel after 4-8 weeks, then every 6 months thereafter

63
Q

Tocilizumab adverse effects

A

(1) infections
(2) liver toxicity
(3) thrombocytopenia
(4) neutropenia
(5) lipid abnormalities
(6) intestinal perforations

64
Q

Rituximab is indicated for use in combination with ____

A

methotrexate

65
Q

Rituximab dosing

A

two infusions separated by two weeks, can repeat dosing in 6 months

66
Q

Rituximab is indicated for use in which type of patients?

A

moderate to severe RA in patients with inadequate response to one or more TNF antagonist

67
Q

What are the three most common combinations of therapy in RA treatment?

A

(1) MTX + HCQ/SSZ (or all three)
(2) MTX + leflunomide
(3) MTX + BRM

Therapeutics 1 (24 decks)

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