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Clinical 2.0 winter > RA > Flashcards

RA Flashcards

1
Q

what is ra

A

chornic systemic autoimmune inflammatory disease
symmetric ad erosive polyarthritis
causes pain stiffness and fatigue
if not treated appropriatelu can result in joitn destruction and severe disability

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2
Q

some of the things happening in the joint

A

inflamed tendon
bone erosion
lots of inflammatory cells
thinning of cartilage

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3
Q

bref pathophys

A

form antibodies called rheumatoid factors
anticitrullinated protein antibody is produced
complex interaction of intra and extraellular molecules

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4
Q

onset

A

25-50yrs

cevelops rapidly

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5
Q

joints affected

A

hand

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6
Q

are there systemic symptoms present

A

yes

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7
Q

and notable lab changes or radiograph

A

ESR/CRP
RF/antiCCO
joint space narrowing
erosions (OA you see osteophytes)

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8
Q

differences in pain/stiffness between OA and RA

A

OA: worsened by activity, stiffness lasts <1hr in the morning
RA: pain decreased with activity, tenderness is common, stiffness in the morning lasts >1hr

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9
Q

difference in the radiograph between OA and RA

A

OA: there are osteophytes, the bones rubs together because of the thinned cartilage
RA: bone erosion, swollen inflammed synovial membane

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10
Q

risk factors

A 
genetic predisposition 
exposure to unknown environmental factors
age
gender
obesity
smoking
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11
Q

what is early RA

A

symptoms of less than 3 months duration

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12
Q

what is established RA

A

have symptoms due to inflammation or joint dmaage

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13
Q

why is the time of diagnosis crucial

A

joint damage begins within 2 years of symptoms

early diagnosis is within 6months of the onset of joint symptoms

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14
Q

diagnosing criteria - joint involvement

A 
one medium to large joint = 0
2-10 medium to large joints =1
1-3 small joints = 2
four to ten small joints = 3
more than 10 joints (at least one small) = 5
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15
Q

diagnosing criteria - serology

A

negative RF and negative anti CCP = 0
low + RF and low + antiCCP = 2
high + RF or high + anti CCP = 3

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16
Q

diagnosing criteria - acute phase reactants

A

normal CRP and normal ESR = 0

abnormal CRP or ESR = 1

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17
Q

diagnosing criteria - duration of symptoms

A

<6week = 0

6 weeks or more = 1

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18
Q

what are the criteria for diagnosing RA

A

must have 6 or more points

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19
Q

symptoms of RA

A 
joint pain and stiffness >6weeks 
stiffness lasts >1hr
fatigue, weaknes,, fever
muscle pain and afternoon fatigue 
joint deformity later
symmetrical joitn involvement 
tenderness warmth and swelling over joints
nodules
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20
Q

challenges to lab tests

A

normal >30% of the time

RF and anti CCP not detectable in everyone

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21
Q

compare RF + anti CCP to CRP + ESR

A

RF and anti CCP + patients have a worse prognosis

CRP and ESR are not specific to rheumatoid arthritis

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22
Q

other potential diagnostic tests

A

joitn aspiration fluid - increased WBC without infection, crystals
joint radiographs - periarticular osteo, joint space narrowing, erosions

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23
Q

goals of therapy*

A

control symptoms and halt progression
50% improvement in 3 months and clinical remission

alleviate pain, stiffness, fatigue
maintain physical function and work capacity

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24
Q

what does DMARD stand for

A

non biologic diseas emodifying antirheumatic drugs

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25
Q

role of methotrexate

A

most effective

first line for all levels of disease activity

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26
Q

mtx onset

A

4-6 weeks

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27
Q

mtx safety

A

best side effect to efficacy ratio
stomatitis, nausea, diarrhea, alopecia - give folic acid
avoid sig alcohol
teratogenic

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28
Q

when would sq mtx be recommended

A

GI intolerant

lose benefit over time

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29
Q

mtx lab monitoring

A

CBC, platelets, LFT, albumin, scr, alkaline phosphatse (same as lefluonomide) check every 4 weeks for 3 months then every 8 weeks for 3 months then every 12 weeks
baseling screen for HCV,HBV,HIV in high risk
baseline chest xray in case pulmonary infiltrates develop

30
Q

leflunomide use

A

allternative to mtx

equally effective

31
Q

leflunomide safety

A

diarrhea, alopecia, rash, headache, hepatotoxicity
teratogenic
long half life

32
Q

hydroxychloroquine us

A

monotherpay only in mild disease usualy used in combo

least effective onset 2-6months

33
Q

safety of hydroxychloroquine

A 
best tolerated 
rash, craamps, diarrhea, headache 
blurred vision or difficulty seeing at night reversible upon discontinuation 
ocular toxicity 
hemolysis in G6PD deficiency
34
Q

hydroxychloroquine lab monitoring

A

baseline CBC, platelets, ALT, alkaline phosphate, albumin, scr
complete ophthalmologic exam baselin and annually for high risk (>60, retinal disease, liver disease), every 5 years for low risk

35
Q

mtx dose

A

titrated to max dose 25mg per week

36
Q

lefluonomide dosing

A

10-20mg daily

37
Q

hydroxychloroquine dosing

A

200 bid after 1-2 months may decrease to 200 od

38
Q

sulfasalazine use

A

2nd line is contraindicated to mtx
1st line option when used in combo
less active antiRA drug than mtx so avoid as mono treatment in poor prognosis

39
Q

sulfasalazine onset

A

2-3 months

40
Q

safety of sulfasalazine

A

dose limiting GI effects - nausea, anorexia, diarrhea so titrate slowly
rare hepatitis, leukopenia, agranulocytosis
hemolysis in G6PD deficiency

41
Q

sulfasalazine monitoring

A

CBC, paltelet, alk phos, albumin, scr

42
Q

sulfasalazine CI

A

sulfa allergy

43
Q

sulfasalazine dosing

A

500 BID then 1 g BID

44
Q

tofacitinib MOA

A

JAK inhibitor - decreases signalling by a number of cytokine and growth factor receptors

45
Q

use of tofacitinib

A

monotherapy or with mtx

role yet to be determined may help in patients with inadequate responses

46
Q

safety of tofacitinib

A

black box for serious infections
not approved for use with biologics or other stronger immunosuppresants
abnormalities in liver enzymes and lipids

47
Q

monitoring of RA

A

disease activity every 1-3 months , every 6-12 once goals met
add or change dmards every 3-6months
titrating doses can occur rapidly every 1-3months
radiograph of hands and feet every year or longer
remission or low disease activity
CDAI assessment tool

48
Q

role of oral glucocorticoids

A

short term use at initial diagnosis for symptom control or during flares
more effective than nsaids

49
Q

dosing or oral glucocorticoids

A

lowest effect dose <10mg daily

50
Q

safety of glucocorticoids

A

hyperglycemia and CNS
insomnia, GI, impaired wound healing, irritability
long term use: osteoporosis, glaucoma, weight gain, fluid retenion, increased infection risk

51
Q

steroid injections

A

intraarticular steroid can be used when 1 or a few joints are excessively swollen compared to other affected joints - every 3mont no more than 3x a year
IM of long acting depot available for ppl with poor adherance

52
Q

glucocorticoid monitoring

A

hyperglycemia - diabetes patients daily, every 3 months in others
CNS effects
BP and lipids every 3 months

53
Q

3 possible mechanisms of biologics

A

interfere with cytokine function and growth factors
inhibit the second signal required for t cell activation
deplete B cell s

54
Q

anti-tnf agents

A

infliximab
etanercept
adalimumab
certolizumab pegol

55
Q

biologics that inhibit t cell activation

A

abatacept
tocilizumab
anakinra and canakinumab

56
Q

biologics that deplete b cells

A

rituximab

57
Q

role of biologics

A

50% of patients have an inadequate response to dmards so can try these
consider after 3-6months of 2 dmards

58
Q

biologics onset

A

1-4 weeks

59
Q

biologics have improved efficacy when used with

A

mtx

never use infliximab as monotherapy

60
Q

efficacy of TNF agents

A

quickest onset
largest best symptoms and joint outcomes
use with mtx

61
Q

coverage of biologics

A

part 3 eds

62
Q

when should/can biologics be used in mtx naive patients

A

high disease activity
+ lab tests
bone erosions
large number of affected joints

63
Q

safety of TNF agents

A

serious infetions
must be withheld during systemic infection - monitor for
TB screening mandatory
neoplasm??
avoid in recent history of malignancy
worsening new onset HF
patients with demyelinating disorder should not use it

64
Q

how to discontinue therapy

A

risk for disease flares upon discontinuation
remission must be stable for several months
1. remove nsaids/BC
2. remove least active drugs
3. want mtx indefinitely

65
Q

discontinuing therapy when on a biologic

A
  1. remove nsaid/GC
  2. watch for maintenance of remission
  3. try expanding interval bt doses ro reducing the dose and eventually discontinuing
66
Q

non pharms

A 
rest
exercise
PT, OT
nutrition and dietary therapy 
bone protection 
CV risk reduction -quit smoking, exercise 
vaccinations
67
Q

mtx dosing

A

max dose of 25mg per week

NOT DAILY

68
Q

how to reduce side effects of mtx

A

give folic acid 5mg weekly on the day following mtx

69
Q

addressing vaccinations before starting biologics

A

cant give live vaccines so make sure their vaccinations are up to date before starting

70
Q

anti TNF agents SE and CI

A

SE:injection site reactions, TB, opportunistic infections, malignancy, exacerbate CHF
CI:bacterial or viral infections (stop in illness), latent TB

Clinical 2.0 winter (28 decks)

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