Flashcards in Autoimmune Dx - Rheumatoid Arthritis Deck (87):
What's rheumatoid arthritis?
RA causes inflammation of the joints and other organs in the body, including the kidneys, eyes, heat and lungs
Chronic, symmetrical, systemic and progressive dx
Where does RA typically first presents?
Hands and feet
What's the results of the inflammation that leads to cartilage and bone destruction in RA?
Classic sx of RA
Bone deformity (eventually)
List the diagnostic criteria for RA
Morning stiffness around joints lasting > 1 hr
Soft tissue swelling (arthritis) in 3 or more joints
Swelling (arthritis) of hand, foot or wrist joints
Positive serum rheumatoid factor (about 70% of pts)
Radiograph in erosions or peri articular osteopenia in hand or wrist joints
Howz diagnosis of RA made using the diagnosis criteria?
Criteria 1-4 must be present for >= 6 weeks
4 or more criteria must be present
Describe the articular manifestations (affecting the joints) of RA?
Almost always Polyarticular and Symmetrical
Which synovial joint is most often involved in RA?
Finger joints of the hand
List the typical articular sx of RA
Decreased range of motion
What sx is the clue of RA and differentiates RA from Osteoarthritis (OA)
Morning stiffness that may last for up to 2 hrs is a clue for RA (OA doesn't cause prolonged stiffness)
List non-pharmacologic tx of RA?
Surgical intervention (eg. Joint replacement)
What's the goal of pharmacologic tx of RA?
Goal is to have pt on Disease-Modifying-Antirheumatic Drug (DMARD) within 3 months of diagnosis
T/F? Pts may require bridging therapy (short-term) or in some cases long-term use of anti-inflammatory medications such as NSAIDs or steroids.
List agents used for pain and inflammation
COX-2 selective inhibitor
List NSAID used as agent used for pain and inflammation
Ibuprofen (Motrin, advil)
List COX-2 selective inhibitor used as agent used for pain and inflammation
List steroids used as agent used for pain and inflammation in RA
Prednisone (Prednisone intensol -solution; Rayos - delayed release tablet)
What's the indication of steroids for RA?
Indicated for acute inflammation/pain and as bridge therapy while waiting for DMARDs to take effect
At what dose is steroid used when used chronically in RA?
<= 10 mg daily
List DMARDs used for RA
Methotrexate (Rheumatrex, Trexail)
What's the brand name of methotrexate? (DMARD)
What's the brand name of hydroxychloroquine? (DMARD)
How's methotrexate (Rheumatrex, Trexail) used in RA?
Low weekly doses are used for RA (weekly doses can be split into smaller doses taken over 12-36 hours
Should methotrexate (Rheumatrex/ Trexail) be dosed daily in RA?
What's the SE of methotrexate (Rheumatrex/ Trexail)?
What's the monitoring parameters for methotrexate (Rheumatrex/ Trexail)?
LFTs and SCr (at baseline and every 2-4 weeks for 1st 3 months)
Chest x-ray, hep B & C at baseline
Can methotrexate (Rheumatrex/ Trexail) be used during pregnancy?
Pregnancy category X
What's usually given to decrease the SE of methotrexate (Rheumatrex/ Trexail)?
Folic acid 5mg PO weekly given on the day following methotrexate admin
Which methotrexate med was recently approved? Unique use?
Allows patients to self-admin methotrexate SC once weekly using an auto-injector
What's the SE of hydroxychloroquine (Plaquenil)? (DMARD)
Pigmentation of skin and hair
Vision changes (rare)
What's the contraindication to sulfasalazine use?
Pts with sulfa or salicylate allergy
GI or GU obstruction
SE of sulfasalazine?
GI upset (N/V/D)
Rash (all > 10%)
Effect of sulfasalazine on skin/urine?
Can cause yellow-orange coloration of skin/urine
Effect of sulfasalazine on folate absorption?
Impairs folate absorption
May give 1mg/day folate supplement
How do u prevent Crystalluria from sulfasalazine use?
Take sulfasalazine with food and 8oz of water
What's the main SE of Minocycline use (DMARD)?
What's the black box warning associated with Leflunomide (Arava) use?
Women of child-bearing age (pregnancy should be excluded before Leflunomide is started)
What's the main SE of Leflunomide (Arava) (DMARD)?
How do u ascertain woman is not pregnant while on Leflunomide (Arava)?
Must have negative pregnancy test b4 starting medication + use 2 forms of birth control
If a woman wants to get pregnant while on Leflunomide (Arava) (DMARD)?
Must wait 2 years after discontinuing Leflunomide (Arava)
Give cholestyramine to eliminate Leflunomide (Arava)
What must Tofacitinib (Xeljanz) (DMARD) not be used with ?
Don't use with biologic DMARDs or potent immunosuppressants
What should methotrexate (Rheumatrex/ Trexail) not be used with? Why?
Methotrexate should not be taken with alcohol
May increase risk of liver toxicity
Howz methotrexate dosed?
Once weekly (some pts divide the weekly dose in half and take it over 2 days)
Don't use methotrexate daily or double up doses
Should methotrexate (Rheumatrex/ Trexail) be used during pregnancy?
No. It's category X
If you're pregnant or have a chance of becoming pregnant, u should not use methotrexate
List the biologic agents used in RA?
Etanercept (Enbrel, Enbrel SureClick)
Adalimumab (Humira, Humira Pen)
Certolizumab (Cimzia, Cimzia Prefilled)
Golimumab (Simponi, Spimponi Aria)
MOA of biologic agents in RA?
Tumor Necrosis Factor (TNF-alpha) inhibitors (Anti-TNF biologics)
What's the brand name of Etanercept?(biologic agent used in RA)
What's the brand name of Adalimumab?(biologic agent used in RA)
What's the brand name of Infliximab?(biologic agent used in RA)
What's the brand name of Golimumab?(biologic agent used in RA)
List the biologic agents that must only be given in combo with methotrexate in RA
Golimumab (Simponi, Simponi Aria)
List infusion rxns from the use of Infliximab (Remicade) (biologic agent used in RA )
Pruritus (may benefit with pre-tx with acetaminophen, antihistamine, steroids)
List delayed hypersensitivity rxns from the use of Infliximab (Remicade) (biologic agent used in RA )
3 - 10 days after admin
Fever, rash, myalgia, HA, sore throat
What's the black box warning associated with biologic agents used in RA?
Serious infections (some fatal)
D/c tx of pt develops a severe inf; lymphomas and other malignancies; reactivation of latent TB or new inf; perform test for latent TB prior to starting therapy
List the main warnings associated with biologic agents used in RA
What's the SE of biologic agents used in RA?
Infections and injection site rxns (redness, rash, swelling, itching or bruising)
What's the monitoring parameters for biologic agents used in RA?
TB test (prior to admin and annually)
S/sx of infections
HBV (prior to initiation)
Which tests need to be done PRIOR to starting biologic agents used in RA?
How are biologic agents used in RA stored? Exception?
Etanercept (Enbrel, Enbrel SureClick) can be stored at room temp for 14 days
What's the first line in RA? How are biologic agents used
Methotrexate (Rheumatrex/ Trexail) is first-line
Biologic agents are add-on therapy
Biologic agents may be used as 1st line if initial presentation is severe
Can u use biologic agents concurrently?
No! Don't use more than 1 biologic agent concurrently
Can live vaccines be given with biologic agents used in RA?
No! Don't use live vaccines with biologic agents
What vaccines is recommended that RA pts receive?
Herpes zoster (shingles) (live vaccine)
Remember don't give live vaccine if pts already receiving biologic agents
List other biologics (Non-TNF Biologics) used in RA?
Brand name of Rituximab (other biologics (Non-TNF Biologics) used in RA)?
Brand name of Abatacept (other biologics (Non-TNF Biologics) used in RA)?
Brand name of Tocilizumab (other biologics (Non-TNF Biologics) used in RA)?
What's the main warning for use of Rituximab (Rituxan); Anakinra; Abatacept (Orencia); Tocilizumab (Actemra)?
Screen for latent TB
MOA of rituximab (Rituxan)?
Depletes CD20 B cells
B cells are believed to have a role in RA development and progression
Main SE of Tocilizumab (Actemra)?
Whats the site of injection of all immune modulators used in RA?
Upper middle thigh OR Abdomen
Since all SC biologics are to be refrigerated (except Etanercept (Enbrel)), how should they be used?
Wait until drug is at room temp before injecting
All the SC biologics can be warmed by holding in hand or slowly rubbing together btw palms, except?
Golimumab (Simponi, Simponi Aria)
When's MedGuide given with biologics?
First time you get med and with each refill
Which vaccine can pts on biologics continue to get?
Annual influenza shot (but not nasal mist vaccine)
Biologics block immune system; effect of this?
It may lower ability to fight infections
If a pt has been exposed to TB, but don't have active dx (latent TB) what can be done to prevent TB during therapy?
Pt will need to start taking dp daily TB tx BEFORE staring therapy
What organ may biologics damage?
Call healthcare provider immediately if u have any sx:
Feel tired, skin or eyes look yellow, poor appetite or vomiting, pain on right side of stomach (abdomen)
Injection site of biologic agents?
Skin of thigh
How often should Etanercept (Enbrel) be given?
How often should Adalimumab (Humira) be given?
Q 2 weeks
How often should Certolizumab be given?
Q 4 weeks
How often should Golimumab (Simponi) be given?
How long does it take for biologics to warm up?
15 - 30 mins
Should biologics be shaken before use?
Don't shake medicine
T/F? If particles or discoloration is present, don't use medicine?