DMARDS

Question 1

What are DMARDS for?

Answer 1

RA

Question 2

What do you they aim to do?

Answer 2

For remission or low-disease activity

Question 3

Why is it started as monotherapy?

Answer 3

Risk of toxicity

Question 4

What are the 1st line options?

Answer 4

Methotrexate
Leflunomide
Sulfasalazine

Question 5

When is treatment started?

Answer 5

Within 3 moths of onset of persistent symptoms
= better outcomes when quicker to treat

Question 6

When is hydroxychloroquine considered 1st line?

Answer 6

Palindromic (occasional/flare ups)

Question 7

What is the dose given?

Answer 7

What the patient can tolerate

Question 8

Why is S/C methotrexate good?

Answer 8

More tolerated = often don’t feel sick
BUT PO 1st because it’s cheaper

Question 9

What can you consider to bride the gap for DMARDs to work?

Answer 9

Short course of glucocorticoids

Question 10

How is DAS-28 scored?

Answer 10

Count number of swollen + tender joints
Then a biochemical test = ERS/CRP
Patient global health = how the patient feels

Question 11

What are cs-DMARDS?

Answer 11

Classic synthetic
eg. methotrexate, leflunomide

Question 12

What are B-DMARDS?

Answer 12

Biologic
eg. Etanercept, adalimumab, rituximab

Question 13

What are Ts-DMARDS?

Answer 13

Targeted
eg. Tofacitinib

Question 14

What is the risk of DMARDS?

Answer 14

Alter immune system so become very susceptible to infections = sepsis

Question 15

When are you more at risk?

Answer 15

1st year of treatment = monitored frequently by the hospital

Question 16

What happens when you get an infection?

Answer 16

Steroid tablets = continue
DMARDS + biologics = STOP

Question 17

How does methotrexate work?

Answer 17

Anti-folate medication
= interferes with folate metabolism
= growing cells depend on reduced folate for DNA synthesis
= competitively inhibits dihydrofolate reductase

Question 18

How do you take methotrexate?

Answer 18

ONCE WEEKLY
In 3x tablets all at once
Also need folic acid but must be taken on different day

Question 19

Why do you need to monitor kidneys?

Answer 19

Renally excreted

Question 20

How do methotrexate work?

Answer 20

Dihydrofolate reductase inhibited
= dihydrofolate can’t be converted to tetrahydrofolate
= inhibits production of purines + DNA synthesis

Question 21

Methotrexate can cause foetus damage, so what must happen?

Answer 21

Contraception (men + women) during + 6 months after

Question 22

How is methotrexate monitored?

Answer 22

1-2 weekly then every 2-4months once stabilised

Question 23

What needs to be monitored with methotrexate?

Answer 23

Blood count
LFTs
U&Es

Question 24

What are signs of methotrexate toxicity?

Answer 24

Stomatitis
Immunosuppression = fever, cough, tachycardia, sweat, sore throat
Pulmonary toxicity = dry cough 3 weeks = chest x-ray
Hepatic (cirrhosis) = yellowing of skin/eyes. RUQ pain, urine (brown) + poo (pale)

Question 25

What is Sulfasalazine?

Answer 25

Prodrug - 5-ASA Anti-inflammatory effects

Question 26

What is the counselling for Sulfasalazine?

Answer 26

Signs of infection May discolour urine

Question 27

What are the side effects of Sulfasalazine?

Answer 27

GI intolerance Rashes Blood disorders Pneumonitis

Question 28

What is the dosing for Sulfasalazine?

Answer 28

Target dose 1g BD Gradual dose titration

Question 29

What does Leflunomide do?

Answer 29

Inhibit pyrimidine synthesis Prodrug

Question 30

What does Leflunomide interact with?

Answer 30

Clopidogrel Omeprazole Diazepam Cholestyramine

Question 31

What is the therapeutic effect of Leflunomide?

Answer 31

After 4-6 weeks

Question 32

When is Leflunomide a good option?

Answer 32

Methotrexate + Sulfasalazine cannot be used

Question 33

What are the adverse effects of Leflunomide?

Answer 33

Gi disturbances Weight loss Allergic reaction Reversible alopecia Hypertension

Question 34

What is Hydroxychloroquine?

Answer 34

Anti-malarial

Question 35

What are the side effects of Hydroxychloroquine?

Answer 35

GI Skin rash Vision disorders Headaches