OA, RA

Question 1

1st line for osteomyelitis empiric

Answer 1

Vanc + cefepime/ ceftriaxone

Question 2

targets of RA treatment

Answer 2

Targets immune components involved: T lymphocytes, cytokines, B lymphocytes, kinases

Question 3

do NSAIDs treat underlying dz?

Answer 3

no

Question 4

MOA: Inhibits phospholipase A2. Inhibits cytokines and inflammatory mediators

Answer 4

“Prednisone
Methylprednisolone”

Question 5

steroids for RA

Answer 5

“Prednisone
Methylprednisolone”

Question 6

glucocorticoid interaction

Answer 6

NSAIDs (also thin stomach lining – use caution)

Question 7

which class? Do not initiate during active infx. Consult rheumatology about holding during severe infx, surgery.

Answer 7

DMARDs

Question 8

considerations before starting DMARDs

Answer 8

All patients must be screened for Hep B, Hep C AND latent TB before starting DMARDs. Give any needed live vaccines before initiating DMARDs

Question 9

MTX dose frequency

Answer 9

1x/wk

Question 10

MOA: Inhibitor of dihyrofolate reductase enzyme which is essential for DNA replication (making new cells quickly!)

Answer 10

MTX

Question 11

non-bio DMARDs for RA

Answer 11

Methotrexate PO, SC, IM, dosed once weekly
Hydroxychloroquine (Plaquenil)
Sulfasalzine
Leflunomide (Arava®)”

Question 12

1st line for RA

Answer 12

MTX

Question 13

MTX contras

Answer 13

pregnancy (BBW), lactation, severe liver dz (BBW), use of Bactrim. Avoid in renal impairment, skin cancer

Question 14

AEs: rash, liver/lung/bone marrow toxicity (BBW), folic acid deficiency, n/v/d, gastric ulcer, anorexia, pulm fibrosis, pneumonitis, anemia, leukopenia, thrombocytopenia, pancytopenia, opportunistic infx (BBW), alopecia.

Answer 14

MTX

Question 15

MTX interactions

Answer 15

Bactrim, probenecid, NSAIDs (BBW)

Question 16

pts must take what if on MTX

Answer 16

must take folate 1mg QD

Question 17

AEs: Nausea, vomiting, diarrhea (less than MTX), QTc prolongation. Retinal damage and vision changes (due to highly protein binding of ocular tissue)

Answer 17

Hydroxychloroquine (Plaquenil)

Question 18

monitoring for Hydroxychloroquine (Plaquenil)

Answer 18

MUST HAVE A BASELINE EYE EXAM AND THEN ANNUALLY ON THIS MEDICATION.

Question 19

Sulfasalzine
contras

Answer 19

sulfa allergy, hepatic dysfunction

Question 20

AEs: HA, n/v, dyspepsia, fever, rash, photosensitivity, oligospermia. Rare: leukopenia, aplastic/hemolytic anemia, agranulocytosis, pancreatitis, hepatitis

Answer 20

sulfasalazine

Question 21

pt counseling for sulfasalazine

Answer 21

men must stop 3 mo before trying to conceive

Question 22

monitoring for sulfasalazine

Answer 22

Monitor CBC and LFTs before starting therapy then routinely Q3 mo

Question 23

on the mitochondrial level – inhibits RNA and DNA synthesis. Decreases T and B cell proliferation

Answer 23

”

Leflunomide (Arava®)”

Question 24

”

Leflunomide (Arava®)”
contras

Answer 24

pregnancy, lactation

Question 25

AEs: Nausea, diarrhea, abdominal pain, HTN, HA. BBW: Hepatotoxicity. When combined with MTX, there is a dramatic rise in hepatotoxicity

Answer 25

" Leflunomide (Arava®)"

Question 26

Leflunomide (Arava®)" monitoring

Answer 26

LFTs

Question 27

main types of biologic DMARDs for RA

Answer 27

TNF-alpha inhibitors, IL-1 and IL-6 antagonists

Question 28

5 TNF-alpha inhibitors to treat RA

Answer 28

Etanercept (Enbrel®) Infliximab (Remicade®) IV only Adalimumab (Humira®) Golimumab (Simponi®) Certolizumab (Cimzia®)

Question 29

indications: maintaining remission in CD, UC, RA, psoriasis and psoriatic arthritis, hidradenitis suppuritiva, juvenile RA, ankylosing spondylitis

Answer 29

TNF-alpha inhibitors

Question 30

AEs: "HA, sinusitis, URI, injection site reaction. BBW: Increases risk of serious infections (possibly fatal). Worse if also on MTX or steroids. risk for listeria, invasive fungal dz. BBW: lymphoma / skin cancer in kids"

Answer 30

TNF-alpha inhibitors

Question 31

pt counseling for TNF-alpha inhibitors

Answer 31

rotate injection sites, apply cold pack after administration and 1% hydrocortisone cream. Must get periodic skin exams

Question 32

Anakinra (Kineret®) class

Answer 32

Interleukin-1 Antagonist

Question 33

Interleukin-1 Antagonist indications

Answer 33

Adults who have failed non-biologic DMARDs. Systemic RA and continued disease activity after trial of NSAIDs and glucocorticoids. Not FDA-approved for JIA. alone or in combo w/ MTX

Question 34

AEs: Injection site reaction. Increased risk of infection (rare; URI). Neutropenia. Increased risk of malignancy

Answer 34

Interleukin-1 Antagonist: Anakinra (Kineret®)

Question 35

monitoring for Interleukin-1 Antagonist: Anakinra (Kineret®)

Answer 35

neutrophils

Question 36

AEs: Rash. BBW: Fatal infusion related reactions, Mucocutaneous reactions (SJS, TEN)

Answer 36

Rituximab (Rituxan®)

Question 37

class: Tocilizumab (Actemra®) Sarilumab (Kevzara®)

Answer 37

IL-6 Antagonist:

Question 38

class: "only PO options Tofacitinib (Xeljanz®) Tofacitinib extended release (Xeljanz XR®) Upadacitinib (Rinvoq®)"

Answer 38

Janus-Kinase Inhibitors

Question 39

contras: Janus-Kinase Inhibitors

Answer 39

Hx of VTE/DVT/PE

Question 40

AEs: GI perforation. Esophageal candidiasis. Risk of skin cancer and lymphomas. Altered lipid profile. increases risk of herpes zoster (so must get vax). BBW: serious infx (URI, UTI most common), malignancies, thrombosis

Answer 40

Janus-Kinase Inhibitors

Question 41

Janus-Kinase Inhibitors interactions

Answer 41

biologic DMARD (due to increased immunosuppression and risk of infection). CYP3A4

Question 42

Janus-Kinase Inhibitors monitoring

Answer 42

lipid profile

Question 43

1st line for mod-severe OA

Answer 43

NSAIDs

Question 44

MOA: induces release of substance P (primary chemomediator of pain impulses from peripheral sensory neurons to CNS)

Answer 44

"topical capsaicin OTC apply 3-4x/d"

Question 45

AEs: "application site edema and pain Decreased sensory function (patch) PAIN if gets into eyes or genitals"

Answer 45

"topical capsaicin OTC apply 3-4x/d"

Question 46

pt counseling for capsaicin

Answer 46

wash hands well after application or use gloves

Question 47

intra-articular Corticosteroids for OA

Answer 47

(methylprednisolone; triamcinolone)

Question 48

indications: 2nd line to PO and topical agents for pain. Does NOT reverse dz progression, only relieves symptoms

Answer 48

corticosteroid injections