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PHM 702: Pulm and ToXXX > OA, RA, PSA: i don't want to study anymore > Flashcards

OA, RA, PSA: i don't want to study anymore Flashcards

1
Q

Difference between OA and RA: age

A
  • OA: in pts > 50
  • RA: variable age (most commonly in 50+, juvenille RA occurs in pts < 16)
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2
Q

Difference between OA and RA: onset

A
  • OA: gradula onset
  • RA: variable onset
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2
Q

Difference between OA and RA: joint s/s

A
  • OA: localized s/s that usually only last 30 min and occur with joint use
  • RA: general malaise/prodromal s/s tht can last over an hour and are present with use and at rest
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2
Q

Difference between OA and RA: joint involvement

A
  • OA: larger, weight-bearing joints; unilateral involvement
  • RA: b/l small jonts of hands, wrists and feet
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3
Q

Difference between OA and RA: auto-Ab involvement

A
  • OA: no auto-Ab involement
  • RA: auto-Ab present
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4
Q

OA

A

failure of the jont and surrounding tissues

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5
Q

OA signs

not syptoms

A
  • usualy just one joint or oligoaricular (asymmetrical joints)
  • local tenderness
  • limted motion with passive/active movement
  • bone proliferation or synovitis
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6
Q

OA symptoms

not signs

A
  • pain
  • deep aching
  • stiffnes in affected joint
  • usually < 30 min duration
  • often related to weather
  • limited joint movement
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7
Q

OA goals of dx

A
  • distinguish between primary and secondary
    • Primariy: no identifiable cause; idiopathic
    • Secondary: associated with known cause - inflammation, trauma, metabolic/endocrine disorders, or congenital factors
  • clarify which joints are involved and seveirty
  • assess response to prior therapies
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8
Q

OA risk factors

A
  • obesity - esp knees
  • sex
    • More common in men if <45 y/o
    • More common in women if >45 y/o
  • occupation
    • certain sports
  • hx of joint injury or surgury
  • genetics: black men
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9
Q

Hand OA: non-pharm

A

strongly recommended
- exercise
- CMC orthosis
conditionally
- Heat, therapeutic cooling
- CBT
- acupuncture
- kinesiotaping
- other hand orthoses
- paraffin

don’t forget pt educaton

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10
Q

Knee OA: non-pharm

A

strongly recommended
- exercise
- wt losss
- tai chi
- cane
- knee brace
conditionally
- Heat, therapeutic cooling
- CBT
- acupuncture
- kinesiotaping
- balance training
- PF knee brace
- yoga
- RFA

don’t forget pt education

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11
Q

Hip OA: non-pharm

A

strongly recommended
- exercise
- wt loss
- taichi
- cane
conditionally
- Heat, therapeutic cooling
- CBT
- acupuncture
- balance training

don’t forget non-pharm

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12
Q

Hand OA: pharm

A

strongly recommended
- PO NSAIDs
conditionally
- Topical NSAIDs: diclofenac 2gm QID
- I-A steroid
- APAP
- Tramadol
- Duloxetine
- Chondroitin (NOT glucosamine, recommended against)

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13
Q

Knee OA: pharm

A

strongly recommended
- PO NSAIDs
- Topical NSAIDs: diclofenac 4gm QID
- I-A steroid
conditionally
- APAP
- Tramadol
- Duloxetine
- Topical capsaicin

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14
Q

Hip OA: pharm

A

strongly recommended
- PO NSAIDs
- I-A steroid with US guidance
conditionally
- APAP
- Tramadol
- Duloxetine

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15
Q

Which NSAIDs have a lower risk of GI tox and lower risk of plt inhibition

A
  • celebrex
  • valdecoxib
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16
Q

I-A steroid onset and duration and admin OA

A
  • Give Q3 months
  • Onset 2-3 days
  • lasts 4-8 weeks
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17
Q

I-A relative CI

A
  • ctive superficial skin or soft tissue infections
  • Suspected joing infection
  • Unstable coaguloapthy
  • Uncontrolled DM
  • Broken skin at injection site
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18
Q

Duloxetine OA dose and osnet

A
  • 60mg QD
  • onset: 4 wks
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19
Q

Duloxetine AE

A
  • N/V
  • Constipation
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20
Q

Capsaicin counselingn points

A
  • may initially cause more pain befoe helping
  • must be used regularly for efficacy
  • onset 2 wks
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21
Q

RA dx

A
  • Dx
    • Early dx is difficult
    • Lab findings:
      • ESR/CRP: inflammatory factors
      • Rheumatod factor
      • ACPAs: peptide antibodies
      • ANAs: antinuclear Ab
    • Dx scoring system: based on 4 domains
      • Joint involvement
      • Serology
      • Acute phase rectants
      • Duration of s/s
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22
Q

RA flare: most common trigger

A

virus

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23
Q

RA signs

not symptoms

A
  • symmetric swelling of hands, wrists, ankles, feet
    • Synovitis
    • Erthematous and warm over affected joints
    • Rhematod nodules present
    • Potential grip weakness, deformity and muscle atrophy
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24
Q

RA symptoms

not signs

A
  • Occur with use AND at rest
    • Joint pain and stiffness lasting > 6 weeks
    • Prodromal symptoms
      • Fatigue
      • Fever
      • Weakness
      • Wt less
      • Decreased bood
      • Myalgias
      • Joint swelling
    • Decresed range of motion
    • Joint deformity (late in disease
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25
Q

RA extra-articular involvement

RA is a multi-system inflammatroy disease

A
  • Rheumatoid nodules: subq manifestations of macrophages surrounded by lymphocytes and fibroblasts; commonly found in forearms, elbows, and hands
  • Pulmonary complications: intersitital lung disease is most common, may sometimes see pleural effusions
  • Vasculitis: invasion of arterila walls by inflmamtory cells → narrow vessels
  • Ocular manifestations: decreased tear formation → dry itchy eyes
  • Cardiac involvement: RA is a risk factor for CAD and incraesed CV mortality
  • Hematologic involvement: neutropenia
  • Lymphadenoopathy
  • Amyloidosis: protein buildup in organs → renal, GI complications
  • Osteoporoiss
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26
Q

What are the available guidelies for RA treatment

A
  • merican College of Rheumatology (ACR)
  • National Institute for Health and Care Excellence (NICE)
  • European League Againt Rheumtism (EULAR)
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27
Q

Goals of treatment: RA

A
  • Improve/maintain functional status: decrease pain, joint mobility, maintain daily activities
  • Slow destructive joint chages
  • Achieve diesase remission or low activity
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28
Q

RA: non-pharm

A
  • Rest
  • Wt loss
  • Pain coping
  • Physica and occupational therapy
    • Assistive devices
    • Exercise
    • Physiotherapy
    • Biofeedback
  • Surgery
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29
Q

RA: non-disease modifyig pharm

A
  • NSAIDs: decrease pain and inflammation
    • NOT MONOTHERAPY
  • CS: decrease pain and inflammation
    • NOT MONOTHERAPY
    • Low dose for chronic or refractory
    • High dose for short course during flares
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30
Q

RA: disease modifying drug types

A

DMARDs (Disease Modifying AntiRheumatic Drugs)
- csDMARDs: conventional synthetic
- bDMARDs: biolgoics (TNF and non-TNF)
- tsDMARDs: target synthetics (JAKi)

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31
Q

List the csDMARDs

A
  • MTX
  • leflunomide
  • sulfasalzine
  • HCQ
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32
Q

MTX MOA

A

folate atag with anti-inflammatory properties

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33
Q

MTX admin RA

A

start 7.5mg PO QW and titrate to 15mg PO QW withun 4-6 weeks

If pt unable to tolerate PO dose:
- split oral dose over 24H
- switch to subq

Take a folic acid 1-5mg QD, or if not taking every day, to at least take the day after MTX to reduce AE

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34
Q

MTX monitorring

A

CBC, LFTs, SCr
- Q2-4 W during first 3 months
- Q8-12 W during month 3-6
- Q12 W from month 6 onwards

Preggers test before starting
Chest x-ray before starting

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35
Q

MTX AE

A

BBW
- GI tox
- derm reaction
- pneumonitis
- pulmonary fibrosis
- myelosuprresion
- icnreased LFTs

Stomatis
Dyspepsia
Immunosuppression
Bone marrow suppression
Hepatotox
Nephrotox

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36
Q

MTX CI

A

BBW
- preggers
- breast feeding
- renal disease
- liver disease
- myelosuppression

Immunodeficiency

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37
Q

Leflunomide MOA

A

inhibit pyriidine synthesis → decrease lymphocyte proliferation

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38
Q

Leflunomide admin RA

A

loading dose of 100mg PO QD 3D then 20 mg QD (can decrease to 10mg QD if 20mg no tolerated)

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39
Q

Leflunomide monitoring

A

CBC, LFTs, SCr
- Q2-4 W during first 3 months
- Q8-12 W during month 3-6
- Q12 W from month 6 onwards

Preggers test before starting

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40
Q

Leflunomide AE

A
  • N/V/D
  • Reversible alopecia
  • Rash
  • Peripheral neuropathy
  • HTN
  • Hepatotox
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41
Q

Leflunomide CI

A

BBW
- preggers - if pt wants to become preggers, cholestyramine and verify plasma levels are < 0.02 mg/L by 2 seperate tests at least 14 days apart

  • breast feeding
  • hepatotoxicity: dc if ALT 3x ULN, take cholestyramine if hepatotox is d/t leflunomide

long half life, may be detectable for up to 2 yrs after cessation
- eliminate: cholestyramine 8mg TID 11D

42
Q

Leflunomide DDI

A
  • CYP2C8 inhibitor
  • Warfarin: decrease INR
  • CYP1A2 inducer
  • OAT3 inhibitor: many ABX [ ] go up
  • BCRP and OATP1B1/1B3 inhibitor:
    - if pt on crestor, crestor dose =/< 10mg
    - also dose adjust, lipitor, pravastatin, simvatatin
43
Q

Sulfasalazie MOA

relative to RA

A

unknown, however, its active meetabolites do have anti-inflammatory properties

44
Q

Sulfasaline admin RA

A
  • 500-1000mg QD
  • if no effect after 12 W can titrate up to 3g
45
Q

Sulfazalzine monitoring

A

CBC, LFTs, SCr
- Q2-4 W during first 3 months
- Q8-12 W during month 3-6
- Q12 W from month 6 onwards

Rule out G6PD deficiency before starting

46
Q

Sulfasalzine AE

A

N/V
Abdominal pain
HA
Wt loss
Reversible oligospermia (low sperm count)
Rash, pruitis, urticaria
Hemolytic anemia

47
Q

Sulfasalazine CI

A
  • Interstitital or urinary obstruction
  • Porphyria
  • Sulfa allergy
48
Q

HCQ MOA

relative to RA

A

unknown MOA for RA, but it’s a cytokine production inhibitor

CAN BE USED IN PREGGERS

49
Q

HCQ admin

A
  • initial: 400-600mg QD
  • maintenance: TDD of 200-400mg

RA and SLE

50
Q

HCQ monitoring

A
  • RA: Eye exam at baseline and Q3 months
  • SLE: baseline, in 5 years, then annually
51
Q

HCQ AE

A
  • N/V/D
  • QT prolongation → do NOT exceed MDD
    • avoid if already at risk for arrhythmias
  • Serious skin reactions
  • Irreversible retinal damage; higher risk if
    • low TBW
    • renal or hepatic impairment
    • previous retinal or macular disease
    • on med for 5+ years
  • flu-like s/s
  • allergic skin eruption
  • skin and hair pigment changes
  • hematologic changes
  • myopathies, palsis, CNS
  • cardiomyopathy
  • hearing loss
52
Q

When to use bDMARDs

A
  • n combo with MTX if possible
  • Moderate/high disease activity desptie DMARD monotherapy
  • Unable to tolerate /has CI to csDMARD
53
Q

bDMARD BBW

A
  • malignancy and serious infecgtion leading to hospitalization or death
    • Get TB test before starting
      • Latent TB: pt can start RA agent after 1 month of TB tratment
      • Active TB: pt can start RA agent after completing TB treatment

also get a HepB test before starting

54
Q

Adquate trial for bDMARDs

A
  • TNF inhibitors: 3 months
  • non-TNF inhibitors: 6 months
55
Q

bDMARD TNF inhibiors monitoring

A
  • CBC at bseline ad periodically
    • if on infliximab: get LFT at baseine and then again after 4-8 W
56
Q

List the bDMARD TNF inhibitors

A
  • etanrecept
  • infliximab
  • adalimumab
  • golimumab
  • certolizumab
57
Q

etanerecept admin

A
  • 50mg SQ QW or 25mg SQ 2xW
  • +/- MTX
58
Q

etanerecept AE

A
  • infection
  • inj site reaction
  • diarrhea
  • rash
59
Q

infliximab admin

A
  • 3mg/kg IV QW for 3 doses then 3-10 mg/kg IV Q4-8W
  • WITH MTX only
60
Q

infliximab AE

A
  • URTI
  • inf related rx
  • HA
  • abdominal pain
61
Q

Adalimumab admi

A
  • with MTX: 40mg SQ Q2W
  • without MTX: 40mg SQ QW
62
Q

adalimumab AE

A
  • infection (sinusitis, URTI)
  • HA
  • rash
  • inj site reaction
63
Q

golimumab admin

A
  • SQ: 50mg SQ Q mo.
  • IV: 2mg/kg IV Q4W for 2 doses then 2mg/kg Q8W
  • WITH MTX only
64
Q

Golimumab AE

A
  • URTI
  • SQ
    • nasopharyngitis
    • inj site reaction
  • IV
    • LFT elevation
    • HTN
    • Rash
    • Decreased neuutrophil count
65
Q

certolizmumab admin

A
  • 400mg SQ Q2W for first 3 doses then 200mg SQ Q2W
  • +/- methotrexate

supposedly don’t need to know dose….

66
Q

certolizumab AE

A
  • URTI
  • rash
  • UTI
67
Q

List the bDMARD non-TNF inhibitors

A
  • abatacept
  • rituximab
  • tocilizumab
  • anakinra
  • sarilumab
68
Q

abatacept target

A

T cells

69
Q

abatacept admin

A
  • SQ: 125mg SQ QW
  • IV: wt based dose Q2W for 3 doses then Q4W
70
Q

abatcept monitoring

A

CBC at baseline and periodically

71
Q

abatacept AE

A
  • HA
  • URTI
  • Nasopharyngitis
  • Nasuea
72
Q

rituximab target

A

anti-CD20 Ab

73
Q

Rituximab admin

A
  • 1g IV Q2W for 2 doses
    • repeat prn Q16-24 W
  • WITH MTX only

supposedly don’t need to know dose….

74
Q

rtiuximab monitoring

A

CBC at baseline adn with each dose

75
Q

rituximab AE

A
  • URTI
  • UTI
  • Nasopharyngitis
  • Inf related rx: pre medicatie with antihistamines, APAP, and GC
76
Q

tocilizumab target

A

IL-6 inhibitor

77
Q

tocilizumab admin/dose

A
  • SubQ
    • < 100kg: 162mg SQ QOW
    • > 100kg: 162g SQ QW
  • IV: 4mg/kg IV Q4W
    • can increase to 8mg/kg Q4W

supposedly don’t need to know dose….

78
Q

tocilizumab monitoring

A
  • ANC: at baseline
  • CBC: at baseline, after 4-8 weeks, then Q3mo
  • LFTs: at baseline, after 4-8 weeks, then Q3mo
  • FLP: at baseline, after 4-8 weeks, then Q6mo
79
Q

tocilizumab AE

A
  • URTI
  • Nasopharyngitis
  • HA
  • HTN
  • Inj site reaction
  • Increased ALT
80
Q

anakira target

A
  • IL-1 inhibitor
  • less effective than the other non-TNF inhibitors
81
Q

anakira admin

A

100g SQ QD

82
Q

anakira monioring

A

CBC at abaseline an Q3mo.

83
Q

anakira AE

A
  • URTI
  • Rash
  • Pyrexia
  • Flu-like s/s
  • Gastroenteritis
84
Q

sarilumab target

A

IL6 inhibior

85
Q

sarilumab admin

A

200mg SQ Q2W

86
Q

sarilumab monitoring

A
  • ANC: at baseline
  • CBC: at baseline, after 4-8 weeks, then Q3mo
  • LFTs: at baseline, after 4-8 weeks, then Q3mo
  • FLP: at baseline, after 4-8 weeks, then Q6mo
87
Q

tsDMARD MOA

A

inhibit janus kinase enzymes expressed by inflammatory cytokiens

88
Q

tsDMARD BBW

A
  • Risk of opportunistic infections (TB)
    • Get TB test bebfore iitation
      • Latent TB: pt can start RA agent after 1 month of TB tratment
      • Active TB: pt can start RA agent after completing TB treatment
  • Malignancy
  • Thrombosis (DVT, PE, arterial thrombosis)
89
Q

List the tsDMARDs

A
  • tofacitinib
  • baricitinib
  • upadacitinib
90
Q

tofacitinib admi

A
  • IR: 5mg PO BID
  • XR: 11mg PO QD
91
Q

tofacitinib AE

A
  • Increased HDL, LDL
  • HA
  • UTI
  • URTI
  • GI perforation
  • Anemia
  • Neutropenia
  • Skin cancer
  • PE
  • Infections
92
Q

baricitinb admin

A

2mg PO QD

93
Q

baricitinib AE

A
  • Increased LFTs
  • Nausea
  • Herpes zoster and other infections
  • GI perforation
  • Thrombosis
94
Q

upadacitinib admin

A

15mg PO QD

95
Q

upadacitinib AE

A
  • Increased HDL, LDL, TC
  • Increased LFTs
  • Nausea
  • URTI
  • Skin cancer
  • GI perforation
  • Thrombosis
  • Anemia
  • Neutropenia
  • Infections
96
Q

What vaccines are recommnded to pts with RA

A
    • pneumococcal
    • inactive flu
    • HepB
    • HPV
    • live herpes zoster - do NOT give during biologics therapy, give before
97
Q

Treatment for pts who are DMARD naive and have had RA < 6 months (early symptoamtic RA)

A
  • DMARD monotherapy (HCQ if low disease acctivity, MTX if moderate to severe)
    • If pt has moderate or high disese therapy desptie DMARD, can try one of the following: can use short term CS to bridge onto these
      • Combo csDMARDs
      • bDMARD with methotrexate
      • tsDMARD with methotrexte
98
Q

Treatment for pts who are DMARD naive and have had RA > 6 months (established RA)

A
  • DMARD monotherapy (HCQ if low disease acctivity, MTX if moderate to severe)
    • If pt has moderate or high disese therapy desptie DMARD, can try one of the following: can use short term CS to bridge onto these
      • Combo csDMARDs
      • bDMARD with methotrexate
      • tsDMARD with methotrexte
99
Q

RA treatment specific considerations: pt has moderate to high disease actiivty that persists and has had prior csDMARD but NOT MTX

A

Swtich to MTX

100
Q

RA treatment specific considerations: pt has moderate to high disease actiivty that persists and is currently on PO MTX

A

switch to SQ MTX or add antoher DMARD

101
Q

RA treatment specific considerations: pt has moderate to high disease actiivty that persists and does NOT have poor prognostic factors

A

add an additional csDMARD

subejct to pt preference

102
Q

RA treatment specific considerations: pt has moderate to high disease actiivty that persists and HAS poor prognostic factors

A

add tsDMARD or bDMARD

subject to pt preference

103
Q

What is/are considered poor prognostic factors in RA

A
  • High disease activity
  • Early presence of erosion
  • autoAb positivity
104
Q

RA therapy efficacy monitoring and when to consder lowering dose or dc

A
  • Assess efficacy Q3mo
  • Can consider tapering to dc after being at target for 6 months - but we would rather you continue
    • Would prefer dose reduce over complete dc
    • If on triple therapy (HCQ + MTX + sulfasalazine) - get rid of sulfasalazine
    • If on MTX + bDMARD or tsDMARD - get rid of MTX
105
Q

RA comorbiditties to consider

A
  • Preggers: no MTX or LEF
  • HF NYHA Class III-IV: use non-TNFi or tsDMARD
  • Lymphoproliferative disorder: rituximab preferred
  • HepB: caution sue with biologics and JAKi
  • Liver disease: avoi MTX and LEF

PHM 702: Pulm and ToXXX (14 decks)

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