RA Flashcards
(123 cards)
1
Q
Reumatoid arthritis characterized by what
A
systemic double join involvement
2
Q
age of onset RA and gender
A
30-50 years
more common in females
shortens life span
3
Q
race considerations in RA
A
no discrimination
4
Q
what to consider to see if genetic?
A
MHC typing to get HLA level
5
Q
etiology of RA
A
unknown
6
Q
RA has synovial space in joints infiltrated with what
A
inflammatory cells
(macrophage, t cells, plasma cells)
7
Q
what is pannus
A
inflamed proliferation synovium
8
Q
what do the inflammatory cells do once they invade synovial
A
release cytokines that lead to cellular proliferatiion and death
9
Q
what does a pannus do?
A
invades healthy cartilage and bone and produces erosions that destroy joint
10
Q
clinical presentation of RA
A
stiffness and muscle ache - joint swelling
- fatigue
- weak
- loss appetite
- fever
11
Q
clinical criteria for diagnosis of RA
A
score of 6 or more points
based on type of joint and number of joints involved
12
Q
most common joints in RA
A
hands
wrists
feet
13
Q
common joints in OA
A
hands
knee
hip
14
Q
not as common places for joint inflammation in RA
A
elbows
shoulder
hip
ankle
knee
15
Q
reumatoid nodules location
A
hands
elbow
forearm
16
Q
reumatoid nodules when to treat
A
only if symptomatic
usually no intervention required
17
Q
vasculitis symptoms
A
inflammation of small supervicial blood vessels
stasis ulcers
infarction leading to necrosis
18
Q
pulmonary symptoms RA
A
pleural effusion
pulmonary fibrosis
inflam of arteries and lungs (pnemonitis)
19
Q
ocular symptoms of RA
A
inflam of eye, nodules on sclera
keratconjunctivitis sicca - Sjorens syndrome
itchy dry eyes
20
Q
cardiac effects RA
A
increase risk CV mortality
pericarditis
conduction abnormalities
myocarditis
21
Q
Feltys sx RA
A
splenomegaly - inflamed spleen
neutropenia
22
Q
additonall disease states that could happen from RA
A
lympadenopathy
renal disease
thrombocytosis
anemia
(could be from drugs taken)
23
Q
erythrocyte sedimentation rate and C reactive protein used for what
A
to see if meds working, disease progression
both non-specific to RA
24
Q
rheumatoid factor used for what
A
most patients are RF +
specfic antibody for IgM
higher titer = poorer prognosis
25
Anti-CCP or ACPA used how
high specificity
marker of poor prognosis
26
antinuclear antibodies (ANA)
suggest autoimmune disease
more suggestive of SLE
27
what is joint aspiration
take out fluid from joint to measure
turbid
WBC increased
glucose decreased
28
radiographic images used how
evaluate disease progression
29
what increases risk of poor prognosis
elevated CRP and ESR
RF high titers
elevated Anti-CCP / ACPA
erosions on Xray
duration of disease
swelling > 20 joints
30
goals of therapy
relieve symptoms
preserve function
prevent damage
control extra-articular manifestations
31
non-pharm treatment RA
rest
weight reduction
surgery
PT/OT
splints/prosthetics
support groups
education
32
adjunct therapies for RA
NSAIDs
corticosteroids
33
NSAIDs help with what
pain, swelling, stiffness
DO not alter disease progression
34
NSAIDs and coritcosteroids as monotherapy?
NO, use with DMARDs
35
NSAIDs dosed at what
anti-inflammatory doses
36
if sulfa allergy, what NSAID can we not use?
celecoxib
37
corticosteroids used for what
anti-inflammatory and immunosuppressive
38
when could we use corticosteroids?
acute flares
extra-articular manifestations
39
dose goal for steroids
physiological dose to reduce adverse effects
40
do not use intraarticular injections how freuntly
more than every 2-3 months
41
short term side effects corticosteroids
hyperglycemia
gastritis
mood changes
increased BP
42
long term side effects corticosteroids
aseptic necrosis
cataracts
obesity
growth failure
osteoporosis
HPA suppression
43
baseline monitoring for corticosteroids
BP
BG
44
maintenance monitoring for corticosteroids
BP
BG
every 3-6 months
45
what is a DMARD
disease modifying anti-reumatic drug
46
what can DMARDs do
decrease/prevent joint damage
preserve joint integrity
47
onset of action DMARDs
6 months, takes awhile
48
conventional synthetic DMARDs still used
methotrexate
sulfasalazine
hydroxychloroquine
leflunomide
49
DMARD of choice
methotrexate, best long term outcome
50
methotrexate dosing and onset
7.5 mg PO or IM weekly
(max 15-20 mg in 1 day)
onset 1-2 months
51
how is methotrexate metabolized
hepatic w some renal
52
methotrexate adverse effects
bone marrow supression
N/V/D, stomatitis, mucositis
cirrhosis, hepatitis, fibrosis
teratogenic
rash
53
how long to wait after methotrexate to consider getting pregnant
3 months
54
what can be given with methotrexate to decrease symptoms of BMS and stomatitis/mucosisit
folic acid 1 mg / day
55
contraindications to methotrexate
pregnancy
pleural effusions
chronic liver disease/ alcohol abuse
immunodeficiency
blood dyscrasias
leukopenia
CrCl < 40 ml/min
56
baseline monitoring for methotrexate
CXR
CBC
SCr
LFTs
Albumin
hep B and C studies
57
maintenance monitorign for methotrexate
CBC, SCr, LFTs
< 3 month: 2-4 weeks
3-6 month: 8-12 weeks
6 month: 12 weeks
58
leflunomide is a _____
prodrug
59
leflunomide dosage form
oral
60
leflunomide onset
1 month
61
leflunomide caution
if taken with methotrexate may cause liver tox
62
halflife of leflunomide and excretion
14-16 days
hepatobilliary
63
leflunomide adverse effects
diarrhea
rash
alopecia
increased LFTs
teratogen
64
what can we use if trying to get pregnant and need leflunomide out of the system
cholestrymine
65
baseline monitoring leflunomide
CBC
SCr
LFTs
66
maintenance monitoring leflunomide
CBC
SCr
LFTs
< 3 month: 2-4 weeks
3-6 month: 8-12 weeks
6 month: 12 weeks
67
sulfasalazine is a ____ and inhibits what
prodrug, IL-1 inhibitor
68
onset of sulfasalazine
1-2 months
69
70
sulfasalazine side effects (8)
N/V/D
headache
anorexia
rash
thrombocytopenia
hepatotoxicity
anemia
hypersensitivity to sulfa - photosensitivity
71
baseline monitoring sulfasalazine
CBC
LFTs
SCr
72
maintenance monitoring sulfasalazine
CBC
SCr
LFTs
<3 months: 2-4 weeks
3-6 months: 8-12 weeks
6 months: 12 weeks
73
hydroxychloroquine effectivenss
not as good as methotrexate or leflunomide
74
hydroxychloroquine onset
2-4 months, d/c if no effect at 6 month
75
HCQ advantage
no myelosupression, hepatic, or renal toxicities
76
HCQ adverse effects
retinal toxicity
N/V/D
rash, alopecia
77
HCQ monitoring
vision exam at baseline and every 6-12 months
78
biologic DMARD drugs
etanercept
infliximab
adalimumab
golimumab
certolizumab
79
TNF inhibitors class side effects (7)
infections
risk malignancy
HSTCL
demyelinating disease
CHF exacerbation
hepatotoxicity
Hep B reactivation
no live vaccine admin
headache/rash
80
etanercept dosage form
SQ
81
etanercept can be used with what
methotrexate
or monotherapy
82
monitoring for etanercept, infliximab, adalidumab, certolizumab
TB skin test befoer therapy
no other lab monitoring
83
infliximab must be used with what
methotrexate, if inadequate response to methotrexate alone
84
can infliximab be monotherapy
no, use with MTX
85
indication for adalidumab
monotherapy or combination with MTX or other DMARDs
use after failure of one or more DMARDs
86
dosing regimen for adalidumab
40 mg SQ every other week or every week if not taking MTX with it
87
golimumab indication
combo with MTX
mod to severe RA
88
monitoring for golimumab
CBC w PLT
LFTs
89
certolizumab indication
mod to severe RA
with or without DMARD
90
anakinra MOA
IL-1 antagonist
91
anakinra indication
mod to severe RA
failure on DMARD
mono or + DMARD
92
anakinra side effects
injection site reactions
headache
N/V/ flu sx
hypersensitivity to e. coli proteins
risk infections
decreased neutrophils
93
anakinra monitoring
neutrophil count
baseline
monthly x 3 months
quarterly for 1 year
94
abatacept MOA
selective T cell co-stimulation modulator
95
abatacept indication
mod to severe RA
mono or + DMARD
must fail a DMARD
96
abatacept caution in which pts
COPD
97
abatacept adverse effects
headache
nausea
upper resp infection
nasopharyngitis
infusion rxns
serious infection
malignancy
98
abatacept monitoring
no hematologic monitoring
99
IL-6 inhibitors
tocilizumab
sarilumab
100
tocilizumab and sarilumab indication
mod to severe RA
mono or with DMARD
after failure of DMARD
101
IL-6 inhibs warning
black box for serious infections
102
IL-6 inhibs contraindications
liver toxicity
thrombocytopenia
neutropenia
103
IL-6 inhibitors side effects
serious infection
liver toxicity
thrombocytopenia
neutropenia
lipid abnormalities
intestinal perforations (toc)
infusion reactions (toc)
104
tocilizumab and sarilumab monitoring
neutrophil count
platelet count
LFTs
lipid profile
at 4-8 weeks then every 3 months
105
rituximab indication
with methotrexate
mod to severe RA after fail of TNF
106
rituximab MOA
Anti CD20
107
rituximab dosage form
IV infusion
108
tocilizumab dosage form
IV infusion
109
sarilumab dosage form
SQ
110
what can be given before retuximab to reduce chance of infusion reaction
methylprednisolone IOV
111
black box warning retuximab
fatal infusion reaction
tumor lysis syndrome
112
side effects retuximab
tumor lysis syndrome
mucocutaneous reaction
viral infection
hypersensitivity
renal tox
bowek obstruction
hep B reactiv
cardiac arrythmia
113
retuximab monitoring
CBC w plt
SCr
vital signs during infusion
114
targeted synthetic DMARDs
tofacitinib
baricitinib
updacitinib
115
tofacitinib
baricitinib
updacitinib MOAs
JAK inhibitors
116
indication for JAK inhibs
mod to severe RA after fail TNF
mono or with MTX / DMARD
117
JAK inhibs cant be used with what
cyclosporine
azathioprine
biologics
118
warnings of JAK inhibs
CYP 450
hepatic impairment - do not use
risk infection
risk malignancies
risk CV events
risk thrombosis
no live vaccines
119
do not use JAK inhibitors if what
Hg < 9
ANC < 1000
ALC < 500
120
adverse effects JAK inhibs
upper respiratory
headache
nausea
121
JAK inhibitors monitoring
lymphocyte
neutrophil
hemoglobin
LFTs
lipid profile
122
what is early RA considered
< 6 months
late > 6 months
123
jfode
