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PHAR 557 > RA > Flashcards

RA Flashcards

1
Q

What is RA?

A

An autoimmune dz that involves the joints, mostly

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2
Q

Describe the dz process of RA

A

Immune sys attacks synovial and connective tissues > inflammation > chronic inflammation leads to growth of tissue called pannus > leads to loss of bone and cartilage

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3
Q

Main affect site in RA?

A

Joints (synovial tissues)

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4
Q

T or F: RA is more likely to affect older inds than younger inds

A

F (anyone is susceptible since this is an autoimmune dz)

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5
Q

Signs and sx’s of RA

A

a. SYMMETRICAL joint pain/stiffness for >6 weeks
b. muscle pain
c. systemic sx’s (fatigue, fever, loss of appetite) (late dz)
d. joint tenderness, warmth, swelling
e. rheumatoid nodules (unctrled dz)

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6
Q

Joint consequences of RA

A

Joint consequences:

a. Joint damage and bone erosion
b. ulnar drift in hands

There’re extraarticular consequences (blood vessels, eyes, lungs, bone, etc.)

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7
Q

What single lab test can definitively establish RA?

A

None exists > must be diagnosed using certain criteria

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8
Q

What body part must be involved to consider a dx of RA?

A

JOINTS

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9
Q

Ultimate goal of tx?

A

Remission

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10
Q

Sig damage occurs in the first __ years of RA.

A

Sig damage occurs in the first 2 years of RA.

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11
Q

T or F: DMARDs should be started v. slowly in the beginning to reduce AEs.

A

F

Tx aggressively to get early remission

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12
Q

T or F: Rheumatoid factor must be present for a dx of RA.

A

F (only 60-70% of pts have this)

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13
Q

Main classes of meds used to tx RA?

A
  1. Traditional DMARDs
  2. Biologic DMARDs
  3. Synthetic DMARDs (Janus Kinase inhibitor)
  4. CS’s
  5. NSAIDs (analgesia)
  6. Combo
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14
Q

Are traditional DMARDs good for flares? Why or why not?

A

No b/c they have a SLOW ONSET

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15
Q

What classes of drugs are used for maintenance tx?

A

Traditional DMARDs, biologic DMARDs, synthetic DMARDs

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16
Q

What classes of drugs are used for flare tx?

A

NSAIDs, CS’s

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17
Q

List the traditional DMARDs

A

methotrexate (MTX), leflunomide (LEF), hydroxychloroquine (HCQ), sulfasalazine (SSZ)

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18
Q

Which trad DMARDs inhibit the immune sys more upstream?

A

MTX and LEF

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19
Q

What do HCQ and SSZ ultimately do (MOA-wise)?

A

Reduce inflammation

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20
Q

Important dosing point of methotrexate?

A

Must be TITRATED

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21
Q

Very common AE of methotrexate?

A

Fatigue

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22
Q

A patient has a cold. Should we put him on MTX? Why or why not?

A

No bc MTX suppress the immune response, which would prevent the body from dealing w/ the infection

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23
Q

Is there bone healing with MTX?

A

Yes

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24
Q

MTX’s place in tx?

A

FIRST LINE/Backbone of tx

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25
Common LEF A/E's?
N/D
26
T or F: LEF is safe in pregnancy, whereas MTX is not.
F They're BOTH CI in pregnancy (and lactation for that matter)
27
When is LEF used?
Either 1. added to MTX when RA isn't well-ctrled 2. monotx when MTX is not tolerated
28
Is there bone healing with LEF?
Yes
29
Best tolerated trad DMARD?
HCQ (hydroxychloroquinone)
30
Most important AE assoc w/ HCQ?
Ocular tox
31
How long does it take for ocular toxicity to show up when taking HCQ?
≥7 years
32
A patient has retinopathy. Which trad DMARD are we gonna avoid giving him?
HCQ (it causes ocular tox)
33
HCQ - place in tx
Almost always added on to other DMARDs OR Used for early, mild RA
34
Important DI with sulfasalazine (SSZ)?
Warfarin (it causes an increased INR)
35
Name the biologic DMARDs
TNF-alpha inhibitors, IL-1/6 inhibitors, T-cell co-stimulation inhibitors, B-cell depletors
36
TNF-alpha drugs:
``` adalimumab certolizumab etanercept golimumab infliximab ```
37
Which TNF-alpha inhibitor(s) is/are always given with MTX?
golimumab and infliximab
38
Which TNA-alpha inhibitors are safe during pregnancy?
adalimumab, etanercept > both are safe up to the 3rd trimester certolizumab > safe in all trimesters
39
Why might TNF-alpha inhibitor efficacy drop over time?
Ab development
40
Initial biologic DMARD of choice?
TNA-alpha
41
IL-1/IL-6 inhibitor drugs:
IL-1 blocker: anakinra | IL-6 blockers: tocilzumab, sarilumab
42
T or F: IL-1/IL-6 experience Ab development.
T (but there's no reduced efficacy, interestingly)
43
Why is simvastatin CI'ed with tocilumab (IL-6 blocker)?
Bc toci increases simvastatin levels by 4-10x
44
Is there bone healing with IL-1/6 inhibitors?
Yes
45
Which biologic would be considered if the pt has liver tox?
abatacept (T-cell co-stimulation inhibitor) > only biologic known for this
46
What unique A/E is assoc w/ abatacept (T-cell co-stim inhibitor)?
It worsens COPD
47
Name the B-cell depletor drug:
rituximab
48
In what kind of pts is rituximab more effective?
In rheumatoid factor-positive pts
49
T or F: rituximab (B-cell depletor) is not affected by Ab development
F
50
What is the initial biologic DMARD attempted?
TNF-inhibitors
51
What initial biologic DMARD is tried if TNF-alpha blockers are not tolerated?
IL-1/6 blockers
52
When are T-cell co-stim inhibitors indicated?
When trad DMARDs and TNF blockers have failed
53
Last line biologic DMARD?
B-cell depletor (rituximab) > when ALL ELSE has failed
54
Another name for synthetic DMARD?
Janus kinase inhibitor
55
How do janus kinase inhibitors work (MOA)?
they inhibit JK enzymes > reduces IL signalling > reduces inflammation
56
Name the janus kinase inhibitor drugs (synthetic DMARDs):
1. tofacitinib | 2. baricitinib
57
Ab development with synthetic DMARDs?
No
58
Which DMARDs lose their efficacy due to Ab development?
1. TNF-alpha blockers (biologic DMARD) 2. T-cell co-stim inhibitors (??) (biologic DMARD) 3. B-cell depletors (biologic DMARD)
59
Which DMARDs DO NOT lose their efficacy due to Ab development?
1. IL-1/6 inhibitors (biologic DMARD) 2. Synthetic DMARDs 3. All traditional DMARDs
60
When are Synthetic DMARDs considered?
When pt has failed on 3 other biologics
61
When are CS's used in RA pts?
During flares
62
How are CS's usually used to tx flares?
10-15 mg prednisone equivalent/day for 2-3 months (yes, MONTHS for short-term use) > taper afterwards
63
T or F: It's safe to use CS's as monotx during RA flares.
F (a DMARD should always be on board)
64
How are NSAIDs dosed for RA flares?
High doses at initial RA dx > used for 2 weeks for max effect
65
Common combinations seen in RA tx:
1. NSAID's/CS's can be added to any regimen 2. MTX can be added to any biologic 3. Trad DMARD combos: a. any 2 of the 4 trad DMARDs (double tx) b. MTX + SSZ + HCQ (triple tx)
66
Which RA tx combos are avoided or questionable?
1. Multiple biologics = avoided | 2. Biologic + 2 DMARDs = questionable efficacy
67
T or F: Intra-articular CS's are NEVER used in RA.
F They are s.times used, esp. during flares that affect 1 or a few joints only
68
Why are NSAIDs used in RA?
To treat the PAIN assoc w/ RA flares.
69
Live, attenuated vaccines are CI'ed with what kind of tx?
biologic DMARD tx
70
Which DMARDs should be stopped before thinking about pregnancy?
MTX and LEF
71
Safest trad DMARDs during pregnancy?
HCQ and SSZ
72
Which biologics are safe during pregnancy?
TNF-alpha blockers: 1. adalimumab (up to the 3rd trimester) 2. atanercept (up to the 3rd trimester) 3. certolizumab (safe for all trimesters)
73
How much folic acid should be used during preg in RA pts?
0.4-1 mg usually 5 mg if previous MTX use
74
Safest options for maintenance drugs during lactation?
HCQ, SSZ, TNF-alpha inhibitors
75
Systemic JRA (juvenile rheumatoid arthritis) tx's:
1. NSAIDs + physical tx 2. CS's (cautiously and sparingly) 3. Biologic (if indicated) - tocilzumab (IL-6 blocker)
76
Pauciarticular/Polyarticular JRA tx
MTX or TNF-alpha blocker = 1st line
77
What kind of drug is anakinra?
IL-1 inhibitor
78
What kind of drug is certolizumab?
TNF-alpha blocker
79
What kind of drug is etanercept?
TNF-alpha blocker
80
What kind of drug is abatacept?
T-cell co-stimulation inhibitor
81
What kind of drug is rituximab?
B-cell depletor
82
What kind of drug is baricinib?
Janus kinase inhibitor
83
What kind of drug is sarilumab?
IL-6 inhibitor
84
What kind of drug is tofacitinib?
Janus kinase inhibitor
85
What kind of drug is golimumab?
TNF-alpha blocker
86
What kind of drug is infliximab?
TNF-alpha blocker

PHAR 557 (36 decks)

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