RA and SLE

Question 1

The classic symptoms of RA include:

Answer 1

Joint swelling, Stiffness, Pain, Weakness and eventually Bone deformity

Question 2

What time of day do RA symptoms seem to be the worst in patients:

Answer 2

Morning

Question 3

Diagnostic criteria for RA include: 1) Morning stiffness of joints lasting >1hr; 2) Arthritis in 3 or more joints; 3) Swelling (arthritis) of hand, foot or wrist joints; 4) Symmetric involvement; 5) Subcutaneous nodules; 6) Positive serum rheumatoid factor (~70% of patients); 7) Radiographic erosions or periarticular osteopenia in hand or wrist joints. How long much symptoms be present for diagnosis?

Answer 3

> =6 weeks. Must have criteria 1-4. Minimum of 4 criteria for diagnosis.

Question 4

How long after diagnosis of RA should patients be started on DMARDs?

Answer 4

within 3 months of diagnosis.

Question 5

What class of drugs may be used as bridge therapy for patients with RA?

Answer 5

NSAIDs or steroids.

Question 6

What class of drugs help to slow down RA and help prevent further joint damage?

Answer 6

DMARDs (Disease-Modifying Antirheumatic Drugs).

Question 7

Name some short term side effects of Prednisone therapy.

Answer 7

Fluid retention, Stomach upset, Emotional instability, Increased appetitie, Weight gain. (With high doses: increased blood glucose and/or BP)

Question 8

Name some long-term side effects of Prednisone therapy.

Answer 8

Adrenal suppression/Cushing’s syndrome; Impaired wound healing; HTN; Hyperglycemia, Cataracts; Osteoporosis; Hypokalemia; Grouth suppression in children; Muscle wasting; Dermal thinning; Bruising; Can; Menstrual irregularities; and others

Question 9

Methotrexate (Rheumatrex), Hydrochloroquine (Plaquenil), Sulfasalazine; Minocycline; Leflunomide (Arava) are all examples of (biologic/non-biologic) DMARDs

Answer 9

Non-biologic. Methotrexate and Hydroxychloroquine are most commonly used.

Question 10

Most common side effects of Methotrexate include:

Answer 10

N/V/D, GI upset, Anorexia, Reddening of skin, can cause LIVER, LUNGS (dammage) , nausea, darreha and STOMATITIS (MOUTH SORES). Hence dry cough, sob, weakness, yellow skin

Question 11

What is the dosing interval of Methotrexate for RA?

Answer 11

WEEKLY. Dose may be spread over 12-36 hours. It is NEVER dosed daily for RA.

Question 12

Methotrexate is a Pregnancy category _

Answer 12

X. Under no circumstances should it be used during pregnancy or suspected pregnancy.

Question 13

Hydroxychlorquine common side effects inlude:

Answer 13

Decreased visual acuity, Photophobia, Blurred vision, Corneal deposits, N/V, Others: SJS, pruritus, alopecia, ataxia, pigmentation of skin and hair, neuromyopathy with long-term use

Question 14

Etanercept (Enbrel), Adalimumab (Humira), Infliximab (Remicade), Crtolizumab (Cimzia), Golimumab (Simponi), Rituximab (Rituxan), Anakinra (Kineret) Abatacept (Orencia) and Tocilzumab (Actermra) are all examples of (biologic/non-biologic) DMARDs

Answer 14

Biologic. (Note the mab suffixes of more of these drugs)Most commonly used: Etanercept, Adalimumab, Infliximab, Rituximab

Question 15

Infliximab (Remicade) and Rituximab (Rituxan) may be given with ___ for the treatment of RA.

Answer 15

Methotrexate

Question 16

The DMARDs Etanercept (Enbrel), Adalimumab (Humira), Infliximab (Remicade), Certolizumab pegol (Cimzia) and Golimumab (Simponi) are all part of the class __ __ __ __ inhibitors

Answer 16

Tumor necrosis factor alpha inhibitors (TNF-alpha inhibitors)

Question 17

BBW for most biologic DMARDs includes risk of ____ or ___

Answer 17

Serious infections or malignancies

Question 18

The most common side effects of biologic DMARDs are:

Answer 18

Infections and injection site reactions

Question 19

Biologic DMARDs should not be used if the patient has an active ____.

Answer 19

Infection. (ie severe infection or sepsis)

Question 20

What medication is considered first line for RA?

Answer 20

Methotrexate. Biologic DMARDs may be added on as second-line therapy (most commonly Etanercept (Enbrel) or Adalimumab (Humira))

Question 21

Can you use more than one biologic DMARD for RA at once?

Answer 21

No. Do not use biologics in combination. TNF inhibitors may cause neurological reactions, demyelinating disease, malignancies, HepB reactivation, TB activation, HF, SLE, or immunosuppression

Question 22

(True/False) Live vaccines should not be given to patients using biologic DMARDs

Answer 22

True. Avoid live vaccines.

Question 23

All TNF-alpha blockers requires a test for this infectious disease prior to administration, then annually thereafter:

Answer 23

TB. TNF-alpha blockers may activate latent TB.

Question 24

Name the 7 drugs commonly associated with Drug induced lupus:

Answer 24

Procainamide, Hydralazine, Isoniazid, Quinidine, Chlorpromazine, Methyldopa, and Minocycline.

Question 25

The most common symptoms of SLE include:

Answer 25

Fatigue, Fever, Anorexia, Weight loss, Muscle aches, Arthritis, Rash (Butterfly rash), Photosensitivity, Joint pain, Stiffness

Question 26

(True/False) SLE can cause severe damage to several organs

Answer 26

True. It is important to treat SLE to prevent disease flares.

Question 27

What two antimalarial agents may be used to treat SLE?

Answer 27

Hydroxychloroquine or Chloroquine. May take up to 6 months to see maximal effects.

Question 28

What medication may be prescribed at higher doses to help control a current flare or at lower doses as chronic, suppressive therapy for SLE?

Answer 28

Prednisone

Question 29

What biologic agent may be used for SLE?

Answer 29

Belimumab (Benlysta) - inhibits B cells* know brand name

Question 30

The cytotoxic agents Cyclophosphamide, Azathioprine or Mycophenolate mofetil (Cellcept) may be used in (mild/moderate/severe) SLE.

Answer 30

Severe.

Question 31

MESNA therapy and hydration may help with this side effect of Cyclophosphamide:

Answer 31

Hemorrhagic cystitis

Question 32

Can methotrexate be used while breastfeeding?

Answer 32

No

Question 33

Methotrexate may cause failure of this organ:

Answer 33

Liver (Toxicity)

Question 34

Etanercept may cause damage to of this organ:

Answer 34

Liver

Question 35

Etanercept is injected where and how often?

Answer 35

SC into thigh, abdomen, or upper are. One time or weekly

Question 36

How should Etanercept (Enbrel) be stored?

Answer 36

Refrigerator. Allow to cool to room temperature before injecting. Do not shake. If particles or discoloration are present then do not use.

Question 37

Brand name of Etanercept:

Answer 37

Enbrel

Question 38

Brand name of Adalimumab

Answer 38

Humira

Question 39

Brand name of Infliximab

Answer 39

Remicade

Question 40

Brand name of Rituximab

Answer 40

Rituxan

Question 41

prior to starting enbrel get tested for

Answer 41

TB, WBC and liver enzymes

Question 42

TB positive and found to be latent now what w/ tnf?

Answer 42

Start tb therapy BEFORE starting on TNFF

Question 43

leflunamide and pregnancy

Answer 43

wait 2 years after stopping to start this agent. teratogenic.

Question 44

All TNF blockers BBW

Answer 44

BBW: infection and malignancies

Question 45

All TNF blockers ADR

Answer 45

ADR: injection site reactions (fever rash etc)

Question 46

All TNF blockers CI

Answer 46

CI: sepsis

Question 47

All TNF blockers monitoring

Answer 47

Montior: WBC, HF, LFTs

Question 48

what are the first line in biologics?

Answer 48

Enbrel and Humira - Self inject and first line w/ biologics

Question 49

All TNF blockers special injection instructions

Answer 49

Do not shake, refrigiergate and bring to room temp before injecting

Question 50

All TNF blockers, what disease should they be evaluated for and what is the treatment?

Answer 50

Evauluate for TB- if latent give ISONIAZID!!!! nothing else.

Question 51

adalimumab humira dosing

Answer 51

EVERY OTHER WEEK!!!

Question 52

ENBREL- dosing

Answer 52

ENBREL- once a week enbrel is the only weekly one

Question 53

INFLIXIMAb dosing

Answer 53

INFLIXIMAN also 0,2, 6,8 (every other)

Question 54

abatacept

Answer 54

Orencia

Question 55

Rituxan

Answer 55

Anti Cd 20 monoclonal antibody** note NOT TNF but still a biologics

Question 56

BBW of rituxan:

Answer 56

1. progressive multifocal leukoencephlopathy, Tumor lysis, Fata mucocutaneous reactions (SJS, TEN)

Question 57

monitoring of rituxan

Answer 57

monitoring: cardiac, vital signs, CBC, CD20, REnal

Question 58

tofacitinib, MPOA, Pregancy category?

Answer 58

Tofacitinib (Xeljanz) is an inhibitor of Janus kinase (JAKs). It is a new ORAL medication that is taken BID. Tofacitinib is pregnancy category C and should not be used with biologic DMARDS or other potent immunosuppressants like cyclosporine or azathioprine.

Question 59

cytotoxic agents

Answer 59

cyclophosphamide, azathioprine, mycophenalate mofetil all cause hepatotoxicity, malignancy, and bone marrow supression

Question 60

anakinra

Answer 60

kineret

Question 61

abacept

Answer 61

orenecia

Question 62

tocilizumab

Answer 62

actemra

Question 63

name two NSAIDs commonly used for RA treatment?

Answer 63

Ibuprofen and celecoxib

Question 64

the celecoxibe dose for RA ?

Answer 64

100-200 po BID whihci s a higer dose than the max dose for OA 200 QD

Question 65

what are some contraindationts to prednisone?

Answer 65

live vaccines, systemic fungal infections, and varicell (see immunizations chapter)

Question 66

trexall

Answer 66

methotrexate

Question 67

rheumatrex

Answer 67

methotrexate

Question 68

plaquenil

Answer 68

hydroxycholorquin

Question 69

contraindications for methotrexate?

Answer 69

pregnacy alcoholoism chronic liver disease bloodyscrasias

Question 70

mechanism of action of methotrexate?

Answer 70

folate antimetabolite that inhibits DNA synthesis ( decreasing the activity of immune system)

Question 71

hydroxycholorqine dose for RA

Answer 71

400-600mg per day initially then 200-400 mg/day maintenance. Take with food.

Question 72

which agents can you used for mild RA?

Answer 72

minocycline, sulfasalazine, hydroxycholroquine

Question 73

dyancin

Answer 73

minocycline

Question 74

minocycline dose

Answer 74

100mg po bid

Question 75

enbrel

Answer 75

etanecept

Question 76

etanercept MOA

Answer 76

TNF inhibitor

Question 77

adalimumab moa

Answer 77

tnf inhibitor

Question 78

infliximab MOA

Answer 78

TNF inhibitor

Question 79

remicade

Answer 79

infliximab

Question 80

humira

Answer 80

adalimumab