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Therapeutics III > RA - Block 1 > Flashcards

RA - Block 1 Flashcards

1
Q

Women are ___ as more likely to develop RA?

A

twice

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2
Q

What is the leading cause of death in patients with RA?

A

CV disease

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3
Q

What type of disease is RA?

A

Chronic, progressive autoimmune disease that affects the body’s joints & synovium that is a common comorbid of autoimmune conditions

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4
Q

What are genetic factors of RA?

A
  1. Genetic polymorphisms
  2. Patiets with 1st degree relatives with RA
  3. Hypogonadism (low testosterone)
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5
Q

What are the nongenetic facotrs of RA?

A
  1. Smoking
  2. Coffee
  3. Obesity
  4. Occupational hazard (silica)
  5. Viral infection (Epstein-Barr)
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6
Q

What antibody to IgG has a strong corrleation with poor RA prognosis?

A

Rheumatoid factor (RF)

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7
Q

What is a common B cells inflammaotry cytokine associated with RA?

A

Tumor necrosis factor:
1. Induction of adhesion molecules to the endothelium
1. Boosting T cell proliferation & differentiation
1. Promoting cell migration
1. Regulating matrix modeling

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8
Q

What is the inflamed, fibrotic synovium observed in patients with RA?

A

Pannus

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9
Q

Inflammatory cytokines (i.e., IL-8, prostaglandins, VEGF) promote angiogenesis, which stimulates additional migration of innate & adaptive immune responses to the synovium resulting in?

A

Inflammation

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10
Q

Inflammatory cytokines can circulate in the bone tissue & promote osteoclast activity/differentiation, resulting in?

A

Bone destruction

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11
Q

Compare and contrast OA with RA?

A
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12
Q

What are the sx of RA?

A
  1. Joint involvement
  2. Extra-articular involvement
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13
Q

What are joint sx with RA?

A
  1. Bilatteral
  2. Warthm and swelling (+/- pain)
  3. Morning stiffness (≥30 min in duration)
  4. Sx ≥6 weeks
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14
Q

What are extra articular sx of RA?

A
  1. Fatigue
  2. Weakness
  3. Decreased mood
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15
Q

What is are the lab findings of RA?

A
  1. ESR and CRP (non-specifity inflammatory process)
  2. RF
  3. Anti-cyclic citrullinated peptide (anti-CCP) antibodies
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16
Q

What lab result is more specifc for RA in early stages?

A

Anti-cyclic citrullinated peptide (anti-CCP) antibodies

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17
Q

What are the radiographic presentations of RA?

A
  1. Soft tissue swelling
  2. Joint space narrowing
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18
Q

What is the criteria of scoring RA?

A

Total score of ≥ 6 out of 10 points -> meets diagnostic criteria for RA

Not all patients with RA may score > 6 on the initial assessment, but scores may progress over time.

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19
Q

What are Current ACR & EULAR guidelines for RA?

A

Treat-to-target approach

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20
Q

What is the overall goal of treating RA?

A

Disease remission

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21
Q

What is the tx approach for RA?

A

Under the supervision of rheumatologist:
1. Includes non-pharmacologic & pharmacologic therapies
2. Focused on reducing inflammation & symptoms (i.e., joint pain, stiffness)
3. Does not reverse previously established joint damage
4. Slows RA progression -> reducing irreversible joint damage, disability, while improving quality of life

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22
Q

Non-pharm tx for RA?

A
  1. Exercise
  2. Weight loss
  3. Referral to occupational and physical therapy
  4. Referral to psychiatry
  5. Referral to social work
  6. Comprehensive patient education
  7. Surgery
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23
Q

What are the pharm tx for RA?

A
  1. Traditional DMARDs (methotrexate, leflunomide, sulfasalazine, hydroxychloroquine)
  2. Biologic DMARDs (Anti-TNF, Non TNF biologics)
  3. Janus Kinase Inhibitors (tofacitinib, baricitinib, upadacitinib)
  4. Adjunt tx (NSAIDs, CS)
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24
Q

Methotrexate

CI, Counseling

A

1st line for DMARD in most patient
CI: Pregnancy, breastfeeding, alcoholism, chronic liver dx, blood dyscrasias
Counseling:
* folic acid supplementation
* Hepatitis B and C before starting tx

25
Leflunomide | CI, Monitoring, Counseling, OD
**CI:** pregnancy, severe hepatic impairment, concomitant teriflunomide therapy **Monitoring:** TB & pregnancy screenings before starting therapy **Counseling:** * negative pregnancy test prior to starting therapy & use two (2) forms of birth control during therapy * If pregnancy is desired, patient must wait 2 years after discontinuation or use an accelerated drug elimination procedure. **Accelerated drug elimination procedures:** * Cholestyramine 8g PO TID x 11 days; use 4g dose, if the 8g dose is not tolerated * Activated charcoal suspension 50g PO every 12 hours x 11 days
26
Sulfasalazine | Warning, Counseling
**Warning:** caution in G6PD deficiency **Counseling:** * Folic acid supplementation * yellow-orange coloration of skin or urine. * glucose-6-phosphate dehydrogenase (G6PD) deficiency, due to the risk of hemolytic anemia.
27
Hydroxychloroquine | ADR
Retinal roxicity
28
What increases the risk of developing retinal tox from hydroxychloroquine?
1. Doses > 5mg/kg/day based on ABW 1. > 5 years of therapy 1. History of renal or macular disease 1. Concurrent tamoxifen therapy
29
What are the dosage forms Anti-TNF Inhibitors?
Intravenous (IV) --- infliximab Subcutaneous (SC) --- etanercept, adalimumab, certolizumab pegol, golimumab
30
What are the dosing frequencies of Anti-TNF inhibiotrs?
* Etanercept --- once weekly (OR) twice weekly * Adalimumab --- once every 2 weeks (OR) once weekly * Certolizumab pegol --- once every 2 weeks (OR) once monthly * Golimumab --- once monthly * Infliximab --- once every 4 – 8 weeks
31
Anti-TNF Inhibitors | Warning, Monitoring, CI, Administration
**Warning:** Avoid in HF **Monitoring:** Before therapy initiation: tuberculosis (TB) and hepatitis B screening * During therapy: signs of infection, CBC, LFTs, hepatitis B and TB screenings, symptoms of HF, malignancies, vital signs * **CI:** Do NOT administer with other biologic DMARDs or live vaccines **Admin:** * Do NOT shake medication or store in the freezer. * Do NOT refrigerate again, once it reaches room temperature. * Rotate injection sites
32
How should you administer infliximab tx?
Pre-medicate with antihistamines, acetaminophen, & corticosteroids to reduce risk of infusion reactions
33
Abatacept | Warning, Storage, Monitoring
**Warning:** Patients with COPD * Do NOT administer with other biologic DMARDs or live vaccines. **Storage:** Protect from light exposure, and do NOT shake the medication. **Monitoring:** Screen high-risk patients for TB and Hepatitis B prior to starting therapy
34
Rituximab | BBW, Adminitoration, Monitoring, CI
**BBW:** Infusion related rx **Admin:** Consider pre-treatment with acetaminophen, diphenhydramine, & corticosteroids to decrease risk of infusion reactions **Monitor:** Screen high-risk patients for TB, Hepatitis B, and Hepatitis C before starting therapy. **CI:** Do NOT administer with other biologic DMARDs or live vaccines.
35
Tocilizumab & Sarilumab | ADR, CI, Monitoring
**ADR:** elevated LDL & total cholesterol **CI:** * Do NOT administer with other biologic DMARDs or live vaccines. * Do NOT use SC injections for IV infusions, due to polysorbate 80 in SC formulations of tocilizumab. **Monitor:** Screen high-risk patients for TB and Hepatitis B before starting therapy
36
What are the trad DMARD?
methotrexate, leflunomide, sulfasalazine, hydroxychloroquine
37
What are the biologic DMARD?
**IV** Anti-TNF biologics * adalimumab, etanercept, certolizumab, golimumab, infliximab Non-TNF biologics * abatacept, tocilizumab, rituximab, sarilumab
38
What are the JAK inhibitors?
**PO** tofacitinib, baricitinib, upadacitinib
39
JAK inhibitors | BBW, ADR, CI, Warning
**BBW:** * serious infections * malignancy, thrombosis * increased risk of mortality in patients ≥ 50 years old with ≥ 1 CV risk factor treated at higher doses **ADR:** GI perforations, Elevated BP and lipids **CI:** Do NOT administer with biologic DMARDs, potent immunosuppressants, or live vaccines. **Warning:** Use caution in Asian patients due to increased frequency of side effects
40
NSAIDs therapy of RA
Adjunct option to DMARD therapy for patients with RA: 1. Do NOT use as monotherapy! 2. Does NOT slow disease progression! 3. More rapid onset of action (vs. DMARDs) -> consider as “bridge therapy” for DMARDs
41
CS tx of RA?
Adjunct option at low-doses to DMARD therapy for patients with refractory RA disese: 1. Do NOT use as monotherapy! 2. Can slow disease progression 3. Consider as “bridge therapy” for DMARDs
42
What are the ACR guidelines for RA?
42
43
What are the EULAR guideline for RA?
For patient with poor prognostic factors: 1. High disease activity 1. Early joint damage 1. Positive RF or anti-CCP antibodies 1. Failure of > 2 traditional DMARDs Reassess dosages & therapeutic responses **every 3 months** after initiating or changing therapies.
44
RA meds safe for pregnancy? CI?
**Safe:** hydroxychloroquine or sulfasalazine * May continue TNF inhibitors, **etanercept** or **certolizumab pegol**, throughout pregnancy. **CI:** Methotrexate and leflunomide
45
RA meds safe for lactation? CI?
**Safe:** hydroxychloroquine, sulfasalazine, corticosteroids, NSAIDs, & acetaminophen **CI:** methotrexate and leflunomide
46
RA medications for men?
1. Discontinue methotrexate 3 months before conception. 2. Discontinue sulfasalazine if the patient experiences any difficulty with fertility
47
RA medications during hx of serious infection?
Recommended to use combination DMARDs, instead of TNF inhibitors * **Abatacept** (non-TNF biologic) -> associated with lower risk of subsequent infections
48
What are the tx options based on TB screening results?
**(+) TB:** Obtain a chest x-ray to determine latent versus active TB. **(+) Chest X-ray:** Obtain sputum for acid-fast bacillus (AFB) stain to rule out active TB. **(+) AFB stain:** Diagnosis of active TB * Complete treatment for active TB before initiating/resuming biologic DMARD or tofacitinib therapy. **(-) AFB stain:** Diagnosis of latent TB * Complete at least 1 month of treatment for latent TB, then initiate/resume biologic DMARD or tofacitinib therapy.
49
Tx for patients with previously treated lymphoproliferative disorders?
Rituximab -> FDA approved for lymphoproliferative disorders
50
Tx for patients with history of melanoma or non-melanoma skin cancer?
Traditional DMARDs
51
Tx option in patients with HF?
* Avoid TNF inhibitors in patients with NYHA class II – IV heart failure * Discontinue TNF inhibitor if patient develops signs of worsening HF. * Recommend alternative therapy (i.e., combination DMARDs, non-TNF biologic, or tofacitinib).
52
Live vaccines during RA?
Avoid use during treatment with biologic therapy. Administer live vaccines prior to initiating biologic therapy (OR) at least 3 months after discontinuing
53
Inactivated vaccines for RA?
Can be administered to patients on traditional DMARDs, TNF biologics, non-TNF biologics, & JK inhibitors
54
Influenza vaccines for RA?
1. Recommend annual IIV or RIV for patients with RA before starting/during therapy 2. Recommend annual high-dose inactivated influenza vaccine (HD-IIV) for patients ≥ 65 years old with RA, regardless of concomitant RA therapy
55
Hep B for RA?
Administer as directed (per package insert), regardless of medications to treat RA
56
Tdap for RA
Recommend a booster dose of Td or Tdap vaccine once every 10 years.
57
Herpes zoster vaccine (RZV) for RA?
0 & 2-6 months after 1st dose Patients receiving rituximab should receive a dose of RZV 4 weeks before next scheduled therapy.
58
Pneumococcal vaccines (PPSV-23, PCV-15, PCV-20) for RA?
Two inactivated vaccine types -> pneumococcal polysaccharide (PPSV) & pneumococcal conjugate (PCV)

Therapeutics III (40 decks)

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