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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
Q

Leflunomide

CI, Monitoring, Counseling, OD

A

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
Q

Sulfasalazine

Warning, Counseling

A

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
Q

Hydroxychloroquine

ADR

A

Retinal roxicity

28
Q

What increases the risk of developing retinal tox from hydroxychloroquine?

A
  1. Doses > 5mg/kg/day based on ABW
  2. > 5 years of therapy
  3. History of renal or macular disease
  4. Concurrent tamoxifen therapy
29
Q

What are the dosage forms Anti-TNF Inhibitors?

A

Intravenous (IV) — infliximab
Subcutaneous (SC) — etanercept, adalimumab, certolizumab pegol, golimumab

30
Q

What are the dosing frequencies of Anti-TNF inhibiotrs?

A
  • 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
Q

Anti-TNF Inhibitors

Warning, Monitoring, CI, Administration

A

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
Q

How should you administer infliximab tx?

A

Pre-medicate with antihistamines, acetaminophen, & corticosteroids to reduce risk of infusion reactions

33
Q

Abatacept

Warning, Storage, Monitoring

A

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
Q

Rituximab

BBW, Adminitoration, Monitoring, CI

A

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
Q

Tocilizumab & Sarilumab

ADR, CI, Monitoring

A

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
Q

What are the trad DMARD?

A

methotrexate, leflunomide, sulfasalazine, hydroxychloroquine

37
Q

What are the biologic DMARD?

A

IV
Anti-TNF biologics
* adalimumab, etanercept, certolizumab, golimumab, infliximab

Non-TNF biologics
* abatacept, tocilizumab, rituximab, sarilumab

38
Q

What are the JAK inhibitors?

A

PO
tofacitinib, baricitinib, upadacitinib

39
Q

JAK inhibitors

BBW, ADR, CI, Warning

A

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
Q

NSAIDs therapy of RA

A

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
Q

CS tx of RA?

A

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
Q

What are the ACR guidelines for RA?

A
42
Q
A
43
Q

What are the EULAR guideline for RA?

A

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
Q

RA meds safe for pregnancy? CI?

A

Safe: hydroxychloroquine or sulfasalazine
* May continue TNF inhibitors, etanercept or certolizumab pegol, throughout pregnancy.

CI: Methotrexate and leflunomide

45
Q

RA meds safe for lactation? CI?

A

Safe: hydroxychloroquine, sulfasalazine, corticosteroids, NSAIDs, & acetaminophen
CI: methotrexate and leflunomide

46
Q

RA medications for men?

A
  1. Discontinue methotrexate 3 months before conception.
  2. Discontinue sulfasalazine if the patient experiences any difficulty with fertility
47
Q

RA medications during hx of serious infection?

A

Recommended to use combination DMARDs, instead of TNF inhibitors
* Abatacept (non-TNF biologic) -> associated with lower risk of subsequent infections

48
Q

What are the tx options based on TB screening results?

A

(+) 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
Q

Tx for patients with previously treated lymphoproliferative disorders?

A

Rituximab -> FDA approved for lymphoproliferative disorders

50
Q

Tx for patients with history of melanoma or non-melanoma skin cancer?

A

Traditional DMARDs

51
Q

Tx option in patients with HF?

A
  • 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
Q

Live vaccines during RA?

A

Avoid use during treatment with biologic therapy.

Administer live vaccines prior to initiating biologic therapy (OR) at least 3 months after discontinuing

53
Q

Inactivated vaccines for RA?

A

Can be administered to patients on traditional DMARDs, TNF biologics, non-TNF biologics, & JK inhibitors

54
Q

Influenza vaccines for RA?

A
  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
Q

Hep B for RA?

A

Administer as directed (per package insert), regardless of medications to treat RA

56
Q

Tdap for RA

A

Recommend a booster dose of Td or Tdap vaccine once every 10 years.

57
Q

Herpes zoster vaccine (RZV) for RA?

A

0 & 2-6 months after 1st dose

Patients receiving rituximab should receive a dose of RZV 4 weeks before next scheduled therapy.

58
Q

Pneumococcal vaccines (PPSV-23, PCV-15, PCV-20) for RA?

A

Two inactivated vaccine types -> pneumococcal polysaccharide (PPSV) & pneumococcal conjugate (PCV)

Therapeutics III (40 decks)

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