RA treatment

Question 1

Methotrexate

Answer 1

GOLD STANDARD

Dosing: 7.5 mg/week can go up to 15-20 mg/week

Route: PO or IM

Question 2

Methotrexate side effects

Answer 2

N/V/D

Fever, rash, alopecia

Bone marrow suppression (anemia)–>add folic acid 1mg/day

Mucositis, stomatitis, hepatitis, pneumonitis

Teratogenic

Question 3

Contraindications to methotrexate

Answer 3

Pregnancy

Pleural effusions

Immunodeficiency

Chronic liver disease, alcohol abuse

Preexisting blood dyscrasias

CrCl < 40

Leukopenia/cytopenia

Question 4

Methotrexate monitoring

Answer 4

CBC
CXR
LFT
SCR
Albumin

Question 5

Leflunomide

Answer 5

Prodrug that inhibits biosynthesis of pyrimidines

LOADING DOSE

Route: PO

Onset: 1 month

T1/2 life: 14-16 days

Question 6

Leflunomide Side effects

Answer 6

Diarrhea
Rash
Alopecia
Teratogenic
Increase LFTs

Question 7

Leflunomide monitoring

Answer 7

CBC
SCr
LFT

Question 8

Sulfasalazine

Answer 8

Route: PO

Onset: 1-2 months

Question 9

Hydroxychloroquine

Answer 9

modification of cytokine infiltration in joint

Route: PO

Onset: 2-4 months

Question 10

Hydroxychloroquine side effects

Answer 10

N/V/D–>take with food
Increase skin pigmentation, rash, alopecia

Retinal toxicity: > 70 yo, cumulative dose > 800 g, night/peripheral changes

VISION EXAM EVERY 6-12 MONTHS

Question 11

Etanercept

Answer 11

TNF inhibitor

SQ weekly

Question 12

Infliximab

Answer 12

TNF inhibitor

IV infusion

Combination required? Yes, with MTX

Question 13

Adalimumab

Answer 13

TNF inhibitor

SQ every other week

Inadequate response to 1 or more DMARDS

Question 14

Golimumab

Answer 14

TNF inhibitor

SQ monthly

Moderate to severe RA

Combination required? Yes, with MTX

Question 15

Certolizumab

Answer 15

TNF inhibitor

SQ

Moderate to severe RA

Question 16

TNF inhibitor monitoring

Answer 16

CXR, PPD skin test
Hep B,C
S/sx of infection
SCr, electrolytes
UA
LFT
CBC

Question 17

Anakinra

Answer 17

IL-1 antagonist
SQ daily: if CrCl < 30 mL/min, every other day

Moderate to severe RA with inadequate response to 1 or more DMARD

Question 18

Anakrina Side effects

Answer 18

N/V, flu-like symptoms
HA, hypersensitivity
Injection site reactions
Decreased neutrophils

Question 19

Anakrina monitoring

Answer 19

Neutrophil count

Prior, monthly x 3 months, every 3 months for 1 year

Question 20

Abatacept

Answer 20

Selective T-cell co-stimulation modulator

IV infusion

Moderate to severe RA with inadequate response to 1 or more DMARDs

CANNOT BE USED IN COMBINATION WITH TNF-inhibitors or IL-1 antagonists

Question 21

Abatacept Side effects

Answer 21

Nausea
HA
Nasopharnygitis
Infusion site reactions
Infection
Malignancy

AVOID IN CPOD

Question 22

Tocilizumab/Sarilumab

Answer 22

IL-6 antagonist

Tocilizumab: IV infusion every 4 weeks
Sarilumab: SQ every 2 weeks

Moderate to severe RA with inadequate response to 1 or more DMARD

Question 23

Tocilizumab/Sarilumab side effects

Answer 23

Lipid abnormalities
Intestinal perforations–>tocilizumab
Infusion reaction–>tocilizumab

BLACK BOX: serious infection
CONTRAINDICATED IN LIVER TOXICITY, THROMBOCYTOPENIA, AND NEUTROPENIA

Question 24

Tocilizumab/Sarilumab monitoring

Answer 24

LFT–>after 4-8 weeks
Lipids–>after 4-8 weeks
Neutrophil–>after 4-8 weeks
Platelets–>after 4-8 weeks

Question 25

Rituximab

Answer 25

anti-CD20 IV infusion Administer methylprednisolone 100 mg 30 minutes before infusion Moderate to severe RA with inadequate response to 1 or more DMARD Combination required? Yes, with MTX

Question 26

Rituximab monitoring

Answer 26

CBC SCr Vital signs (each dose)

Question 27

Tofactinib, Upadacitinib, Baricitinib

Answer 27

JAK inhibitor Route: PO Moderate to severe RA with inadequate response to 1 or more DMARD CANNOT BE USED IN COMBINATION WITH BRM, AZA, CYCLOSPORINE

Question 28

Tofactinib, Upadacitinib, Baricitinib side effects

Answer 28

Nausea Headache Upper respiratory

Question 29

Tofactinib, Upadacitinib, Baricitinib monitoring

Answer 29

LFT Lipids Neutrophil Lymphocytes Hemoglobin