Rheumatoid Arthritis

Question 1

What are prodromal symptoms of RA?

Answer 1

• Fatigue
• Fever
• Weakness
• Weight loss
• Decreased mood
• Myalgias before joint swelling

Question 2

What are disease flares?

Answer 2

Sudden increases in s/s that can last days to months

Question 3

When does RA go from early to established?

Answer 3

6 months

Question 4

What are signs of RA?

Answer 4

• Synovitis
• Joint erythema
• Rheumatoid nodules
• Potential grip weakness, deformity, muscle atrophy

Question 5

What are symptoms of RA?

Answer 5

Occur with use AND at rest***
- Joint pain and stiffening >6 weeks
- Prodromal symptoms
- Decreased ROM
- Joint deformity (late in disease)

Question 6

What are the most common joints involved in RA?

Answer 6

Hands, wrists, ankles, and feet (often bilaterally)

Question 7

What extra-articular involvement can occur in RA?

Answer 7

• Rheumatoid nodules
• Pulmonary complications
• Vasculitis
• Ocular manifestations
• Cardiac involvement
• Hematologic involvement
• Lymphadenopathy
• Amyloidosis
• Osteoporosis

Question 8

What are the four domains of the ACR/EULAR scoring system?

Answer 8

Joint involvement
Serology
Acute-phase reactants
Duration of symptoms

Question 9

What are pearls of RA as opposed to OA?

Answer 9

• Variable age and onset
• Generalized malaise
• Smaller joints
• Prolonged stiffness >1 hour
• With use and at rest
• Bilateral
• Auto-antibodies present

Question 10

What are the goals of RA therapy?

Answer 10

• Improve/maintain functional status (pain, joint mobility, ADLs)
• Slow destructive joint changes (treat early and aggressive)
• Achieve disease remission

Question 11

What are non-pharm treatments for RA?

Answer 11

• Rest
• Weight loss
• Pain coping skills
• PT or OT
• Surgery for severe RA

Question 12

What are pharmacologic treatments of RA?

Answer 12

NSAIDs (not monotherapy)
Corticosteroids (not monotherapy)
DMARDs

Question 13

In early RA, what is first line for moderate or severe disease activity?

Answer 13

Methotrexate

Question 14

In early RA, what is first line for low disease activity?

Answer 14

Hydroxychloroquine

Question 15

A patient is experiencing moderate-high disease activity despite DMARD therapy, what are our options?

Answer 15

• csDMARDs
• bDMARD +/- methotrexate
• tsDMARD +/- methotrexate

Consider short-term corticosteroids

Question 16

A patient is not at target with oral MTX and is experiencing moderate-high disease activity, what should we do?

Answer 16

Switch to SQ MTX

Question 17

A patient is using a csDMARD other than MTX and is experiencing moderate-high disease activity, what should we do?

Answer 17

Switch to MTX monotherapy

Question 18

After trying a DMARD, a patient is experiencing moderate-high disease activity and has no poor prognostic factors or preference, what should we do?

Answer 18

Add additional csDMARD

Question 19

After trying a DMARD, a patient is experiencing moderate-high disease activity and has poor prognostic factors, what should we do?

Answer 19

Add tsDMARD or bDMARD

Question 20

What are examples of poor prognostic factors?

Answer 20

• High disease activity
• Early presence of erosion
• Autoantibody positivity

Question 21

What are bDMARDs?

Answer 21

Biologics: -mabs, -cepts

Question 22

What are tsDMARDs?

Answer 22

Targeted synthetics: -citinib

Question 23

What are csDMARDs?

Answer 23

Methotrexate, leflunomide, hydroxychloroquine, sulfasalazine, gold salts, minocycline, CsA, cyclophosphamide, D-penicillamine

… just remember the other DMARDs lol

Question 24

When do you want to start a DMARD?

Answer 24

Within 3 months of onset of persistent symptoms

Question 25

What is the first line DMARD of choice?

Answer 25

Methotrexate (1-2 month onset of effect)

Question 26

What can be given to reduce methotrexate ADRs without reducing efficacy?

Answer 26

Folic acid supplement 1 day after methotrexate dose

Question 27

What are ADEs of methotrexate?

Answer 27

- GI toxicity - Derma reactions - Lung fibrosis/infection - Myelosuppression - Increased LFTs

Question 28

What are contraindications for MTX?

Answer 28

- Pregnant/breastfeeding - Renal/liver disease - Immunodeficiency - Myelosuppression

Question 29

What are the BBWs for leflunomide?

Answer 29

- Embryo-fetal toxicity - Hepatotoxicity - Drug elimination may be necessary with cholestyramine

Question 30

What are some possible drug/enzyme interactions with leflunomide?

Answer 30

Warfarin OAT3 CYP2C8 Statins

Question 31

What are contraindications to sulfasalazine?

Answer 31

- Intestinal or urinary obstruction - Porphyria - Sulfa allergy

Question 32

What are unique side effects of sulfasalazine?

Answer 32

Reversible oligospermia Hemolytic anemia Weight loss Rashes

Question 33

When is HCQ used as monotherapy?

Answer 33

Low disease activity

Question 34

What are some unique side effects of HCQ?

Answer 34

QT prolongation Irreversible retinal damage Serious skin reactions

Question 35

When should monitoring be done for most csDMARDs?

Answer 35

q2-4w for the first 3 months q8-12w until 6 months q12w thereafter

Question 36

Which csDMARD does not require significant monitoring after baseline?

Answer 36

Hydroxychloroquine

Question 37

What should be ruled out at baseline for sulfasalazine?

Answer 37

G6PD deficiency

Question 38

What should be done at baseline and every 3 months for HCQ?

Answer 38

Ophthalmologic exam

Question 39

When should we use biologics?

Answer 39

- In combo with MTX - Moderate-high disease activity despite DMARD therapy - Unable to tolerate or contraindicated to csDMARD

Question 40

What is an adequate trial for a bDMARD?

Answer 40

TNF: 3 months non-TNF: 6 months

Question 41

Which SC TNFi biologic must be given with MTX?

Answer 41

Golimumab

Question 42

Which biologics are SC TNFis?

Answer 42

- Adalimumab - Etanercept - Golimumab - Certolizumab

Question 43

Which TNFi biologics can be given IV?

Answer 43

- Infliximab - Golimumab

Question 44

What are the BBWs on TNFis?

Answer 44

Malignancy (lymphoma, others) Serious infections (test for latent tuberculosis, HepB)

Question 45

What are safety concerns with TNFis?

Answer 45

- MS or MS-like symptoms - Lupus-like syndrome - Worsening or new onset HF - Hep B reactivation

Question 46

Which biologics are SC non-TNFIs?

Answer 46

- Abatacept - Sarilumab - Tocilizumab - Anakinra (worst)

Question 47

What is the only SC non-TNFi that targets T cells instead of IL-6?

Answer 47

Abatacept

Question 48

Which non-TNFi biologics can be given IV?

Answer 48

- Abatacept - Rituximab - Tocilizumab

Question 49

What is the MOA of rituximab?

Answer 49

Anti-CD20

Question 50

What are some pearls of rituximab?

Answer 50

- Give with MTX - Infusion reactions (premedicate)

Question 51

How often should monitoring be done for TNFIs?

Answer 51

Baseline and every 4-8 weeks

Question 52

What additional monitoring is required for infliximab?

Answer 52

LFTs

Question 53

How often should a CBC be drawn for rituximab?

Answer 53

Baseline and with each dose

Question 54

What should be tested prior to all biologics and throughout treatment?

Answer 54

Latent tuberculosis

Question 55

What are BBWs on JAKis (-citinibs)

Answer 55

- Opportunistic infections - Lymphoma, malignancies - Thrombosis

Question 56

Which therapies should be avoided in pregnancy or liver disease?

Answer 56

MTX, LEF

Question 57

Which therapy is recommended in lymphoproliferative disorder?

Answer 57

Rituximab

Question 58

In which therapies are live vaccines NOT recommended?

Answer 58

TNFi and non-TNFi biologics

Question 59

On triple therapy of SSZ, HCQ, and MTX, which should be gradually discontinued first if indicated?

Answer 59

Sulfasalazine

Question 60

Between MTX or a b/tsDMARD, which should be discontinued first if indicated?

Answer 60

Methotrexate