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PHRM 864 Module 4 > Rheumatoid Arthritis > Flashcards

Rheumatoid Arthritis Flashcards

(55 cards)

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1
Q

Pharmacologic treatment

A

not able to cure pts or reverse the damage that’s been done
adjunct therapy: NSAIDs, corticosteroids
DMARDs, biologic agents anti-TNF, biologic agents (non-TNF)

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2
Q

NSAIDs

A

effective in reducing pain, swelling, and stiffness
do NOT alter disease progression
dose at anti-inflammatory doses
use in combo with DMARDs
ex. ibuprofen, naproxen, celecoxib (don’t use in pts with sulfa allergy!)
antinflammatory doses are higher

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3
Q

Corticosteroids

A

used for anti-inflammatory + immunosuppressive properties
not used as monotherapy
use in combo with DMARD
use in acute flares (to try and decrease the flare to save/preserve the DMARD)
use in pts with extra-articular manifestations
ex. prednisone
trying for lowest dose possible b/c of AEs, try to go for short term treatment

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4
Q

Corticosteroid AES

A

short term: hyperglycemia, gastritis, mood changes, elevated BP
long term: aseptic necrosis, cataracts, obesity, growth failure, osteoporosis

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5
Q

Monitoring parameters for corticosteroids

A

baseline: BP, BG
maintenance: BP q3-6mo, BG q3-6mo

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6
Q

Disease modifying anti-rheumatic drugs (DMARDs)

A

potential to decrease/prevent joint damage and preserve joint integrity
timing of initiation is critical
onset of action is delayed

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7
Q

DMARDs meds

A

methotrexate, sulfasalazine, hydroxychloroquine, leflunomide

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8
Q

Methotrexate

A

gold standard of treatment!
most predictable benefit
DMARD of choice and with best long-term outcome

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9
Q

Methotrexate MOA

A

inhibit dihydrofolic acid reductase (inhibits neutrophil adhesion and chemotaxis)

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10
Q

Methotrexate dosing

A

2.5mg tabs
dose: 7.5mg per WEEK by mouth or IM (up to 15-20 mg)
onset: 1-2 mo

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11
Q

MTX AEs

A

hematologic: bone marrow suppression
gastrointestinal: N/V/D, stomatitis, mucositis (taking with food helps) - folic acid supplementation 1mg/day to reduce sx
hepatic: cirrhosis, hepatitis, fibrosis
pulmonary: pneumonitis, fibrosis
dermatologic: rash, urticaria, alopecia
teratogenic: wait one cycle of BCP, wait 3 mo before considering conception

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12
Q

MTX contraindications

A

pregnancy, chronic liver disease (EtOH abuse), immunodeficiency, pre-existing blood dyscrasias, pleural/peritonal effusions, leukopenia/thrombocytopenia, CrCl< 40ml/min

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13
Q

MTX monitoring

A

baseline: CXR, CBC, SCr, LFTs, albumin
maintenance: CBC, SCr, LFT: <3mo: 2-4wks; 3-6mo: 8-12wks; >6mo: 12wks

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14
Q

Leflunomide MOA

A

prodrug
inhibit de novo biosynthesis of pyrimidines, interferes with tyrosine kinase activity, inhibits cell cycle progression

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15
Q

Leflunomide dosing

A

requires loading dose
teratogenic: use cholestyramine to clear from system b/c of it’s long t1/2 (16 days)

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16
Q

Leflunomide AEs

A

diarrhea, rash, alopecia, increased LFTs, teratogenicity

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17
Q

Leflunomide monitoring

A

CBC, SCr, LFT
baseline and maintenance: <3mo: 2-4wks; 3-6mo: 8-12wks, >6mo: 12wks

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18
Q

Sulfasalazine MOA

A

prodrug - cleaved in colon to sulfpyradine and 5-ASA
inhibits IL-1
do NOT use in pt with sulfa allergy!

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19
Q

Sulfasalazine AEs

A

gastrointestinal: N/V/D, anorexia
dermatologic: rash/urticaria/photosensitivity*
hematologic: leukopenia, thrombocytopenia; rare: hemolytic and aplastic anemia
caution for allergy

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20
Q

Sulfasalazine monitoring

A

CBC, SCr, LFT
baseline
maintenance: <3mo: 2-4wks; 3-6mo: 8-12wks; >6mo: 12wks

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21
Q

Hydroxychloroquine MOA

A

modification of cytokine infiltration in joint
used in earlier treatment (not as effective as others)

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22
Q

Hydroxychloroquine AEs

A

advantage: no myelosuppression, hepatic, renal toxicities*
ocular: retinal toxicity*; >70yo, cumulative dose >800g, night/peripheral changes
gastrointestinal: N/V/D (take w/ food)
dermatologic: increase skin pigment, rash, alopecia

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23
Q

Hydroxychloroquine monitoring

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A

vision exam
baseline
every 6-12mo
“appealing” because really no monitoring

24
Q

Biologic response modifiers (biologic DMARDs)

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A

TNF neutralizers: etanercept, infliximab, adalimumab, golimumab, certolizumab
all impact + neutralize TNF in different ways, if fail one, can try another in same class

25
TNF neutralizers warnings/precautions
risk of infection do not use in combo with IL-1 inhibitors or T-cell co-stimulation modulators (further increases risk of infection + AEs) black box warnings, increased neurologic/demyelinating disorders, malignancies, congestive HF, hepatitis B reactivation, no concurrent live vaccine administration (TB testing to make sure no latent TB)
26
TNF neutralizers AEs
HAs and rash, risk of infection (upper respiratory most common), injection site rxn, exarcerbations of CHF, risk of malignancy, risk of evidence of demyelinating disease
27
Etanercept
binds to and inhibits TNF - binding occurs before the cytokine can interact with cell-surface TNF receptors that would produce an inflammatory response SC!
28
Infliximab
binds and inhibits TNF IV! indicated in combo with MTX, could be used as monotherapy
29
Adalimumab
binds and inhibits TNF for pts who have inadequate response to one or more DMARDs; can be used alone or in combo SC every other week!
30
Golimumab
binds and inhibits TNF for moderate to severe RA; used in combo with MTX SC once monthly! monitor: CBC with PLT and LFTs
31
Certolizumab
binds and inhibits TNF for RA pts with moderate to severe disease; can be used alone or in combo with non-BRM DMARDs SC!
32
Anakinra
IL-1 inhibitor for moderate to severe RA in pts who have failed one or more DMARDs; can use alone or in combo SC! do not use in combo with TNF agents or abatacept
33
Anakinra AEs
injection site rxns, HA, N/V, flu-like sx, hypersensitivity to e.coli derived proteins, increased risk of serious infection, decreased neutrophils
34
Anakinra monitoring
neutrophil count prior to start, monthly for 3 mo, quarterly for up to one year
35
Selective T-cell co-stimulation modulator
abatacept
36
Abatacept
for moderate to severe RA; if had inadequate response to one or more DMARDs monotherapy or in combo with DMARD (not with TNF inhibitors or IL-1 antagonists) inhibits T-cell activation IV!
37
Abatacept warnings
do not use with TNF antagonists or IL-1 antagonists increased risk of infection no live vaccine administration caution in pts with COPD*
38
Abatacept AEs
HA, nausea, upper respiratory infection, nasopharingitis, infusion rxns, serious infection, malignancy
39
IL-6 receptor inhibitors
tocilizumab (IV) and sarilumab (SC) for moderate to severe RA after inadequate response to one or more DMARDs alone or in combo with MTX or another DMARD
40
IL-6 receptor inhibitors MOA
binds to soluble and membrane bound IL-6 receptors
41
IL-6 inhibitor warnings
black box warning: serious infections* contraindicated in pts with liver toxicity, thrombocytopenia, and neutropenia
42
IL-6 inhibitor AEs
serious infection, liver toxicity, thrombocytopenia, neutropenia, lipid abnormalities, intestinal perforations (tocilizumab), infusion rxns (tocilizumab)
43
IL-6 inhibitor monitoring parameters
neutrophil count - at 4-8wks then q3mo platelet count - at 4-8wks then q3mo LFTs - at 4-8wks then q3mo lipid profile - after 4-8wks then q6mo
44
Anti-CD20 antibody
rituximab "last resort" - reserved for pts who have failed others; for moderate to severe RA; in those with inadequate response to TNF antagonists; used in combo with MTX bind specifically to antigen CD20
45
Rituximab dosing
IV administer methylprednisolone 30 min before infusion to reduce infusion rxns
46
Rituximab AEs
tumor lysis syndrome, mucocutaneous rxns, viral infection, hypersensitivity, renal toxicity, bowel obstruction, hep B reactivation, cardiac arrhythmia
47
Rituximab monitoring
CBC with platelet, serum creatinine, vital signs (during infusions)
48
Targeted synthetic DMARDs
janus kinase inhibitors
49
Janus kinase inhibitors
these are oral agents! for moderate to severe RA after inadequate response to TNF; used alone or in combo with MTX or another DMARD; NOT in combo with BRM, azathioprine, or cyclosporine
50
Janus kinase inhibitors MOA
inhibits janus kinase
51
JAK inhibitor meds
tofacitinib baricitinib upadacitinib
52
JAK inhibitors warnings
cytochrome P450 interactions; do not use in hepatic impairment; risk of infection; risk of malignancy; major adverse CV events; thrombosis; GI perforations; no live vaccines do NOT use if: Hgb < 9mg/dL, ANC < 1000 cells/mm^3, ALC < 500 cells/mm^3
53
JAK inhibitors AEs and monitoring parameters
upper respiratory, HA, nausea monitoring: lympocyte count, neutrophil count, Hgb, liver enzymes, lipid profile
54
Combination therapy
drugs with different MOA; allows for decreased dosages and minimizes AEs; more effective in treating resistance; may provide dramatic slowing of progression; MTX most common in combo with other DMARDs
55
Therapeutic decisions
treat to target approach different considerations for stratification of patients: early RA vs established RA

PHRM 864 Module 4 (7 decks)

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