Rheumatoid arthritis

Question 1

Describe the clinical presentation of RA

Answer 1

Joint pain and stiffness for 6 weeks or longer
Nonspecific symptoms like fatigue, weakness, low-grade fever, loss of appetite, etc
Distribution of joint involvement often symmetrical (but not always)

Question 2

RA usually effects what joints?

Answer 2

RA usually affects smaller joints in the hands and feet

OA usually affects bigger joints like knees and hips

Question 3

What are the goals of treatment of RA?

Answer 3

Primary goal: Improve or maintain functional status

Ultimate goal: Achieve complete remission or achieve low disease activity

Question 4

What non-pharmacologic options are available for RA?

Answer 4

Rest
Occupational therapy
Physical therapy
Assistive devices
Weight loss
Surgery

Question 5

What are DMARDs?

Answer 5

Nonbiologic DMARDs are older and oral
Biologic DMARDs are injections, split into Anti-TNF and Non-TNF biologics

Disease-modifying antirheumatic drugs (DMARDs)

Decrease pain and inflammation, and reduce disease progression

Question 6

What supportive care is available for RA?

Answer 6

NSAIDs

Corticosteroids

Question 7

What is the most commonly used DMARD?

Answer 7

Methotrexate

Question 8

How long before you determine if a drug isnt working

Answer 8

1-2 months (takes this long for a DMARD to work)

Question 9

What supplemental treatments are needed with methotrexate?

Answer 9

Folic acid

or Leucovorin

Question 10

How is methotrexate dosed

Answer 10

7.5 mg WEEKLY (up to 25 mg/week)

NEVER DOSE DAILY!

Question 11

What monitoring is required with MTX

Answer 11

CBCs
LFTs
SCr at baseline, monthly for 6 months, then q1-2 months forever

Question 12

What option do we have besides methotrexate for Non-biologic DMARDs

Answer 12

Leflunomide
Efficacy comparable to methotrexate, but more expensive
Worry about hepatotoxicity and it also CANNOT be given in pregnancy

Question 13

What drugs cannot be given in pregnancy

Answer 13

Leflunamide

Question 14

What drug is the least potent / least effective DMARD

Answer 14

Hydroxychloroquine

Question 15

What drug has interactions with antibiotics, iron supplements, and warfarin?

Answer 15

Sulfasalazine

Question 16

What if Methotrexate doesn’t work?

Answer 16

Can use it with any of the other agents, or even do triple therapy

Question 17

When do we use biologic DMARDs?

Answer 17

When non-biologics fail

Question 18

How are biologic DMARDs administered?

Answer 18

All injections every 1-4 weeks, Infliximab is an infusion every 8 weeks

Question 19

What do we have to do before giving biologic DMARDs?

Answer 19

Make sure pts are tested and treated for TB before starting treatment

Question 20

What is Tofacitinib citrate?

Answer 20

New oral agent, oral BID dosing
Only use after biologic treatment failure
Much more expensive

Question 21

When should treatment be started?

Answer 21

A DMARD should be started within 3 months of symptom onset

MTX first line, but no single DMARD is superior to another

Question 22

Which drug is proven to be less efficacious?

Answer 22

Anakinra

Question 23

If a biologic doesn’t work, can we combine therapy?

Answer 23

No - it’s no better than monotherapy and gives you increased risk of infections bc immune suppression

Question 24

What is early RA? What are the treatment options?

Answer 24

Early RA is less than 6 months

High disease/good prognosis: Methotrexate, leflunomide, sulfasalazine, or combi
High disease/poor prognosis: Combination DMARD or TNF inhibitor with or without MTX

Low disease/good prognosis: Hydroxychloroquine or minocycline
Low disease/poor prognosis: Methotrexate, leflunomide, sulfasalazine, or combination DMARD

Question 25

What is Late RA? What are the treatment options?

Answer 25

Late RA is 6 months or more Low disease activity: Use Nonbiologic DMARD, if that doesn't work use combo nonbiologics or anti-TNF High disease activity/good prognosis: Nonbiologic DMARD, poor response use Anti-TNF or combination non-bioogic High disease acitivity/poor prognosis: MTX, leflunomide, nonbiologic combination or Anti-TNF

Question 26

What Anti-TNFs are there?

Answer 26

``` Adalimuban Etanercept Certolizumab Golimumab Infliximab ``` Adam Eats Cereal with Gollum and watches Netflix

Question 27

What Non-TNF biologics are there?

Answer 27

Abacept Rituximab Tocilizumab Anakinra ABBA stayed at the Ritz To visit their Kin

Question 28

What drugs are not recommended in pregnancy?

Answer 28

MTX Leflunomide Minocycline

Question 29

Which drugs are not recommended in CHF?

Answer 29

Anti-TNF biologics ``` Adalimuban Etanercept Certolizumab Golimumab Infliximab ```

Question 30

What drugs are not recommended in Tb?

Answer 30

MTX Leflunomide Tofacitinib Any biologic

Question 31

What drugs are recommended in Hepatitis C?

Answer 31

Etanercept

Question 32

What drugs are recommended in malignancy (cancer)?

Answer 32

Rituximab | Any biologic

Question 33

What vaccinations should be avoided? When?

Answer 33

Pts taking Anti-TNF biologics or Non-TNF biologics should not get live attenuated Herpes zoster vaccine DMARDs are ok

Question 34

Nancy is a 35 year old female who received a prescription today for methotrexate 15 mg tablets weekly for management of rheumatoid arthritis. Her physician consults you to recommend laboratory monitoring and recommendations to reduce drug toxicity. What laboratory monitoring would you recommend today at baseline for Nancy? ᅞ A: Lipid panel and ophthalmologic examination ᅚ B: CBC, liver function panel, serum creatinine ᅞ C: Chest x-ray and tuberculin skin test D: Hemoglobin A1c and BMP

Answer 34

B: CBC, liver function panel, serum creatinine ᅞ

Question 35

Mrs. Bloom is a 38 year old woman with a 1 year history of rheumatoid arthritis. Her current medications include: methotrexate 25 mg once weekly, folic acid 1mg daily, sulfasalazine 500 mg delayed-release tablets 2 tablets twice a day, and prednisone 7.5 mg daily. She returns to her rheumatologist today (last visit 3 months ago) with complaints of worsening pain bilaterally in her hands and feet and declines in her ability to do chores around the house. Her ESR and CRP levels are elevated and joint radiographs indicate multiple erosions of MCP and PIP joints bilaterally (worsened from 6 months ago). Which of the following options is the BEST treatment plan for Mrs. Bloom based on her current presentation? A: Continue current therapy and re-evaluate in 3 months. B: Add anakinra 100 mg subcutaneously daily C: Discontinue methotrexate and sulfasalazine, begin etanercept 50 mg subcutaneously weekly D: Discontinue sulfasalazine, begin adalimumab 40 mg subcutaneously every other week

Answer 35

D: Discontinue sulfasalazine, begin adalimumab 40 mg subcutaneously every other week