Rheumatoid Arthritis Treatment Flashcards
(109 cards)
1
Q
What is the goal of RA Treatment?
A
Low disease activity or remission
2
Q
What is DMARDs and what is included?
A
Disease modifying anti rheumatic drugs
1. Nonbiologic
2. Biologic
3
Q
NSAIDs have what main effect in RA treatment?
A
Anti-Inflammatory
4
Q
HPA Axis Steps
A
Hypothalamus: Corticotropin releasing hormone –> Pituitary: Corticotropin ACTH –> Adrenals: Cortisol –> neg feedback on Pituitary
5
Q
What are the indications of Corticosteroids?
A
- Extaarticular disease
- Vasculitis
- Active RA during pregnancy or breastfeeding
6
Q
What are the AEs of Corticosteroids?
A
- 2-4x increased GI risks when given with NSAIDs
- Moon face
7
Q
What can be accelerated with corticosteroids?
A
Atherosclerosis or Osteoporosis
8
Q
How can you prevent osteoporosis when taking corticosteroids?
A
- Calcium
- Vitamin D
- Weight baring exercise
- Bisphosphonate if moderate/high fracture risk
9
Q
When is pulse dose IV methylprednisolone used?
A
Lupus
10
Q
When is IM depot methylprednisolone used?
A
Immediate relief of pain
11
Q
What are the Nonbiologic DMARDs csDMARDs?
A
- Methotrexate
- Sulfasalazine
- Leflunomide
- Hydroxychloroquine
- Minocycline
- Cyclosporine
- Azathioprine
- Gold
- D-Penicillamine
12
Q
What is the primary nonbiological drug for RA?
A
Methotrexate
13
Q
Methotrexate absorption decreases with what?
A
Increased doses and food
14
Q
What is the onset of effect for Methotrexate?
A
Onset 3-6 weeks, max effect 3-6 months
15
Q
What is the hepatic concern with Methotrexate?
A
Fibrosis and Cirrhosis
16
Q
What is the pulmonary concern with Methotrexate?
A
Acute hypersensitivity pneumonitis vs. toxic drug reaction
Dyspnea, drug cough, and fever
17
Q
What are the toxicities of Methotrexate?
A
- Fetal abnormalities/abortifacient
- Oligospermia
18
Q
How do you decrease toxicity of Methotrexate?
A
Take with Folic Acid 1 mg/day
19
Q
What are the drugs that can cause decreased renal clearance and increased risk of toxicity of Methotrexate?
A
- Probenecid
- Salicylate
- NSAIDs
- Diuretics
20
Q
What are the drugs that displace Methotrexate from binding sites?
A
- Salicylate
- Sulfonamides
- Phenytoin
21
Q
What are the CIs of Methotrexate?
A
- Acute or chronic liver disease
- Excessive alcohol consumption
- Pregnanc
22
Q
What is precaution of Methotrexate?
A
Obesity, diabetes aka Fatty Liver, which the risk of fatty liver can be increased with Methotrexate
23
Q
What is the dosing frequency of Methotrexate?
A
EVERY WEEK
PUT DAY of week on the Rx Label
24
Q
What are the monitoring concerns with Methotrexate?
A
- CBC
- Cr
- Liver Enzymes
Q2-4 wks every 3 months, then q8-12 weeks for 3-6 months, and then q12 weeks after 6 months
25
What is the main takeaway of Methotrexate in RA?
Initial drug of choice, anchor for most combinations
26
What is the efficacy monitoring of Sulfasalazine?
1. Improvement detectable at 4-8 weeks
2. Failure identifiable within 3 months
27
What is the CI of Sulfasalazine?
Hypersensitivity to salicylate or sulfonamide
28
What is the monitoring for Sulfasalazine?
1. Baseline G6PD
2. CBC and LFTs within 1 month
29
What is the main toxicity of Sulfasalazine?
GI Effects 19%
30
What is the concern of Sulfasalazine during pregnancy?
Safe during pregnancy, but NOT safe AT TERM because it can cause Kernicterus: jaundice in the newborn
31
What are the PK parameters of Leflunomide?
Prodrug for Teriflunomide and still detectable 2 years later
32
What is the main toxicity of Leflunomide?
Increased LFTs, Severe Liver Injury
Stop is ALY 3x ULN
33
What are the CIs of Leflunomide?
1. Teratogenicity
2. Prior to pregnancy, drug is eliminated with cholestyramine until plasma concentration <0.02 ng/L
34
What is the monitoring of Leflunomide?
1. Baseline Hep B and C
2. Same as MTX and SAS
35
How long does it take to determine efficacy of Hydrochloroquine?
6 months to determine failure
36
In mild RA, how is Hydrochloroquine utilized?
Monotherapy
37
What is the elimination half life of Hydrochloroquine?
40 days
38
What is the main side effect of hydrochloroquine, and what is a side effect that Dr. Resman-Targoff was surprised by?
1. Retinal Damage
2. Skin Hyperpigmentation (dr. resman)
39
What are the counseling points of Hydroxychloroquine?
1. Considered safe in pregnancy
2. Take with food or milk
40
What are the monitoring parameters of Hydroxychloroquine?
1. CBC
2. LFTs
3. Creatinine
41
What is Minocycline?
1. Not currently in ACR RA treatment guidelines
2. Previously used for Mild RA off label
42
What is the plasma half life of Cyclosporine?
1-45 hrs
43
What is the efficacy of Cyclosporine?
Seen at 2-12 weeks
Peaks at 6 months
44
What are the toxicities of Cyclosporine?
1. Nephrotoxicity
2. Hypertension
3. Gingival Hyperplasia
4. Hyperkalemia
5. Hypomagnesemia
6. Hyperuricemia
7. GI
8. Neuropathies
9. Hirsutism
45
What are the monitoring parameters of Cyclosporine?
1. Cr
2. BP
3. K
4. Uric Acid
46
There is a high risk of toxicity for Azathioprine is what?
Low or Absent TPMT
47
What is the concern in pregnancy for Azathioprine?
Considered safe in pregnancy but use CI by manufacturer?
48
What is the efficacy of Azathioprine?
Onset 6-12 weeks
Peak 6 months
49
What are the Targeted Synthetic DMARDs/Oral Janus Kinase JAK Inhibitors?
1. Xeljanz
2. Olumiant
3. Rinvoq
50
How to spell Tofacitinib brand name?
X E L J A N Z
51
How to spell Baricitinib brand name?
O L U M I A N T
52
How to spell Upadacitinib brand name?
R I N V O Q
53
What can you NOT combine JAK Inhibitors with?
1. Azathioprine
2. Cyclosporine
3. Tacrolimus
4. Biologics
5. Other JAK Inhibitors
54
What is the toxicity of JAK Inhibitors?
1. Thrombosis
2. Zoster
3. GI Perforation
4. Increased LDL Cholesterol
5. Increased LFTs
55
What is a risk of JAK Inhibitors?
Risk of Major CV Events and malignancy
56
What should monitor for with JAK Inhibitors?
1. CLOTS
2. CBC
3. Lipid Panel
4. Infections
57
Xeljanz dosing is what?
PO
58
Olumiant dosing and caution is what?
PO
Not used for GFR <60
59
Rinvoq dosing and caution is what?
PO
AVOID if severe hepatic impairment
60
What are the Anti-TNF Monoclonal Antibodies?
1. Infliximab
2. Adalimumab
3. Golimumab
4. Certolizumab Pegol
5. Entanercept
6. Rituximab
7. Abatacept
61
What does (I)I mean?
Immune target
62
What does xi mean?
Chimeric
63
What does (m)u mean?
Fully human
64
What does zu mean?
Humanized
65
What should you avoid when taking TNFa Inhibitors?
Avoid foods with listeria risk
66
What happens to the fetus when mother is taking TNFa Inhibitors?
Immunosuppression after birth
67
What is the MOA of Etanercept and its dosing?
Soluble TNF receptor, binds TNFa, blockers interaction
SUB Q
68
What is the main drug warning of Entanercept?
CNS Demyelinating disorders
69
What is the MOA of Infliximab and its dosing?
Chimeric, binds to TBFa
IV INFUSION
70
What are the toxicities of Infliximab?
1. TB Reactivation
2. Acute infusion reaction
3. Hypesensitivity
4. Increased infection risk
71
What is the MOA of Adalimumab and its dosing?
HUMAN IgG1, binds TNFa
SUB Q, Without or without MTX
72
What is the MOA of Golimumab and its dosing?
HUMAN IgG1, binds TNFa
SUB Q or IV WITH MTX in RA
73
What is the MOA of Certolizumab Pegol and its dosing?
Peglayted Fab Fragment
SUB Q, alone or with nonbiologic DMARD in RA
74
What is the MOA of Rituximab?
CHIMERIC, directed against B cell surface antigen CD20, depletes B Cells
75
When do you use Rituximab in RA?
1. Active RA
2. Inadequate response or intolerance to TNF inhibitors
76
Can you use Rituximab in pregnancy?
NO, not recommended
77
What is the dosing of Rituximab?
1. With MTX
2. IV Infusion day 1 and 15
3. Q 24 weeks
78
What is the MOA of Abatacept?
Selective Costimulation Modulator
79
What are the toxicities of Abatacept?
COPD Exacerbations
80
What is the dosing of Abatacept?
IV Infusion or SUB Q
Avoid silicone syringes
81
What are the Il-6 Antagonists?
1. Tocilizumab
2. Sarilumab
3. Anakinra
82
What is the MOA of Tocilizumab?
HUMANIZED IL-6 Receptor inhibiting monoclonal antibody
83
What is the toxicity of Tocilizumab?
1. Gastrointestinal perforation
Increased liver enzymes and lipids, decreased neutrophils and platelets
84
Can you use Tocilizumab in pregnancy?
NO
85
What is the dosing of Tocilizumab?
IV Infusion or SUB Q
86
What is the MOA of Sarilumab?
FULLY HUMAN IL-6 receptor inhibiting monoclonal antibody
87
What are the toxicities of Sarilumab?
1. GI Perforation
Increased liver enzymes and lipids
88
What is the dosing for Sarilumab?
SUB Q
89
What is the MOA of Anakinra?
RECOMBINANT IL-6 receptor antagonist
90
What is the dosing of Anakinra?
SUB Q DAILY
91
Is Anakinra recommended in pregnancy?
NO
92
What is Comorbidity?
2 simultaneous diseases that occur together more often than by chance
93
What is Multimorbidity?
2 simultaneous disease that occur together randomly
94
What should be in lab monitoring of RA?
1. ESR
2. CRP
3. Hemoglobin/Hamtocrit
4. Platelets
5. X-Rays
95
Do you use RF in monitoring of RA?
NO, only used to establish diagnosis
96
What are the RA Treatment Strategies?
1. Combo therapy
2. A+B+C+D
3. Methotrexate Anchor
97
Why do you want to give Chimeric monoclonal antibodies with Methotrexate?
To decrease formation
98
Can Biologics and JAK Inhibitors be combined?
NO
99
Which drug needs an elimination procedure prior to pregnancy and what is it?
Leflunomide, eliminate with Cholestryramine
100
What is the initial treatment guideline?
1. DMARD naive, low disease activity = HCQ>MTX>LEF
2. DMARD naive, mod/high disease activity = MTX mono>HCQ mono, SAS, bDMARD, tsDMARD, or combo
3. csDMARD without glucocorticoid preferred
101
What is methotrexate admin guideline?
Initial oral MTX preferred over SUB Q
102
What is the treatment modification guideline?
1. Max tolerated MTX dose, adding bDMARD or tsDMARD preferred over cs DMARD triple therapy
2. Adding/switching DMARDs preferred over continuing/adding glucocorticoid to stay at target
103
What is the tapering of DMARD guideline?
1. Gradually DC Drugs
2. If on triple csDMARDs, gradually DC SAS>HCQ
3. Gradually DC MTX>stopping bDMARD or tsDMARD
104
How long should RA treatment be at target prior to tapering?
At target >6 months before tapering
105
When should you screen TB?
Before biologic or JAK inhibitor
106
Which drugs have the highest reactivation of tuberculosis?
TNFa Inhibitors Infliximab or Adalimumab
107
What is the screening for TB?
1. Screen with PPD or IGRA, if positive get CXR
2. If CXR positive, get sputum for AFB
3. If AFB positive, treat for TB >3 months before starting biologic/JAK
4. If AFB or CXR neg, treat for latent Tb 1 month before biologic/JAK
108
Immunosuppressed patients may have diminished response to vaccines and increased risk for infections. Vaccine may trigger autoimmune diseases and therefore,
Should be administered before starting
109
For patients older than 50 yrs what vaccine should you consider?
Shingrix, especially before JAK inhibitors
