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Pharmacotherapy > Rheumatoid Athritis > Flashcards

Rheumatoid Athritis Flashcards

1
Q

Presentation of Rheumatoid arthritis

A

Chronic

Symmetrical

Systemic

Progressive

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2
Q

What Rheumatoid Arthritis

A

Immune system unable to differentiate native from non-native tissues attacking mostly synovial and other connective tissues

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3
Q

What is pannus

A

Inflammation and proliferation of synovial tissue lining the joints

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4
Q

What is the pathophysiology of Rheumatoid Arthritis

A

Macrophages release cytotoxins activating free oxygen radicals inducing cellular damage and inflammation

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5
Q

True/false: RA can manifest in areas outside the joints

A

True

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6
Q

Where does RA most commonly occurs

A

In diseases that are longstanding, and active

Rheumatoid factor positive

Anti-cyclic citrullinated peptide positive

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7
Q

What are the systemic involvement of RA

A

Rheumatoid nodules

Vascular

Pulmonary

Ocular

Cardiac

Hematologic

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8
Q

How is RA compared to OA

A

Proximal fingers joints, wrist, toes and elbow

Symmetric

Inflammation of soft connective tissue and accumulation of fluid

Better with activity

Affects 1% of the population

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9
Q

OA compared to RA

A

Hips, knees, lower back

Asymmetric

Wearing of cartilage

Worse with activity

15% of the population

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10
Q

To Hal one patients major complaint in the clinic for RA (Clinical presentation)

A

Diffuse pain > 6 weeks

Morning stiffness < 1 hour

Tenderness with warmth and swelling of affected joints

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11
Q

What labs factors are used to diagnose RA

A

Rheumatoid factor

ACPA positive

ESR elevated and CRP marker

CBC with differential to identify mild/ moderate thrombocytopenia or anemic

Turbid synovial find

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12
Q

What imaging are used to diagnose and track progression of the disease

A

Radiography

Ultrasonography

MRI

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13
Q

What is the criteria for RA

A

Synovitis of at least one joint with no other explanation

A score greater than 6 in 2010 ACR/EULAR classification criteria

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14
Q

What are the nonpharmacologic approach to addressing RA

A

Rest

PT/OT

Exercise

Surgery

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15
Q

Synthetic DMARDS csDMARDs

A

Hydroxychloroquine

Methotrexate

Leflunomide

Sulfasalazine

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16
Q

Synthetic targeted DMARDs

A

Tofacitinib

Upadacitinib

Baricitinib

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17
Q

Biologic DMARDS TNFi

A

Adalimumab and biosimilars

Certolizumab

Etanercept and biosimilars

Golimumab

Infliximab and biosimilars

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18
Q

Biologic DMARDS non-TNFi

A

Abatacept

Anakinra

Rituximab

Tocilizumab

Sarilumab

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19
Q

Supportive medication

A

NSAIDs

Steroids

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20
Q

NSAIDs

A

Work quickly

Systemic or oral

Does not impact disease progression

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21
Q

Steroids

A

Work quickly

Systemic or intra-articular injections

Long term risks

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22
Q

Methotrexate MOA

A

Increase AMP to suppress inflammatory actions of neutrophils, macrophages and lymphocytes

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23
Q

Methotrexate dosing

A

7.5-25 mg/week

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24
Q

Methotrexate PK

A

Absorption: 60%

1/2 life: 8 hours

Renally excreted

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25
Q

Methotrexate ADR

A

Mucositis

GI ulcers

Alopecia

Photosensitivity

Hepatotoxicity

Nausea/vomiting/ diarrhea

Myelosuppression

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26
Q

Which vitamin is giving to reduce ADR methotrexate

A

B9 = folic acid

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27
Q

How often is methotrexate administered

A

Weekly

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28
Q

What is methotrexate onset

A

2-3 weeks of onset use corticosteroids in the meantime

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29
Q

What other formulation is methotrexate available in

A

Injections

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30
Q

What is important to know when using methotrexate

A

Not for pregnancy = teratogenic

Do not use with alcohol

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31
Q

For whom is methotrexate contraindicted tor

A

CrCL < 30 ml/min

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32
Q

What should be monitored for methotrexate

A

Liver transaminases

Serum creatinine

CBC

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33
Q

Leflunomide MOA

A

Inhibits pyrimidine synthesis in lymphocytes and osteoclasts activity

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34
Q

How is leflunomide closed

A

100 mg TID followed by 20 mg daily

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35
Q

Leflunomide PK

A

Absorption: 80%

1/2 life: 14 days

Renal and hepatic elimination

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36
Q

Leflunomide toxicity

A

Hepatotoxicity

Alopecia

GI upset

NVD

Rash

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37
Q

What should be monitored of leflunomide is giving in combination with methotrexate

A

Hepatotoxicity

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38
Q

If leflunomide full dose is intolerable what should be done

A

Reduce dose by 10 mg and loading dose may be omitted

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39
Q

Why leflunomide not giving to pregnant women

A

Teratogenic

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40
Q

What should be monitored with leflunomide

A

Liver transaminases

CBC with platelets

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41
Q

Hydroxylchloroquine MOA

A

Anti-inflammatory and immunomodulatory effects

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42
Q

Hydroxychloroquine dosing

A

200-300 mg twice daily

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43
Q

Hydroxychloroquine PK

A

Absorption: 70%

1/2 life: 40 days

Renally excreted

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44
Q

Hydroxychloroquine ADR

A

NVD

Rash

Weakness

Macular damage

Pigmentation changes

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45
Q

When is hydroxychloroquine used in RA therapy

A

Less active form of RA

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46
Q

Should hydroxylchloroquine be taken with food

A

Yes

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47
Q

What is the onset for hydroxychloroquine

A

Delayed for upto 6 weeks

48
Q

What should be monitored with hydroxychloroquire

A

CBC

Vision

Liver transaminases

49
Q

Sulfasalazine MOA

A

Modulate local chemical mediators of inflammatory response

50
Q

Sulfasalazine MOA

A

0.5-1 g daily

51
Q

Sulfasalazine MOA

A

Absorption:10%

1/2 life: 14 hours

Renally excreted

52
Q

Sulfasalazine ADR

A

Myelosuppression

Rash

Headache

NVD

Anorexia

Skin and urine pigmentation

53
Q

When is the effects of Sulfasalazine seen

A

2 months

54
Q

What can decrease absorption of Sulfasalazine

A

Antibiotic that destroy colonic bacteria

55
Q

Who should avoid Sulfasalazine

A

Patient with sulfa allergy

56
Q

Should Sulfasalazine be taking with full glass of water and food

A

Yes

57
Q

What vitamin can be supplemented with Sulfasalazine 1 mg daily

A

Folic acid

58
Q

What should be monitored in Sulfasalazine

A

CBC

Liver transaminases

59
Q

What is Tofacitinib , Baricitinib, Upadacitinib MOA

A

Janus kinase inhibitors preventing cytokine/ growth factor signaling

60
Q

Tofacitinib dosing

A

5 mg BID

61
Q

Tofacitinib PK

A

Absorption; 70%

1/2 life: 3 hours

Renally excreted

62
Q

Tofacitinib ADR

A

Myelosuppression

Infection

Diarrhea

Headache

GI perforations

Increased lipids

63
Q

What should patient that use tofacitinib avoid

A

biologic or potent immunosuppressant

Strong CYP450 inducers

64
Q

What changes to dose of tofacitinib should be made when taking with 3A4 and 2C19 inhibitors

A

Reduce to 5 mg daily

65
Q

Baricitinib dosing

A

2 mg daily

66
Q

Baricitinib and upadacitinib PK

A

Absorption: 80%

Half life:.12 hours

Elimination: Kidney and feces

67
Q

Baricitinib ADR

A

URTI

Hepatic dysfunction

Infections and increased lipids

68
Q

Upadacitinib dosing

A

15 mg daily

69
Q

Upadacitinib MOA

A

URTI

Nausea

Cough

Pyrexia

70
Q

What should not be used in patients taking: Tofacitinib, Baricitinib, upadacitinib

A

Biologics or potent immunosuppressants

71
Q

What should patient taking; tofacitibinib, Baricitinib or upadacitinib be instructed to monitor

A

Infection

Shortness of breath

Signs of bleeding

72
Q

What should be monitored in patients taking: Tofacitinib, Baricitinib, upadacitinib

A

CBC

Liver transaminases

Lipids

Hemoglobin

73
Q

BBW: thrombosis and tuberculosis

A

Upacitinib and Baricitinib

74
Q

Avoid use with strong CYP3A4 inducers/inhibitors

A

Baricitinib and upadacitinib

75
Q

What are the dual of therapy MTX

A

Leflanomide

HCQ

Sulfasalazine

Tofacitinib

76
Q

Dual therapy for Sulfasalazine

A

HCQ

77
Q

Triple therapy

A

Sulfasalazine + MTX + HCQ

78
Q

TNF alpha inhibitors MOA

A

Suppress inflammatory actions of TNF

79
Q

TNF alpha inhibitors ADR

A

Immunosuppression

Heart failure

Hepatotoxicity

Abdominal pain

Infection site reactions

Rash

80
Q

For whom is TNF alpha inhibitor contradicted

A

Congestive heart failure relative

81
Q

What should patient who require TNF alpha inhibitor be tested and treated for?

A

TB

82
Q

What type of vaccines should not be used in patients on TNF alpha inhibitors

A

Live vaccines

83
Q

TNF alpha inhibitors can increase the risk of?

A

Serious bacterial and fungal infections

84
Q

True/false: more than one biologic can be used concomitantly

A

False

85
Q

All TNF alpha inhibitor require refrigeration except

A

Etanercept

86
Q

What should be monitored in patients on TNF alpha inhibitors

A

TST

Hepatitis screening

Sx of infections

87
Q

Which TNF-alpha inhibitors is IV

A

Infliximab

88
Q

Which TNF alpha inhibitors are subcut

A

Adalimumab

Etanercept

Certolizumab

Golimumab

89
Q

Which TNF-alpha inhibitors is used in combination with metothrexate

A

Infliximab

Adalimumab

Golimumab

Rituximab

90
Q

Which TNF-alpha inhibitor requires premedication

A

Infliximab

91
Q

For patients with congestive heart failure for whom infliximab recommended what is the dose needed

A

Not greater than 5 mg/kg

92
Q

Which has high rate of injection site reaction

A

Infliximab

93
Q

Inhibit t-cell activation

A

Abatacept

94
Q

Abatacept PK

A

1/2 life: 13 days

renally excreted

95
Q

Abatacept ADR

A

Infection

Infusion reaction

False hyperglycemia

96
Q

Can use csDMARDs

A

Abatacept

Tocilizumab

Sarilumab

Rituximab (MTX)

97
Q

Can worsen COPD

A

Abatacept

98
Q

Monitor for TST and signs of infections

A

Abatacept

Rituximab

99
Q

Chimeric monoclonal CD-20 antibody

Targets b-cells

A

Rituximab

100
Q

Rituximab PK

A

1/2 life: 18 days

101
Q

Rituximab ADR

A

Arthralgias

Myelosuppression

Hyperphosphatemia

Hypertension

102
Q

Infusion requires premedication

A

Rituximab

103
Q

IL-6 receptor antagonist

A

Tocilizumab

Sarilumab

104
Q

Tolicizumab PK

A

1/2 half: 6 days

105
Q

Tocilizumab MOA

A

Hypersensitivity reactions

Immunosuppression

GI perforation

Dyslipidermia

Infections

106
Q

Tocilizumab monitoring parameters

A

Liver transaminases

CBC

Lipids

Sx of infection

107
Q

IL-1 receptor antagonist

A

Anakinra

108
Q

Anakinra Dosing

A

100 mg subcut daily

109
Q

Anakinra PK

A

1/2 half:4-6 hours

110
Q

Anakinra ADR

A

Neutropenia

Diarrhea

Influenza like reaction

Injection site reaction

111
Q

Which drugs require renal adjustment

A

Anakinra

112
Q

Anakmira monitoring parameter

A

Neutrophil count

Symptoms of infection

113
Q

Sarilumab dosing

A

200 mg subcut every 2 weeks

114
Q

Sarilumab PK

A

1/2 life concentration dependent: 8-10 days

115
Q

Sarilumab ADR

A

Injection site reactions

Dyslipidemia

Infection

Neutropenia

Hepatotoxicity

GI perforation

116
Q

Sarilumab monitoring parameters

A

TST

Sx of infections

Liver transaminases

Lipids

Pharmacotherapy (12 decks)

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