Rhuematoid arthritis Flashcards
(135 cards)
1
Q
Rheumatoid Arthritis defintion
A
systemic inflammatory disease characterized by symmetrical joint involvement
2
Q
Age of onset of RA
A
15-45 years
3
Q
Most common antigen found in RA pts
A
HLA-DR4
4
Q
RA is more common in which gender
A
female
5
Q
symptoms of RA
A
joint pain or stiffness > 6 weeks fatigue and weakness low grade fever, loss of apetite anemia muscle pain and afternoon fatigue
6
Q
Rheumatoid factor to be considered positive
A
> 1: 80; 80% have >1:320
7
Q
Antibodies against citrullinated antigens (Anti CCP)
A
positive in 80-90% of RA pts.
strongly positive > 60
negative < 20
8
Q
Labs useful for diagnosing RA
A
anti CCP RF ESR C reactive protein (CRP) hematologic abnormalities
9
Q
hematologic abnormalities seen in RA
A
Thrombocytosis and anemia
10
Q
Score needed to diagnose RA
A
6+ /10
11
Q
points for involvement of 1 medium to large joint
A
1
12
Q
points for involvement of 2-10 medium to large joints
A
2
13
Q
points for involvement of 1-3 small joints (w or w/o involvement of large joints)
A
3
14
Q
points for involvement of 4-10 small joints (w or w/o involvement of large joints)
A
4
15
Q
points for involvement of 10+ joints (at least one small joint)
A
5
16
Q
how many serology tests needed for diagnosis of RA (RF or anti CCP)
A
at least 1
17
Q
how many acute phase reactants needed for diagnosis of RA (CRP, ESR)
A
at least 1
18
Q
how many points for a negative RF and negative anti CCP
A
1
19
Q
how many points for a low positive RF or low positive anti CCP
A
2
20
Q
how many points for a high positive RF or high positive anti CCP
A
3
21
Q
how many points for a normal CRP and normal ESR
A
0
22
Q
how many points for an abnormal CRP or abnormal ESR
A
1
23
Q
how many points for duration of symptoms < 6 weeks
A
0
24
Q
how many points for duration of symptoms 6+ weeks
A
1
25
Functional classification I for RA
able to perform daily activites
26
functional classification II for RA
some restriction of performing daily activities
27
functional classification III for RA
Considerable restriction of performing daily activities
28
Functional classification IV for RA
restricted to bed or wheelchair
29
RA goals of therapy
```
early diagnosis
reduce progression of joint damage and pain
control disease
alleviation of pain
improve QOL
Maintain joint function
```
30
Non pharmacological therapy for RA
```
rest
PT
assistive devices
weight reduction
short term pain relief
surgery
```
31
rest for RA includes
relaxation
stress management
coping skills
32
PT for RA includes
Joint flexibility, muscle strength
| daily activities
33
Assistive devices used for RA include
proper footwear
34
Short term pain relief for RA includes
wax baths
| TENS
35
Surgery for RA includes
```
persistent pain due to joint damage
progressive deformity or prevention of deformity
persistent localized synovitis
tendon rupture
stress fracture
```
36
symptom control for RA includes what medications
NSAIDS, Corticosteroids, opioids (last line)
37
Advantages for use of corticosteroids in RA
quick relief properties, low cost, antiinflammatory action
38
Disadvantages of corticosteroids in RA
do not modify disease process
| associated with long term AEs
39
DMARD definition
disease modifying antirheumatic drugs
40
nonbiologi DMARDS
```
methotrexate
leflunomide
hydroxycholoquine
sulfsalazine
gold salts
D-penicillamine
azathioprine
cyclophosphamide
cyclosporine
```
41
signs of RA
```
symmetrical
tenderness and warmth, swelling over joints
joint damage +/- deformities
Rheumatoid nodules (elbows, forearms, hands)
```
42
normal CRP
0-0.5 mg/dL
43
TNF inhibitors include
```
Adalimumab
Certolizumab pegol
etanercept
golimumab
infliximab
```
44
adalimumab brand name
humira
45
certolizumab pegol brand name
cimzia
46
etanercept brand name
enbrel
47
golimumab brand name
simponi
48
infliximab brand name
remicade
49
abatacept brand name
orencia
50
anakinra brand name
kineret
51
canakinumab brand name
ilaris
52
rituximab brand name
rituxan
53
tocilizumab brand name
actemra
54
tofacitinib brand name
xeljanz
55
non-biologic DMARD of choice
methotrexate
56
methotrexate MOA
inhibits purine synthesis
57
response to methotrexate takes
2-3 weeks
58
dose of methotrexate
7.5 mg QW PO
59
max dose of methotrexate
30 mg/week
60
methotrexate available forms
PO
IM
subQ
61
AEs of methotrexate
```
elevated LFTs
N/V
stomatitis
malaise
anorexia
bone marrow suppression
folic acid deficiency
hypersensitivity pneumonoitis
```
62
Monitoring for methotrexate
CBC w/ platelets
AST
albumin
SCr
63
Avoid methotrexate in who
pregnant
64
To avoid methotrexate toxicity give what
Folic Acid 1 mg PO QD or 7 mg QW
or
Leucovorin (folinic acid) 2.5-10 mg QW PO
65
CIs to methotrexate
```
pregnancy/nursing
chronic liver disease
immunodeficiency
pleural or peritoneal effusions
leukopenia or thrombocytopenia
decreased renal function (< 30)
```
66
Drug interactions with methotrexate
Caffiene (>180 mg)
Trimethoprim
NSAIDs, salicylates, probenecid, penicillin, ciprofloxacin
67
Leflunomide brand name
Arava
68
Leflunomide MOA
inhibits pyrimidine synthesis
69
Leflunomide dosage
100 mg PO QD 3 days, 20 mg PO QD
70
Leflunomide AEs
```
Diarrhea
Alopecia
Nausea
Rash
Hepatotoxicity
Teratogenicity
```
71
Leflunomide monitoring
LFTs at baseline and monthly until stable
| CBC
72
Avoid pregnancy how long after leflunomide
4 months
73
Hydroxychloroquine brand name
Plaquenil
74
Hydroxychloroquine benefit seen when
2-4 months, maybe 3-6 months
75
hydroxycloroquine dose
200 mg PO BID
76
hydroxychloroquine AEs
agranulocytosis, thrombocytopenia, aplastic anemia
Hemolysis if G6PD deficient
Seizures
Visual changes - exam annually
77
Sulfasalazine brand name
Azulfidine
78
Sulfasalazine response seen when
after 1-2 months
79
Sulfasalazine dose
1000mg 2-3 x daily after meals, drink fluids
80
sulfasalazine AEs
```
steven's johnson syndrome
hepatitis
agranulocytosis
peripheral neuropathy
decrease in sperm count
HA
depression
rash, pruritus
thrombocytopenia
jaundice
fever
```
81
Minocycline dose for RA
50-200 mg /day in divided doses
82
minocycline AEs
drug induced lupus
83
CIs to minocycline
young children
| pregnant/nursing
84
Azathioprine brand name
imuran
85
oral gold brand name
auranofin
| ridaura
86
injectable gold brand name
aurothioglucose
| solganal
87
D-penicillamine brand name
Cuprimine
88
Black Box warnings for all biologic DMARDS
Risk of infections - Tb, fungal
| Risk of lymphoma or other cancers
89
CIs to biologic DMARDs
moderate to severe congestive heart failure
| multiple sclerosis or optic neuritis
90
ADRs to all biologic DMARDS
```
infections
- give live vaccines prior to start
- PPD prior to start
- pt education and monitoring
Allergic reactions
- local: redness and itching
- systemic: hypotension, fever, chills
```
91
Adalimumab dose
40 mg SubQ
| recommended take with methotrexate
92
adalimumab AEs
```
upper respiratory infection
HA
rash
sinusitis
injection site reaction
```
93
Certolizumab pegol dosage
400 mg SubQ, at 2, 4, weeks, then 400 mg subQ 4 weeks
94
Etanercept response time
2 weeks
95
Etanercept dosage
50 mg SubQ weekly or 25mg SubQ twice weekly
| alone or with MTX
96
Do not take what with etanercept
anakinra
sulfasalazine
live vaccines
97
Etanercept AEs
mild erythema/itching
Risk of severe infections
CNS demyelinating disorders
Hematologic events (pancytopenia, aplastic anemia)
98
Golimumab dosage
50 subQ once monthly with MTX
99
Golimumab drug interactions
TNF blockers
| cyclosporine, theophylline, warfarin
100
Infliximab dosage form
IV infusion in outpatient clinics over 2 hours
| premedicate with APAP, corticosteroids, and antihistamines
101
Infliximab AEs
risk of infections
| fever, chills, urticaria, HA, nausea
102
Infliximab CIs
CHF, > 5mg/kg moderate to severe heart failure
103
Infliximab dosage
3 mg/kg IC infusion 2,6 weeks then Q 8 weeks with MTX
104
Do not use infliximab with what
Abatacept
anakinra
TNF blockers
Tocilizumab
105
Check with infliximab
weight
| dosage rate
106
Rituximab MOA
causes B-lymphocyte depletion
107
Rituximab dosage
two 1000mg infusions separated by 2 weeks OR
3mg/kg IC infusion, 2,6 weeks then Q8 weeks
Given with MTX
108
Rituximab should be infused how
over 4 hours
| premedicate with antihistamines, APAP, corticosteroids
109
Abatacept MOA
selectively modulating a co-stimulatory signal required for full T cell activation
110
Do not give Abatacept with what
TNF blockers
111
Abatacept dosage
10mg/kg IV infusion over 30 minutes, repeat in 2 weeks, 4 week, Q4weeks. or give SubQ QW starting day after IV
112
Tocilizumab Dosage
4mg/kg IV over 60 minutes Q4W. increase to 8mg/kg if necessary max 800 mg per infusion
with or w/o MTX
113
Tocilizumab drug interactions
biologic DMARDS, decreased warfarin, PPIs, cyclosporine, BCPs, statins
114
Anakinra Indication
Active RA 18+ failed 1+ DMARDs including TNF blockers
115
Anakinra MOA
Interleukin 1 receptor antagonist
116
Anakinra dosage
100 mg subQ QD
117
Anakinra AEs
transient injection site reactions
| Suppression of immune system, neutropenia, and pneumonia
118
Avoid what with Anakinra
TNF blockers
119
Tofacitinib MOA
Janus associated kinase inhibitor
120
Tofacitinib dosage
5 mg PO BID
121
Monitoring for tofacitinib
Infections, WBC
122
Drug interactions for tofacitinib
biologic DMARDS
strong immunosuppressants
strong 3A4 inducers
123
Canakinumab MOA
Interleukin 1 blocker
124
Canakinumab indication
Systemic juvenile Idiopathic Arthritis
125
Canakinumab dosage
4mg/kg (max 300 mg) SubQ Q4W
126
Cankinumab AEs
Infections
Abdominal pain
injection site reactions
127
Treatment of RA with non bio agents with low disease activity and poor prognosis
MTX, leflunomide, sulfasalazine or combination DMARD
128
treatment of RA with non bio agents with low disease activity and no poor prognosis
hydroxychloroquine or minocycline
129
treatment of RA with non bio agents with high disease activity and poor prognosis
MTX, leflunomide, or combination DMARD
130
treatment of RA with non-bio agents with high disease activity and no poor prognosis
MTX, leflunomide, sulfasalazine, or combinatin DMARD
131
Treatment of RA with biologic DMARDs with low disease activity
1. nonbiologic DMARD
| 2. if poor response then combination non-bio DMARD or anti-TNF
132
Treat of RA with biologic DMARDs with high disease activity and poor prognosis
MTX, leflunomide, or combination, or Anti-TNF
| 2. if poor response anti-TNF, rituximab, or abatacept
133
Treatment of RA with biologic DMARDs with high disease activity and no poor prognosis
1. non-bio dmard
| 2. if poor response anti-TNF or combination nonbiologic
134
Required Immunizations for RA pts
Pneumococcal, influenza, hepatitis, HPV, and herpes zoster
135
Comorbidities with RA
CV disease
Infections
Malignancy
Osteoporosis
