wk 10- rheumatology

Question 1

what is RA

Answer 1

chronic autoimmune, systemic inflammation

Question 2

what are aims for treatment of RA

Answer 2

1. symptomatic relief (pain and stiffness)
2. maintain level of function
3. prevent damage to bones, joints and organs

Question 3

TREAT TO target principle

Answer 3

goal is to be in remission or low disease activity with adapted therapy, if its not achieved in 3-6 months then alter therapy to achieve this

Question 4

how do they monitor RA disease activity

Answer 4

1. measuring inflammation through swollen/tender joint counts and or ESR and or CRP levels
2. and patient reported outcomes questionaires
3. joint damage throughout disease course with medical imaging

for activity level and deciding whether to change treatment

Question 5

drug classes for RA

Answer 5

1. corticosteroids
2. calcineurin inhibitors
3. monoclonal antibodies
4. cytokine modulators
5. antiproliferative immunsuppressants
6. Disease Modifying Anti Rheurmatic Drugs

Question 6

what are DMARDs

Answer 6

drugs that stop synovial inflammation and prevent joint damage

Question 7

length and dosing of DMARDs

Answer 7

response should be seen within 12 weeks but can take up to 6 months

once control is achieved, the dose is reduced to lowest effective

Question 8

types of DMARD therapy

Answer 8

1. conventional synthetic disease modifying ARD
2. biological disease modifying ARD
3. targeted synthetic DMARDs

Question 9

example of CSDMARDS

Answer 9

methotrexate
lefluomide
sulfasalazine
hydroxychloroquine

Question 10

example of BDMARDS

Answer 10

abatacept
adalimumab
certolizumab
etanercept

Question 11

example of targeted synthetic DMARDs

Answer 11

tofacitinib

Question 12

treatment for RA

Answer 12

initially is a csDMARDS with or without a corticosteriod

typically
1. methotrexate
2. if MTX not tolerated, then lefluonmide

if remission not achieved with csDMARD then bDMARD or tsDMARD trialled

Question 13

different severities of RA and initial treatment

Answer 13

mild RA- Hydroxychloroquine with or without sulfasalazine

mild-mod RA- MTX

active RA- combination therapy with the 3 above

Question 14

pre screening before RA treatment, for what?

Answer 14

• active infection
  -tuberculosis
  -vaccination status
• liver, kidney, bone marrow
  -history of malignancy
• reproductive health education
• medication review
• monitoring regime every 3-6 months

Question 15

criteria for qualifying for a biologics (cytokine modulators)

Answer 15

1. established severe active RA
2. 6 more swollen and tender joints, 4 non hand joints or DAS 28 score 3.2 or more
3. failed to get into remission with 2 stndard DMARDs, MTX being one of them

Question 16

what do corticosteroids do

Answer 16

rapid symptoms control at presentation and control disease through anti inflammatory and DMARD effects

use while waiting for the effects of csDMARD

Question 17

when to use NSAIDs with RA

Answer 17

before DMARD therapy is commenced to control symptoms but do not reduce joint damage

can also be used during flares of joint pain/swelling

Question 18

MOA methotrexate

Answer 18

inhibits dihydrofolate reductase

Question 19

side effects of methotrexate

Answer 19

bone marrow suppression
liver toxicity
immunosuppression
folic acid

Question 20

hydroxychloroquine side effects/complications

Answer 20

risk of retinopathy with long term use
blood dyscrasias
ototoxicity- hearing/balance issues
major drug interactions with antacids, rosuvastatin, duloxetine, atorvastatin

Question 21

sulfasalazine side effects

Answer 21

increased photosensitivity
itching
skin rash
vomiting
drug interactions with aspirin, celecoxib, warfarin, lidocaine

Question 22

leflunomide MOA

Answer 22

inhibits dihydroorotate dehydrogenase

Question 23

leflunomide side effects

Answer 23

N, V, D
skin rash
alopecia- hair loss
drug interactions with aspirin, celecoxib, etanercept, adalimumab, atorvastaitn

Question 24

bDMARDs and MOA

Answer 24

1. TNF-α: adalimumab, certolizumab, etanercept, golimumab, infliximab (all drugs bind and
   neutralise TNF)
2. IL-1: anakinra (competitive inhibition of IL-1 receptors)
3. IL-6: tocilizumab (binds to soluble and membrane-bound IL-6 receptors)
4. Target B cells: Rituximab
5. Target T Cells: Abatacept

Question 25

what do bDMARDS target

Answer 25

cytokines

Question 26

bDMards are associated with and complications that occur are

Answer 26

onychocryptosis have to cease with nail surgery increased risk of non serious infections (fungal)

Question 27

tsDMARDs moa

Answer 27

inhibit JAK1, 2, 3 to inhibit immune response

Question 28

what is included under spondyloarthropathies

Answer 28

psoriatic reactive arthritis ankylosing spondylitis

Question 29

treatment for anklyosing spondylitis

Answer 29

NSAIDS and exercise to control symptoms if symptoms not controlled or severe disease, bDMARDs are used csDMARDs no effect

Question 30

treatment for reactive arthritis and time course

Answer 30

commonly resolves within 6 months 1. NSAIDs mild/mod symptoms 2. prednisone severe symptoms 3. local corticosteroid injection for isolated peripheral joint

Question 31

treatment of PsA

Answer 31

1. NSAIDS symptoms 2. corticosteroids for mono or oligoarticular peripheral arthriitis 3. DMARD for polyarthritis or severe cases csDMARD- avoid hydroxychloroquine causes psorarias flare up bDMARD- if standard dont work tsDMARD as another option

Question 32

OA mangement/treatment

Answer 32

1. exercise/weight loss 2. paracetamol 3. low dose, short acting NSAID as required, consider CSI 4. higher dose NSAID 5. oral opioid

Question 33

gout management of an acute attack

Answer 33

reduce inflammation through 1. local CSI 2. NSAID 3. prednisone 4. colchicine

Question 34

colchicine MOA

Answer 34

inhibits neutrophil motility and disrupts phagocytosis

Question 35

colchicine side effects

Answer 35

GI neutropenia neuropathy anaemia bone marrow suppression interat with some statins

Question 36

chronic gout management

Answer 36

dissolve tophi prevent future attacks urate lowering therapy lifelong 1. allopurinol- 1st line 2. febuxostat 3. probenecid

Question 37

allopurinol MOA

Answer 37

inhibits xanthine oxidase

Question 38

side effects of allourinol

Answer 38

headache upset stomach pruritic rash

Question 39

febuxostat MOA

Answer 39

inhibits xanthine oxidase

Question 40

adverse effects of febuxostat

Answer 40

small risk of CVD events

Question 41

dont change chronic mangement of gout when

Answer 41

during an attach can make worse

Question 42

difference between acute and chronic gate mangement

Answer 42

acute- symptom and pain relief chronic- urate lowering to prevent recurrence