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Thera XI > 08 Arthritis (RA) Lau > Flashcards

08 Arthritis (RA) Lau Flashcards

1
Q

What is RA?

A

Chronic inflammatory disease of unknown etiology marked by SYMMETRIC, peripheral polyarthritis

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2
Q

What is the clinical presentation of RA?

A

Early morning stiffness > 1 hour and easing with physical activity. Pain and stiffness of more than 6 weeks duration. Usually symmetric. Typically occurs first with the small joints of the hands and feet

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3
Q

What is Flexor Tendon Tenosynovitis?

A

A frequent hallmark of RA and leads to decreased range of motion, reduced grip strength, and trigger fingers

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4
Q

What is Secondary Sjogren’s Syndrome?

A

10% of RA patients get it. Atrophy of lacrimal duct. Atrophy of salivary glands

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5
Q

What is the lung involvement like for RA?

A

Nodules. Pulmonary effusions. Pulmonary fibrosis (increased w/ smoking)

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6
Q

What serology is looked at for RA diagnosis?

A

High-positive RF or high-positive anti-CCP antibodies (>3 times ULN)

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7
Q

What acute-phase reactants are looking at for RA?

A

Abnormal (increased) CRP or abnormal (increased) ESR

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8
Q

What is the goal of RA therapy?

A

Increased QOL (increased dexterity w/ decreased pain). Achieve remission (simplified disease activity score of 3.3)

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9
Q

What are the two classes of pharmacological treatment for RA?

A

Non-Biologic Disease Modifying Anti-Rheumatic Drugs (DMARDs). Biologic DMARDs

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10
Q

What are some of the common Non-Biological DMARDs?

A

MTX. Hydroxychloroquine. Cyclosporine. Minocycline. Sulfasalazine, etc.

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11
Q

What are some of the common Biologic DMARDs?

A

Etanercept. Infliximab. Rituximab. Abatacept. Tocilizumab, etc.

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12
Q

What vaccinations do you need BEFORE starting DMARD or biologic agents (they can still be done after DMARDs are started, but not recommended)?

A

Pneumococcal. Influenza IM. Hep B. Human Papillomavirus. Herpes Zoster

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13
Q

**What is DMARD Initiation like?

A

Onset: 6-12 weeks. Bridging with Glucocorticoids (rapid disease control, predisone 5-10mg daily, Provide osteoporosis prophylaxis if > 3 months. Can use with NSAIDs or Analgesics for symptomatic relief (no disease modifying benefit)

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14
Q

**What is the DOC for RA?

A

MTX

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15
Q

**What are some general comments about MTX use?

A

Folic acid supplementation does not compromise efficacy (MTX depletes folic acid levels). Give doses > 25mg parenterally. Keep hydrated!

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16
Q

**What are some common ADRs with MTX?

A

GI (N/V/D). Heme (decreased WBC and platelets). Increased LFTs (d/c if 2x ULN). Teratogenic (3 months contraception for men, 2 menstrual periods for women)

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17
Q

What are some general comments about Hydroxychloroquine?

A

Considered tx failure at 6 months w/o response. Lack of myelosuppressive, hepatic, and renal toxicity. Take w/ food or milk

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18
Q

What are some ADRs associated with Hydroxychloroquine?

A

GI (N/V/D). Ocular (blurred vision). Rash, alopecia. HA, vertigo, insomnia

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19
Q

How does Sulfasalazine work?

A

Sulfasalazine –> SULFAPYRIDINE (active component) + 5-aminosalicylic acid

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20
Q

What are some general comments about Sulfasalazine?

A

Start low, go slow. Antibiotics decrease bioavailability. Warfarin displacement. NOT a true DMARD. Take after meals and keep hydrated (renal stones), iron chelation, urine discoloration

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21
Q

**What is the timeline for early and established RA?

A

Early RA: < 6 months. Established RA > 6 months

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22
Q

**What is a poor prognosis for RA?

A

Presence of 1 or more of the following features: Functional limitation, Extraarticular, Positive rheumatoid factor or anti-cyclic citrullinated peptide antibodies, or Body erosions by radiograph

23
Q

**What is the main medication that can be used in poor prognosis RA?

A

MTX or Leflunomide (these can be used with any RA duration or disease activity)

24
Q

How do Biologic Agents work?

A

Inhibit pro-inflammatory cytokines (TNF, IL-1, IL-6). Deplete peripheral B cells. Prevent T cell activation

25
Q

**What is TB screening like for RA?

A

Tuberculin skin test or interferon-gamma-release assays in all patients starting Biologic Agents (if positive –> CXR, if active –> sputum exam). Treatment with biologic agents can be initiated or resumed after 1 month of LTBI tx. Annual TB test for patients at risk

26
Q

**What are some common TNF-Inhibitors used?

A

Infliximab. Etanercept. Adalimumab. Golimumab. Certrolizumab. Treatment in combo w/ MTX is better than either alone

27
Q

**What is the BBW with TNF-Inhibitors?

A

Increased risk of infections, Lymphoma. Increased mortality with CHF (contraindicated with Stage IV)

28
Q

Why are obese patients less likely to have good treatment outcomes with anti-TNF agents?

A

Obesity already puts the body in some sort of inflammatory state

29
Q

What are some common ADRs with Infliximab?

A

Infusion reactions (fever, chills, etc). GI, Fatigue, increased infections. Loss of response over time

30
Q

What should you use to pre-medicate a patient before Infliximab?

A

Antihistamines, APAP, Corticosteroids

31
Q

What is Infliximab usually given with?

A

MTX

32
Q

What are some general comments about Abatacept?

A

Live vaccines should not be given during and for 3 months after treatment

33
Q

What is the BBW for Rituximab?

A

Fatal infusion reactions. JCV –> PML. Premed 30 minutes before (antihistamine, steroid, APAP)

34
Q

What is Toclizumab?

A

IL-6 receptor inhibitor. All IL-inhibitors require more monitoring

35
Q

What is combination therapy like for biologics?

A

Combination biologic DMARD therapy is not recommended because of the increased risk for infection

36
Q

IL-inhibitors require a lot more monitoring, what needs to be monitored while on Tocilizumab?

A

AST/ALT, CBC w/ platelet, lipids Q4-8 weeks

37
Q

IL-inhibitors require a lot more monitoring, what needs to be monitored while on Anakinra?

A

Neutrophil count monthly for 3 months then quarterly up to 1 year

38
Q

What agent can potentially still be used in patients with Hepatitis C?

A

Etanercept

39
Q

When can biologics be used with history of Malignancies?

A

If they were treated > 5 years ago. If less than 5 years you can still use Rituximab

40
Q

What is biologic use like in CHF patients?

A

Recommends NOT using anti-TNF biologic in NYHA Class III or IV with EF < 50%

41
Q

What is Osteoarthritis?

A

Common degenerative disorder of the articualr cartilage associated with hypertrophic bone changes

42
Q

What type of OA is seen in men and women?

A

Men: more hip. Women: more hands, knee, foot

43
Q

**What is the clinical presentation of OA?

A

Morning stiffness < 30 minutes. Pain worsens with activity. Joint locking or instability. ASYMMETRIC distribution

44
Q

**What are the therapeutic recommendations for OA of the Hand?

A

At least 1 or more: Topical capsaicin, Topical NSAIDs, Oral NSAIDs, Tramadol

45
Q

**What are the therapeutic recommendations for OA of the Knee?

A

Only 1 med: APAP, Oral NSAIDs, Topical NSAIDs, Tramadol, Intraarticular corticosteroid injections

46
Q

**What are the therapeutic recommendations for OA of the Hip?

A

Only one: APAP, Oral NSAIDs, Tramadol, Intraarticular corticosteroid injections

47
Q

What do you look for when radiographically (MRI > X-Ray) diagnose OA?

A

Presence of osteophytes. Joint space narrowing. Cysts. Deformity. Sclerosis

48
Q

What injectable steroids can be used for OA?

A

Methylprednisolone ACETATE (needs to be acetate!). Betamethasone. Triamcinolone

49
Q

What injectable Hyaluronic Acid can be used for OA?

A

Euflexxa, Hyalgan, Orthovisc, Supartz, Synvisc, Nuflexxa. Start with steroids first, if they fail then try these

50
Q

What is Diacerein?

A

Disease modifying OA drug. Inhibits IL-1 synthesis, prevents remodeling, preliminary studies

51
Q

**For step-wise therapy, what is done for increasing mild OA?

A

Start with APAP and continue until effective or step up to NSAID. Also, encourage regular exercise and consider physical therapy

52
Q

**For step-wise therapy, what is done for increasing moderate OA?

A

Add combination glucosamine and chondroitin for moderate to severe knee OA; d/c if no change after 3 months

53
Q

For step-wise therapy, what is done for increasing Severe OA?

A

Consider opioid therapy –> consider corticosteroid injection –> consider hyaluronic acid –> discuss total joint replacement

Thera XI (16 decks)

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