3-2 Rheumatoid Arthritis & Gout Flashcards
What is Rheumatoid arthritis?
Chronic, system autoimmune disease of unknown etiology
What characterizes rheumatoid arthritis? (2)
-inflammation and pain in the joints -progressive joint destruction (can also involve extra-articular sites)
What are the mediators of rheumatoid arthritis? (6)
- T cells
- B cells
- TNF alpha
- IL-6
- IL-1
- Prostaglandin
What are the treatment goals for Rheumatoid Arthritis? (2)
- Decrease ACUTE joint pain
- Prevent/control joint damage
What are the classes of drugs to decrease acute joint pain? (3)
- NSAIDs
- Analgesics
- Glucocorticoids
*Symptomatic relief only!
What are the classes of drugs to prevent/control joint damage? (2)
- Disease-Modifying anti-Rheumatic drugs (DMARDs)
- Biological Response Modifiers (BRMs)
When would you normally use the drugs to reduce ACUTE joint pain?
Typically used to minimize symptomatics effects of RA while waiting for the clinical effects of the slow acting DMARDS and BRMs
What are some examples of analgesics? (3)
- Acetominophen
- Capsacin
- Opioids
What is an example of a Glucocorticoid?
Dexamethasone
What are some examples of NSAIDS? (2)
- ibuprofen
- naproxen
What are some DMARDs? (4)
- hydroxychloroquine
- sulfasalazine
- methotrexate
- leflunomide
What are some classes of BRMs/Biologics? (5)
- anti-TNF drugs
- other anti-cytokine drugs
- drugs that inhibit T cells
- drugs that inhibits B cells
- Chemical inhibitors of cytokine signaling
How long does it take for DMARDs to show efficacy?
weeks to months
*slow acting anti rheumatic drugs
How long are DMARDs typically taken?
Long periods
such as, months to years
What are some less commonly used DMARDs? (5)
- Azathioprine
- D-Penicillamine
- Gold Salts
- Cyclosporin
- Cyclophosphamide
What is hydroxychloroquine?
Anti-malarial drug that is moderately effective for mild Rheumatic Arthritis
What is the mechanism of Hydroxychloroquine?
Thought to involve
- inhibition of TLR signaling in dendritic/B cells
- inhibition of antigen presentation to T cells
*Low yield (unlikely to be a test question)
How long does it take for hydroxychloroquine to take effect?
3 - 6 months
*Low yield (unlikely to be a test question)
What is the side effect of Hydroxychloroquine?
- Occular Toxicity that can result in permanent visual loss RARE (1/40,000)
- Risk factors
- Length of treatment > 5 yrs
- Age > 60 yrs
- High dose
- Risk factors
Safe during pregnancy and lactation
Generally well tolerated
What is a drug considered to be a Sulfasalazine?
Azulifidine
How efficacious is sulfasalazine compared to methotrexate?
Similar efficacy
*Effective in up to 50% of patients
How does Sulfasalazine become active?
Begins as a prodrug (5-aminosalicyclic acid) covalently linked to sulfapyridine
Cleaved to active components by bacteria in the gut THEN sulfapyridine is absorbed and is the active component in RA
Mechanism of action of Sulfasalazine
thought to interfere with T and B cell immune responses
possibly inhibits activation of NF-kB
*low yield
When will you see the effects of Sulfasalazine?
1 - 3 months
*Low yield
Side effects of Sulfasalazine (2)
- Agranulocytosis within 2 weeks
- fully reversible Hepatotoxity
More toxic than hydroxychloroquine
Safe during Pregnancy
How is it often prescribed?
In combination with other DMARDs (e.g. Hydroxychloroquine)
Indication for Methotrexate
Drug of choice for patients with patients with active moderate/severe disease (60% of RA patients)
-used at 10-1000X lower dose than that used in cancer treatment
Results of Methotrexate use (3)
- decreases appearance of new bone erosions
- improves the long term clinical outcome
- up to 70% of patietns experience some response to the drug
How long does it take for Methotrexate to take effect?
4 - 6 weeks
*low yield
Mechanism of Methotrexate
In Powerpoint FYI only
Side effects fo Methotrexate (4)
Common SE - dose related hepatotoxicity (abstain from alcohol)
Rare SE
- Pulmonary toxicity
- Bone Marrow suppression
- Increased risk of lymphoma
Generally well tolerated (>50% of pts continue taken for over 3 years)
How is methotrexate excreted?
MTX is 80 - 90% renally excreted
*adverse effects frequently observed in patients with renal impairment
What are the contraindications for Methotrexate? (3)
- Pregnancy/breast feeding (used as abortifacient)
- Not recommended for patients with pre-existing liver disease
- Not recommended for patients with renal impairment
When would you use Leflunomide?
Alternative for those unable to take or non responsive to MTX
Low cost alternative to TNF inhibitors or those with preference for oral <–(*whistle*)
As effective as either sulfasalazine or MTX
How long does it take for Leflunomide to take effect?
1 - 2 months
Mechanism of Action for Leflunomide(4)
“U GLaD Leflunomide is Low cost! “
- Inhibits Uridine synthesis
- Inhibits G1 cell cycle (arrest)
- Inhibits Lymphocytes
- Inhibits Dihydroororate Dehydrogenase
Inhibitis [Dihydroororate Dehydrogenase] –> DEC Uridine synthesis –> [Inhibits G1 Cell cycle arrest]
Side effects for Leflunomide (4)
- Hypertension (especially with concurrent NSAIDs)
- Diarrhea/nausea
- rash (10 - 15% of patients)
- Hepatotoxicity (10 - 13%)
- more severe in presence of methotrexate requiring liver enzyme monitoring
Contraindications for Leflunomide (2)
- Pregnancy/Breast feeding
- Pre-existing liver diease
What are Biological Response Modifiers/Biologics?
Recombinant drugs that are specifically designed to inhibit either cytokines or cell types involved in the autoimmune response in RA
What are the pathways TNF alpha controls? (3)
- Activated Endothelial cells –> Leukocyte recruitment –> Joint inflammation
- Synoviocyte/Chondrocyte –> Cartilage breakdown
- Osteoclast Different –> Bone resorption –> Bone Erosion
It is synthesized by activated CD4+ T cells, macrophages and mast cells
What are some [TNF Alpha] drugs? (3)
“TNF-(A)IE”
- Etanercept
- Infliximab
- Adalimumab
Administration of anti-TNF alpha drugs (2)
- given either subQ or IV
- administered weekly/bi-weekly
as effective as methotrexate
How long does it take for [TNF alpha] drugs to take effect?
1 - 4 weeks
Clinical outcomes of anti-TNF alpha drugs (3)
- decreased joint pain and swell
- decreased formation of new bone erosions
- decreased progression of structural joint damage
~30 - 60% of patients will exhibit a 20 - 50% improvement in their syptoms