5.1 Drugs in Arthritis - DMARDs for RA

Question 1

What are the joints used for RA monitoring?

Answer 1

MCP, PIP, wrist, elbow, shoulder and knees

Question 2

What is RA?

Answer 2

Autoimmune disease affecting multiple organ systems but mainly characterised by inflammation of the synovial membrane lining the joints causing joint damage from bone erosion, resulting in pain, stiffness and swelling

Question 3

What are the 7 criteria for RA and what is the criteria for diagnosis?

Answer 3

Morning stiffness > 1 hour 
Arthritis in 3 or more areas 
Arthritis of hand joints 
Symmetric involvement 
Rheumatoid nodules 
Serum rheumatoid factor (CCP as well) 
Radiographic changes 

Need at least 4 and the first 4 criteria must be present for 6 weeks

Question 4

When is the bone erosion and joint damage greatest?

Answer 4

In the first 2 years

Question 5

What are the indicators of poor prognosis of RA?

Answer 5

Female
Younger age, disease duration, older at onset
Low education, poverty
Greater number of joints affected
Uncontrolled inflammation with high CRP and ESR
Structural damage/deformity
Nodules, vasculitis and other extra-articular disease
anti-CCP positive
High titre RF

Question 6

What is the treatment guidelines for RA?

Answer 6

Treat hard and treat early –> MTX

Question 7

What is MTX?

Answer 7

Antimetabolite - it is a folic acid analogue which allows it to impair cell division, monocytic cell growth and induce apoptosis. Also has an anti-inflammatory effect at low doses

Question 8

When should patients move to biologic DMARDs?

Answer 8

When there is high RF/ ACPA, high disease activity and early joint damage

Question 9

What is the role of TNF in RA?

Answer 9

Mediates pathologic inflammation
Mediates joint destruction
Mediates systemic extra-articular symptoms of inflammation

Question 10

What do you need to be careful of with bTNF inhibitors?

Answer 10

INFECTION
history of TB
pre-existing or recent onset malignancy or CNS demyelinating disease
Contraindicated in mod-severe heart failure

Question 11

What are the goals of RA treatment?

Answer 11

Therapeutic remission with DMARDs
Minimise adverse effects of DMARDs
Modulate CV risks and other co-morbidities

Question 12

What are the treatment options if MTX fails

Answer 12

Increase MTX dose
Add in corticosteroids
Add in hydroxychloroquine

Try drug with different action: Leflunomide, sulfasalazine
Add biologic DMARD is target not reached and poor prognostic factors