Approach to Therapeutics

Question 1

What are the possible modes of treatment for inflammatory arthritis?

Answer 1

Medicines
Injections
Therapies e.g. physiology, clinical psychology
Surgery

Question 2

What are the therapeutic categories of drugs used in treatment of inflammatory arthritis?

Answer 2

NSAIDs
Disease modifying anti-rheumatic drugs (DMARDs)
Biologics
Corticosteroids

Question 3

What are DMARDs?

Answer 3

A group of structurally unrelated, typically small molecule drugs which have been demonstrated to have slow onset effect on disease activity and to slow disease progression

Question 4

What DMARDs are in use?

Answer 4

Methotrexate
Sulfasalazine
Hydroxychloroquine
Leflunomide

Previously used - gold salts, penicillamine

Question 5

What is the key to obtaining optimal outcomes in the management of RA?

Answer 5

Early and aggressive intervention

Question 6

What effects will effective suppression of inflammation have?

Answer 6

Improve symptoms and prevent joint damage and disability

Question 7

What are the features of methotrexate?

Answer 7

Effective
Well-tolerated
Cheap
Cornerstone of combination treatment

Question 8

What are the treatment strategies for therapy with methotrexate?

Answer 8

Early and aggressive management
Sequential monotherapy
Combination - step up, step down and parallel
Treat to target

Question 9

What are biologic DMARDs?

Answer 9

Typically large complex proteins which have been developed from improved understanding of immunology to target key aspects of the inflammatory cascade

Question 10

How do biologic DMARDs need to be given?

Answer 10

Parenterally

Question 11

What are the differences of biologics compared to traditional DMARDs?

Answer 11

Biologics work rapidly, are generally well-tolerate although have important toxicities, and come at a high cost

Question 12

What biologics are currently in use?

Answer 12

TNF alpha inhibitors e.g. adalimumab, infliximab
IL-1 inhibitors e.g. anakinra
Anti-B cell therapies e.g. rituximab
Anti-T cell therapies e.g. abatacept
IL-6 inhibitors e.g. tocilizumab
Others

Question 13

What are the potential issues with biologics?

Answer 13

Efficacy - enhanced response when co-prescribed with methotrexate
Toxicity - minor e.g. site reaction or more major e.g. infection, malignancy
Cost £9,500 compared to £50

Question 14

What are the features of corticosteroids?

Answer 14

Can be prescribed orally, IA or IM injection and IV infusion
Short term benefit vs long term toxicity
Rarely appropriate as single therapy