Arthritis Flashcards
What is the definiation of Rheumatoid Arthritis?
- MOST COMMON systemic inflammatory disease characterized by Symmetrical Joint involvement.
- CHRONIC
What is the pathophysiology of Rheumatoid Arthritis?
- Chronic Autoimmune
- Synovial Space in joints becomes inflammed –> leading to death
- Forming Pannus: going to cause erosions that break the joint
What are some of the clinical presentions of Rheumatoid Arthritis?
- Fatigue, Weakness, Loss of Appetite, Joint Pain, Lowgrade Fever
- Stiffness & Muscle Ache –> Joint Swelling
In what way is Rheumatoid Arthritis diagnosed?
- Needs a score of 6
- Joint Involvement: 1 Medium-Large Joint to <10 Small Joints [0-5 points]
- Serology: +/- for RF or ACPA [0-3 points]
- Duration of Symptoms: </> 6 weeks [0-1 points]
- Acute Phase Reactant: CRP or ESR [0-1 point]
What are the most common joints that are affected my Rheumatoid Arthritis?
- Most Common: Hands, Wrists, Feet
- Other sites: Elbow, Shouldersm Hips, Knees, Ankles
What are the Extra-Articular Manifestations in Rheumatoid Arthritis?
- Rheumatoid Nodules
- Vasculitis
- Pulmonary
- Ocular
- Cardaic
- Felty’s
- Other
What is important to understand about what Rheumatoid Nodules are in Rheumatoid Arthritis?
- On Pressure Points
- Found within Hands, Wrists, Forearms
- More common in Erosive disease
- Asymptomatic? Dont need to treat
What is important to understand about Vasculitis in Rheumatoid Arthritis?
- Inflammation of Small, Superficial Vessels
- Could lead to necrosis
What is important to understand about Pulmonary in Rheumatoid Arthritis?
- Could cause Pulmonary Embolisms, Pleural Effusions
- RARE: Inflammation within the lungs or arteries
What is important to understand about Ocular in Rheumatoid Arthritis?
- Inflammation in Sclera, Episclera, Cornea
- Sjorgens Syndrome: Icthy, Dry Eyes [Keratoconjunctivitis] + Inflammation [RA]
What is important to understand about Cardaic in Rheumatiod Arthritis?
- Increased risk of CV mortality
- Pericarditis: Inflammed Cardiac Tissue
What is Felty’s within Rheumatoid Arthritis?
- Splenomegaly
- Neutropenia
What are some clincial features for Rheumatoid Arthritis?
- Any Age, Systemic, Elevated ESR, Inflammation, Bilateral, am Stiffness > 1hour, -Osteophyte, +Pannus +RF, +Nodules,
SE: Malase, Fatigue, Musculoskeletal Pain, Fever
What are some clinical features for Osetoarthritis?
- > 40 yo, ONLY joint, Normal ESR, Slight Inflammation, Uni or Bilateral Involvement, am Stiffness < 30mins, +Osteophyte, -Pannus, -RF,
SE: Deep, aching pain
What are the two adjunct therpies?
- NSAIDS
- Corticosteroids
How are NSAIDs used in Rheumatoid Arthritis?
- Great at reducing pain, swelling, stiffness
- Does NOT alter disease progression
- Used WITH DMARDS
How are Corticosteroids used in Rheumatoid Arthritis?
- Used for anti-inflammatory & immunosuppressive
- NOT a monotherpay [same as NSAIDs]
- Used in combo WITH DMARDs
What are the adverse effects fo corticosteroids?
WILL BE ON THE EXAM!!
- Short Term: Hyperglycemia, Increased BP, Gastritis, Mood Swings
- Long Term: Cataracts, Obesity, Osetoporsis, Growth Failure, Apestic Necrosis
Monitor: BP & BG
What is DMARDs and what do they help do?
- Disease Modifying Anti-Rheumatic Drugs
- Decreased/prevent joint damage DOES NOT reverse it
What are some of the Traditional DMARDS [Conventional Synthetic DMARDs] that are used in Rheumatoid Arthritis?
- Methotrexate
- Sulfasalazine
- Hydroxychoroquine
- Leflunomide
What is important to know about Methotrexate in Rheumatoid Arthritis?
MOA? Indication?
- DMARD of choice
- MOA: inhibit dihydrofolic acid reductase
What is the dosing of Methotrexate in Rheumatiod Arthritis?
WILL BE ON THE EXAM!!
`
- 7.5 mg per WEEK PO or IV
- May need to tirate up
What are some of the adverse effects of Methotrexate in Rheimatoid Arthritis?
- Bone Marrow Suppression, N/V/D, Mucositis [should give folic acid]
- Hepatic, Pulmonary, Skin issues
- Teratogenic
CONTRAINDICATION: Pregnancy, Chronic Liver Disese, CrCl < 40
What are some of monitoring for Methotrexate in Rheumatoid Arthritis?
- CXR, CBC, SCr, LFTs, Albumin
What is important to know about Leflunomide in Rheumatoid Arthritis?
MOA? Indication?
- Prodrug
- MOA: Inhibits cell cycle progression
- Should have loading dose THEN maintenance dose
What are some of the adverse effects of Leflunomide in Rheumatoid Arthritis?
- Diarrhea, Rash, Alopecia, Increased LFTs, Teratogenicity
What is some of the monitoring for Leflunomide in Rheumatoid Arthritis?
- CBC, SCr, LFT
What MOA for Sulfasalazine in Rheumatoid Arthritis?
- MOA: Inhibits IL-1; prodrug that is cleased in the colon to Sulfpyradine and 5-ASA
What are the adverse effects of Sulfasalazine in Rheumatoid Arthritis?
- N/V/D, Anorexia, Rash, Hypersensitivity [SULFA Allergy]
What is some of the monitoring for Sulfasalazine in Rheumatoid Arthritis?
- CBC, SCr, LFT
What is the MOA for Hydroxychoroquine in Rheumatoid Arthritis?
- MOA: Modification to cytokine infiltration in joints
- Possibly great to use in New Onset or Low Disease Therapy; so maybe start –> DONT switch to it
What are some of the Advere Effects of Hydrochoroquine in Rheumatoid Arthritis?
- NO myelosuppression
- Retinal Toxicity
- N/V/D [Take with food], Rash, Increased Skin Pigment
What is the monitoring for Hydroxycholorquine in Rheumatoid Arthritis?
- VISION EXAM
6-12 months
What are the TNF Neutralizers that are used in Rheumatoid Arthritis?
- Etanercept
- Infliximab
- Adailmumab
- Golimumab
- Certolizumab
What are some of the general Warnings/Precautions for the TNFs in Rheumatoid Arthritis?
Same as IBD!
- Increased infection risk
- DO NOT use with other TNFs or Biologics
- BLACK BOX: Demylination, CHF Exacerbation, NO live vaccines
What are some of the general Adverse Effects for TNFs in Rheumatoid Arthritis?
- Headache & Rash
- Risk of Infection [Upper Respiratory]
- CHF Exacerbation
- Demylination
- Malignancies
What is important to know for Etanercept in Rheumatoid Arthritis?
MOA? Dosage Form?
- MOA: Binds to and inhibits TNF; binds to the surface and causes inflammation
- SUBQ once weekly
What is important to know about Infliximab in Rheumatoid arthritis?
MOA? Dosage Form?
- MOA: Inhibits TNF; Chimeric
- IV
- Usually taken with Methotrexate
What is important to know about Adalimumab in Rheumatoid Arthritis?
MOA? Indication? Dosage form?
- MOA: Inhibits TNF by blocking p55 and p75 in those that failed other TNFs
- Used ALONE or COMBO
- SUBQ every OTHER week
What is important to know about Golimumab in Rheumatoid Arthritis?
MOA? Dosage Form? Monitoring?
- MOA: Inhibits TNF For Mod-Severe RA; use with Methotrexate
- SUBQ once monthy
- CXR, LFTs
What is important to know about Certolizumab in Rheumatoid Arthritis?
- MOA: Inhibits TNF For Mod-Servere RA
- Used ALONE or COMBO with non-BRM DMARDs?
- SUBQ
What is important to know about Anakinra in Rheumatoid Arthritis?
MOA? Dosage Form?
- MOA: Blocks IL-1 receptors In Mod-Severe RA for those that failed one or more DMARD
- ALONE or COMBO
- SUBQ
What are some of the Advere Effects for Anakinra in Rheumatoid Arthritis?
- Headache, N/V/ Flu-like symptoms
- Injection site reactions, Hypersensitivity, Increased Infections, Decreased Neutrophils
What is the monitoring for Anakinra in Rheumatoid Arthritis?
- Neutriophil Count
What is important to know about Abatacept in Rheumatoid Arthritis?
MOA? Dosage Form? When?
- MOA: Inhibits t-cell activation in Mod-Severe RA in those that failed one or more DMARDs
- ALONE or COMBO [not with TNF or IL-1]
- IV
What are some of the warnings for Abatacept for Rheumatoid Arthritis?
- DO NOT use with TNF or IL-1
- Increased Infection Risk
- NO Live Vaccines
- Caution in COPD
What are some of the Advere Effects of Abatacept in Rheumatoid Arthritis?
- Headache, Nausea, Upper Respiratory Infection, Nasopharingitis
What is important to know about Tocilizumab & Sarilumab in Rheumatoid Arthritis?
MOA? Dosage Form? When?
- MOA: Bind and Inhibit IL-6 for Mod-Servere RA for those that failed one or more DMARDs
- Use ALONE or COMBO with Methotrexate or other DMARDS
- IV [Tocilizumab] & SUBQ[Sarilumab]
What are some of the warnings and contraindications for Tocilizumab & Sarilumab in Rheumatoid Arthritis?
- BLACK BOX: Infections
- Contraindication:Liver Toxicity, Thrombocytopenia, Neutpenia
What are some of the Adverse Effects of Tocilizumab & Sarilumab in Rheumatoid Arthritis?
- Serious Infections, Liver Toxicity, Thrombocytopenia, Neutpenia, Lipid Abnormalities
What are some of the Monitoring for Tocilizumab & Sarilumab in Rheumatoid Arthritis?
- Neutrophil count, Platelet count, LFTs, Lipid Profile
What is important to know about Rituximab in Rheumatoid Arthritis?
MOA? Dosage Form? When?
- MOA: Binds to CD20 [B-cells] in Mod-Severe RA for those that failed TNF
- COMBO with Methorexate
- IV
Give Methylprednisolone 30 mins before infusion
What are some of the monitoring for Rituximab in Rheumatoid Arthritis?
- CBC, Creatinine, Vital Signs
What is important to know about the JAK Kinase Inhibitors in Rheumatoid Arthritis?
MOA?
- MOA: Inhibits Janus Kinase
- Mod-Severe RA for those that failed TNF
- ALONE or COMBO with Methotrexate or other DMARD
- ORAL
NOT with BRM, Azathiprine, or Cyclosporine
What are the JAK Inhibitors that are used in Rheumatoid Arthritis?
- Totacitinib, Baricitinib, Upadacitinib
What are some of the Warnings for the JAK inhibitors in Rheumatoid Arthritis?
A LOT!
- P450 interactions
- Risk of Infection & Malignancy
- CV Issues
- Thrombosis
- NO Live Vaccines
When shoud you NOT used JAK Inhibitors in Rheumatoid Arthritis?
- Hgb < 8mg/dL
- ANC < 1000 cells/mm^3
- ALC < 500 cells/mm^3
