Autoimmune Conditions: RA Flashcards
What are the non-specific lab blood tests that can be useful in detecting inflammation?
ESR
CRP
FR
ANA
The use of strong immunosuppressants can increase the risk of certain conditions including:
re-activation of TB, hep B, hep C; testing needs to be done prior to start
viruses - live vaccines must be given before start
lymphomas and certain skin cancers
infections
This autoimmune disease is a chronic, progressive autoimmune disorder that primary affects the joints
rheumatoid arthritis
Articular symptoms of RA
joint swelling - bilateral
pain
stiffness
bone deformity
Is stiffness and pain worse or better after rest in RA?
worse!
“morning stiffness” common
What are useful lab tests in diagnosing RA?
Anti-citrullinated peptide antibody (ACPA) and rheumatoid factor (RF)
What is the non-drug treatment for RA?
rest
physical therapy
occupational therapy
exercise, diet, weight control
joint replacement
Patients with symptomatic RA should be started on what, regardless of the severity of the disease?
disease-modifying anti rheumatic drug (DMARD)
they slow the disease process and prevent further joint damage
What is the preferred initial therapy for most patients with RA?
methotrexate
For patients with mod-high disease activity, despite methotrexate, a combination of what is recommended?
DMARDs
OR
TNF inhibitor biologic
OR
non-TNF biologic
(with or without MTX) +/- steroid
What should you never use in combination due to the risk of fatal infections?
two biologic DMARDs
What drug is commonly used in RA flares and should be used at the lowest dose & shortest duration
steroids (<10mg/day prednisone or equiv)
What is used to “bridge” DMARDs?
low dose steroids and in patients with DMARD failure
NSAIDs are a weaker option, but less toxic – higher doses needed
Brand: Trexall
generic: methotrexate
What drug?
dosed 7.5-20mg once weekly (PO, SC, IM)
NEVER dosed daily for RA – liver damage
BW: hepatotoxicity, myleosuppression, mucositis/somatitis, pregnancy
methotrexate
What are the SC auto-injectors of MTX?
Otrexup and Rasuvo
This drug works by irreversibly binding and inhibiting dihydrofolate reductase, inhibiting folate, thymidylate synthetase and purine
MTX
What drug?
CBC, LFTs, chest x-ray, hepatitis B & C serologies
MTX
MTX - what can be give to dec hematological, GI and hepatic side effects
folate
List traditional (non-biologic) disease-modifying anti rheumatic drugs (DMARDs)
methotrexate
hydroxychloroquine
sulfasalazine
leflunomide
Brand: Plaquenil
generic: hydroxychloroquine
What traditional DMARD has a warning for irreversible retinopathy?
hydoxychloroquine
What traditional DMARD has a contraindication in patients with a sulfa or salicylate allergy?
sulfasalazine
What traditional DMARD can cause skin/urine to turn yellow/orange?
sulfasalazine
Brand: Arava
generic: leflunomide
This traditional DMARD’s MOA inhibits pyrimidine sythnesis
leflunomide
This traditional DMARD has a boxed warning for use in pregnancy (must wait two years after d/c) and hepatoxicity.
It also has an accelerated drug elimination option
leflunomide
tofacitinib/Xeljanz
baricitnib/ Oluminant
upadacitinib/ Rinvoq
drug class?
Janus Kinase Inhibitors (JAK)
Can you use JAK inhibitors and DMARDs together?
NO!
This drug class has a boxed warning for serious infection (TB, OI); malignancy; thrombosis
JAK inhibitors
Methotrexate should not be taken with ____, this combo can increase the risk of liver toxicity
alcohol
Are needles included with the anti TNF biologics (TNF alpha inhibitors)?
yes!
each drug also has its own pregnancy registry
Brand: Enbrel
generic: Etanercept
Brand: Humira
generic: adalimumab
Brand: Remicade
generic: infliximab
Brand: Cimiza
Brand: certolizumab pegol
Brand: Simponi
generic: golimumab
This anti TNF biologic is dosed 50mg SC weekly
etanercept/ Enbrel
This anti TNF biologic is dosed SC every OTHER week
Humira (40mg), Cimiza (200mg)
This anti TNF biologic is dosed only with IV
Remicade
0,2,6,8 weeks; delayed hypersensitivity, 3-12 days after
NS ONLY
This anti TNF is dosed SC monthly
Simponi
*requires a filter
This drug class has a boxed warning for serious infection and malignancies.
Warnings for demyelinating disease, hep B reactivation, heart failure, hepatoxicity, lupus-like syndrome
anti TNF biologics
*do not shake, freeze – requires fridge!
Can you use anti TNF biologics with biologic DMARDs or with live vaccines?
no!!!!
anti TNF biologics monitoring
TB test, HBV, signs of infection
If TB test is positive, must treat prior to starting
What is first line for RA? what’s add on therapy?
1st - methotrexate
add-on - anti TNF biologics
UNLESS presentation is severe
Rituximab
Abatacept
Anakinra
drug class?
Biologic DMARDs – non-TNF inhibitors
single-dose profiled syringe
needles come w drug
preg registry
This non-TNF inhibitor’s MOA is depletes CD20 B cells
rituximab
This non-TNF inhibitor is premeditated with a steroid, Tylenol, and an anthistamine
rituximab
This non-TNF inhibitor has boxed warnings for infusion-related reactions, HBV reactivation
rituximab
This non-TNF inhibitor has warnings for malignancies, and serious infections
anakinra
What DMARDs are given WITH methotrexate?
Remicade/ infliximab
Simponi/ golimumab
Rituxan/ rituximab
Brand: Rituxan
generic: rituximab
What drug?
dosed once weekly for RA and psoriasis. Can cause liver damage, infection, mouth sores, GI blood
Take folic acid to decrease side effects
MTX
What two drugs are single-use auto-injectors (abdomen or upper thigh only)
Rasuvo (5 seconds)
Otrexup (3 seconds)
These medications are administered subQ and can cause infection, liver damage, and heart failure.
the medication should be stored in the fridge with protection from light and sources of heat.
Adalimumab - room temp for 14 days ok
etanercept - room temp for 14 days ok
golimumab
adalimumab, etanercept, or golimumab?
abdomen or thigh for SC injection
adalimumab
adalimumab, etanercept, or golimumab?
abdomen, upper arm, or thigh for SC injection
etanercept & golimumab
