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NAPLEX Content > Autoimmune Dx - Rheumatoid Arthritis > Flashcards

Autoimmune Dx - Rheumatoid Arthritis Flashcards

1
Q

Describe RA?

A

Chronic, symmetrical, systemic and progressive dx

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2
Q

Where does RA typically first presents?

A

Hands and feet

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3
Q

What’s the results of the inflammation that leads to cartilage and bone destruction in RA?

A

Classic sx of RA

Joint swelling

Stiffness

Pain

Bone deformity (eventually)

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4
Q

List the diagnostic criteria for RA

A

Morning stiffness around joints lasting > 1 hr

Soft tissue swelling (arthritis) in 3 or more joints

Swelling (arthritis) of hand, foot or wrist joints

Symmetric involvement

Rheumatoid nodules

Positive serum rheumatoid factor (about 70% of pts)

Radiograph in erosions or peri articular osteopenia in hand or wrist joints

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5
Q

Howz diagnosis of RA made using the diagnosis criteria?

A

Criteria 1-4 must be present for >= 6 weeks

AND

4 or more criteria must be present

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6
Q

Describe the articular manifestations (affecting the joints) of RA?

A

Almost always Polyarticular and Symmetrical

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7
Q

Which synovial joint is most often involved in RA?

A

Finger joints of the hand

Wrists

Knees

Toe joints

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8
Q

List the typical articular sx of RA

A

Morning stiffness

Swelling

Redness

Edema

Pain

Decreased range of motion

Muscle atrophy

Weakness

Deformity

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9
Q

What sx is the clue of RA and differentiates RA from Osteoarthritis (OA)

A

Morning stiffness that may last for up to 2 hrs is a clue for RA (OA doesn’t cause prolonged stiffness)

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10
Q

List non-pharmacologic tx of RA?

A

Rest

Physical therapy

Occupational therapy

Exercise

Diet

Weight control

Surgical intervention (eg. Joint replacement)

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11
Q

What’s the goal of pharmacologic tx of RA?

A

Goal is to have pt on Disease-Modifying-Antirheumatic Drug (DMARD) within 3 months of diagnosis

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12
Q

T/F? Pts may require bridging therapy (short-term) or in some cases long-term use of anti-inflammatory medications such as NSAIDs or steroids.

A

True

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13
Q

List agents used for pain and inflammation

A

NSAIDs

COX-2 selective inhibitor

Steroids

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14
Q

List NSAID used as agent used for pain and inflammation

A

Ibuprofen (Motrin, advil)

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15
Q

List COX-2 selective inhibitor used as agent used for pain and inflammation

A

Celecoxib (Celebrex)

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16
Q

List steroids used as agent used for pain and inflammation in RA

A

Prednisone (Prednisone intensol -solution; Rayos - delayed release tablet)

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17
Q

What’s the indication of steroids for RA?

A

Indicated for acute inflammation/pain and as bridge therapy while waiting for DMARDs to take effect

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18
Q

At what dose is steroid used when used chronically in RA?

A

<= 10 mg daily

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19
Q

List DMARDs used for RA

A

Methotrexate (Rheumatrex, Trexail)

Hydroxychloroquine (Plaquenil)

Sulfasalazine (Azulfidine)

Minocycline (Minocin)

Leflunomide (Arava)

Tofacitinib (Xeljanz)

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20
Q

What’s the brand name of methotrexate? (DMARD)

A

Rheumatrex

Trexail

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21
Q

What’s the brand name of hydroxychloroquine? (DMARD)

A

Plaquenil

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22
Q

How’s methotrexate (Rheumatrex, Trexail) used in RA?

A

Low weekly doses are used for RA (weekly doses can be split into smaller doses taken over 12-36 hours

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23
Q

Should methotrexate (Rheumatrex/ Trexail) be dosed daily in RA?

A

Never

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24
Q

What’s the SE of methotrexate (Rheumatrex/ Trexail)?

A

Nausea

Vomiting

Increased LFTs

Stomatitis

Alopecia

Photosensitivity

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25
Q

What’s the monitoring parameters for methotrexate (Rheumatrex/ Trexail)?

A

LFTs and SCr (at baseline and every 2-4 weeks for 1st 3 months)

Chest x-ray, hep B & C at baseline

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26
Q

Can methotrexate (Rheumatrex/ Trexail) be used during pregnancy?

A

Pregnancy category X

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27
Q

What’s usually given to decrease the SE of methotrexate (Rheumatrex/ Trexail)?

A

Folic acid 5mg PO weekly given on the day following methotrexate admin

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28
Q

Which methotrexate med was recently approved? Unique use?

A

Otrexup

Allows patients to self-admin methotrexate SC once weekly using an auto-injector

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29
Q

What’s the SE of hydroxychloroquine (Plaquenil)? (DMARD)

A

Nausea

Diarrhea

Rashes

Pigmentation of skin and hair

Weakness

Vision changes (rare)

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30
Q

What’s the contraindication to sulfasalazine use?

A

Pts with sulfa or salicylate allergy

GI or GU obstruction

Porphyria

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31
Q

SE of sulfasalazine?

A

Headache

Anorexia

Dyspepsia

GI upset (N/V/D)

Oligospermia (reversible)

Rash (all > 10%)

Folate deficiency

Arthralgias

Crystalluria

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32
Q

Effect of sulfasalazine on skin/urine?

A

Can cause yellow-orange coloration of skin/urine

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33
Q

Effect of sulfasalazine on folate absorption?

A

Impairs folate absorption

May give 1mg/day folate supplement

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34
Q

How do u prevent Crystalluria from sulfasalazine use?

A

Take sulfasalazine with food and 8oz of water

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35
Q

What’s the main SE of Minocycline use (DMARD)?

A

Photosensitivity

36
Q

What’s the black box warning associated with Leflunomide (Arava) use?

A

Women of child-bearing age (pregnancy should be excluded before Leflunomide is started)

Hepatotoxicity

37
Q

What’s the main SE of Leflunomide (Arava) (DMARD)?

A

Hepatoxicity

38
Q

How do u ascertain woman is not pregnant while on Leflunomide (Arava)?

A

Must have negative pregnancy test b4 starting medication + use 2 forms of birth control

39
Q

If a woman wants to get pregnant while on Leflunomide (Arava) (DMARD)?

A

Must wait 2 years after discontinuing Leflunomide (Arava)

OR

Give cholestyramine to eliminate Leflunomide (Arava)

40
Q

What must Tofacitinib (Xeljanz) (DMARD) not be used with ?

A

Don’t use with biologic DMARDs or potent immunosuppressants

41
Q

What should methotrexate (Rheumatrex/ Trexail) not be used with? Why?

A

Methotrexate should not be taken with alcohol

May increase risk of liver toxicity

42
Q

Howz methotrexate dosed?

A

Once weekly (some pts divide the weekly dose in half and take it over 2 days)

Don’t use methotrexate daily or double up doses

43
Q

Should methotrexate (Rheumatrex/ Trexail) be used during pregnancy?

A

No. It’s category X

If you’re pregnant or have a chance of becoming pregnant, u should not use methotrexate

44
Q

List the biologic agents used in RA?

A

Etanercept (Enbrel, Enbrel SureClick)

Adalimumab (Humira, Humira Pen)

Infliximab (Remicade)

Certolizumab (Cimzia, Cimzia Prefilled)

Golimumab (Simponi, Spimponi Aria)

45
Q

MOA of biologic agents in RA?

A

Tumor Necrosis Factor (TNF-alpha) inhibitors (Anti-TNF biologics)

46
Q

What’s the brand name of Etanercept?(biologic agent used in RA)

A

Enbrel

Enbrel SureClick

47
Q

What’s the brand name of Adalimumab?(biologic agent used in RA)

A

Humira

Humira Pen

48
Q

What’s the brand name of Infliximab?(biologic agent used in RA)

49
Q

What’s the brand name of Golimumab?(biologic agent used in RA)

A

Simponi

Simponi Aria

50
Q

List the biologic agents that must only be given in combo with methotrexate in RA

A

Infliximab (Remicade)

Golimumab (Simponi, Simponi Aria)

51
Q

List infusion rxns from the use of Infliximab (Remicade) (biologic agent used in RA )

A

Hypotension

Fever

Chills

Pruritus (may benefit with pre-tx with acetaminophen, antihistamine, steroids)

52
Q

List delayed hypersensitivity rxns from the use of Infliximab (Remicade) (biologic agent used in RA )

A

3 - 10 days after admin

Fever, rash, myalgia, HA, sore throat

53
Q

What’s the black box warning associated with biologic agents used in RA?

A

Serious infections (some fatal)

D/c tx of pt develops a severe inf; lymphomas and other malignancies; reactivation of latent TB or new inf; perform test for latent TB prior to starting therapy

54
Q

List the main warnings associated with biologic agents used in RA

A

Heart failure

Hapatoxicity

55
Q

What’s the SE of biologic agents used in RA?

A

Infections and injection site rxns (redness, rash, swelling, itching or bruising)

56
Q

What’s the monitoring parameters for biologic agents used in RA?

A

TB test (prior to admin and annually)

S/sx of infections

CBC

LFTs

HBV (prior to initiation)

HF

Malignancies

57
Q

Which tests need to be done PRIOR to starting biologic agents used in RA?

A

TB test

HBV

58
Q

How are biologic agents used in RA stored? Exception?

A

Requires refrigeration

Etanercept (Enbrel, Enbrel SureClick) can be stored at room temp for 14 days

59
Q

What’s the first line in RA? How are biologic agents used

A

Methotrexate (Rheumatrex/ Trexail) is first-line

Biologic agents are add-on therapy

Biologic agents may be used as 1st line if initial presentation is severe

60
Q

Can u use biologic agents concurrently?

A

No! Don’t use more than 1 biologic agent concurrently

61
Q

Can live vaccines be given with biologic agents used in RA?

A

No! Don’t use live vaccines with biologic agents

62
Q

What vaccines is recommended that RA pts receive?

A

Pneumococcal

Influenza shot

Hepatitis A

HPV

Herpes zoster (shingles) (live vaccine)

Remember don’t give live vaccine if pts already receiving biologic agents

63
Q

List other biologics (Non-TNF Biologics) used in RA?

A

Rituximab (Rituxan)

Anakinra (Kineret)

Abatacept (Orencia)

Tocilizumab (Actemra)

64
Q

Brand name of Rituximab (other biologics (Non-TNF Biologics) used in RA)?

65
Q

Brand name of Abatacept (other biologics (Non-TNF Biologics) used in RA)?

66
Q

Brand name of Tocilizumab (other biologics (Non-TNF Biologics) used in RA)?

67
Q

What’s the main warning for use of Rituximab (Rituxan); Anakinra; Abatacept (Orencia); Tocilizumab (Actemra)?

A

Screen for latent TB

68
Q

MOA of rituximab (Rituxan)?

A

Depletes CD20 B cells

B cells are believed to have a role in RA development and progression

69
Q

Main SE of Tocilizumab (Actemra)?

A

Increased LFTs

70
Q

Whats the site of injection of all immune modulators used in RA?

A

Upper middle thigh OR Abdomen

71
Q

Since all SC biologics are to be refrigerated (except Etanercept (Enbrel)), how should they be used?

A

Wait until drug is at room temp before injecting

72
Q

All the SC biologics can be warmed by holding in hand or slowly rubbing together btw palms, except?

A

Golimumab (Simponi, Simponi Aria)

73
Q

When’s MedGuide given with biologics?

A

First time you get med and with each refill

74
Q

Which vaccine can pts on biologics continue to get?

A

Annual influenza shot (but not nasal mist vaccine)

75
Q

Biologics block immune system; effect of this?

A

It may lower ability to fight infections

76
Q

If a pt has been exposed to TB, but don’t have active dx (latent TB) what can be done to prevent TB during therapy?

A

Pt will need to start taking dp daily TB tx BEFORE staring therapy

77
Q

What organ may biologics damage?

A

Liver

Call healthcare provider immediately if u have any sx:
Feel tired, skin or eyes look yellow, poor appetite or vomiting, pain on right side of stomach (abdomen)

78
Q

Injection site of biologic agents?

A

Skin of thigh

Abdomen

Upper arm

79
Q

How often should Etanercept (Enbrel) be given?

A

Once weekly

80
Q

How often should Adalimumab (Humira) be given?

81
Q

How often should Certolizumab be given?

82
Q

How often should Golimumab (Simponi) be given?

83
Q

How long does it take for biologics to warm up?

A

15 - 30 mins

84
Q

Should biologics be shaken before use?

A

Don’t shake medicine

85
Q

T/F? If particles or discoloration is present, don’t use medicine?

86
Q

What’s the correct admin route for Etanercept (Enbrel)?

87
Q

What’s rheumatoid arthritis?

A

RA causes inflammation of the joints and other organs in the body, including the kidneys, eyes, heat and lungs

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