Autoimmune Dx - Rheumatoid Arthritis Flashcards by Blade Joneson

Describe RA?

Chronic, symmetrical, systemic and progressive dx

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Where does RA typically first presents?

Hands and feet

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

Classic sx of RA

Joint swelling

Stiffness

Pain

Bone deformity (eventually)

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List the diagnostic criteria for RA

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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Howz diagnosis of RA made using the diagnosis criteria?

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

AND

4 or more criteria must be present

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

Almost always Polyarticular and Symmetrical

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Which synovial joint is most often involved in RA?

Finger joints of the hand

Wrists

Knees

Toe joints

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List the typical articular sx of RA

Morning stiffness

Swelling

Redness

Edema

Pain

Decreased range of motion

Muscle atrophy

Weakness

Deformity

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

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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List non-pharmacologic tx of RA?

Rest

Physical therapy

Occupational therapy

Exercise

Diet

Weight control

Surgical intervention (eg. Joint replacement)

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What’s the goal of pharmacologic tx of RA?

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

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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.

True

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List agents used for pain and inflammation

NSAIDs

COX-2 selective inhibitor

Steroids

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List NSAID used as agent used for pain and inflammation

Ibuprofen (Motrin, advil)

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

Celecoxib (Celebrex)

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

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

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What’s the indication of steroids for RA?

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

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

<= 10 mg daily

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List DMARDs used for RA

Methotrexate (Rheumatrex, Trexail)

Hydroxychloroquine (Plaquenil)

Sulfasalazine (Azulfidine)

Minocycline (Minocin)

Leflunomide (Arava)

Tofacitinib (Xeljanz)

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

Rheumatrex

Trexail

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

Plaquenil

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

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

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

Never

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

Nausea

Vomiting

Increased LFTs

Stomatitis

Alopecia

Photosensitivity

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

LFTs and SCr (at baseline and every 2-4 weeks for 1st 3 months) Chest x-ray, hep B & C at baseline

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

Pregnancy category X

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

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

Which methotrexate med was recently approved? Unique use?

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

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

Nausea Diarrhea Rashes Pigmentation of skin and hair Weakness Vision changes (rare)

What's the contraindication to sulfasalazine use?

Pts with sulfa or salicylate allergy GI or GU obstruction Porphyria

SE of sulfasalazine?

Headache Anorexia Dyspepsia GI upset (N/V/D) Oligospermia (reversible) Rash (all > 10%) Folate deficiency Arthralgias Crystalluria

Effect of sulfasalazine on skin/urine?

Can cause yellow-orange coloration of skin/urine

Effect of sulfasalazine on folate absorption?

Impairs folate absorption May give 1mg/day folate supplement

How do u prevent Crystalluria from sulfasalazine use?

Take sulfasalazine with food and 8oz of water

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

Photosensitivity

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

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

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

Hepatoxicity

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

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

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

Must wait 2 years after discontinuing Leflunomide (Arava) OR Give cholestyramine to eliminate Leflunomide (Arava)

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

Don't use with biologic DMARDs or potent immunosuppressants

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

Methotrexate should not be taken with alcohol May increase risk of liver toxicity

Howz methotrexate dosed?

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

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

No. It's category X If you're pregnant or have a chance of becoming pregnant, u should not use methotrexate

List the biologic agents used in RA?

Etanercept (Enbrel, Enbrel SureClick) Adalimumab (Humira, Humira Pen) Infliximab (Remicade) Certolizumab (Cimzia, Cimzia Prefilled) Golimumab (Simponi, Spimponi Aria)

MOA of biologic agents in RA?

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

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

Enbrel Enbrel SureClick

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

Humira Humira Pen

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

Remicade

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

Simponi Simponi Aria

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

Infliximab (Remicade) Golimumab (Simponi, Simponi Aria)

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

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

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

3 - 10 days after admin Fever, rash, myalgia, HA, sore throat

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

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

List the main warnings associated with biologic agents used in RA

Heart failure Hapatoxicity

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

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

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

TB test (prior to admin and annually) S/sx of infections CBC LFTs HBV (prior to initiation) HF Malignancies

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

TB test HBV

How are biologic agents used in RA stored? Exception?

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

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

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

Can u use biologic agents concurrently?

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

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

No! Don't use live vaccines with biologic agents

What vaccines is recommended that RA pts receive?

Pneumococcal Influenza shot Hepatitis A HPV Herpes zoster (shingles) (live vaccine) Remember don't give live vaccine if pts already receiving biologic agents

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

Rituximab (Rituxan) Anakinra (Kineret) Abatacept (Orencia) Tocilizumab (Actemra)

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

Rituxan

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

Orencia

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

Actemra

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

Screen for latent TB

MOA of rituximab (Rituxan)?

Depletes CD20 B cells B cells are believed to have a role in RA development and progression

Main SE of Tocilizumab (Actemra)?

Increased LFTs

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

Upper middle thigh OR Abdomen

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

Wait until drug is at room temp before injecting

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

Golimumab (Simponi, Simponi Aria)

When's MedGuide given with biologics?

First time you get med and with each refill

Which vaccine can pts on biologics continue to get?

Annual influenza shot (but not nasal mist vaccine)

Biologics block immune system; effect of this?

It may lower ability to fight infections

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?

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

What organ may biologics damage?

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)

Injection site of biologic agents?

Skin of thigh Abdomen Upper arm

How often should Etanercept (Enbrel) be given?

Once weekly

How often should Adalimumab (Humira) be given?

Q 2 weeks

How often should Certolizumab be given?

Q 4 weeks

How often should Golimumab (Simponi) be given?

Monthly

How long does it take for biologics to warm up?

15 - 30 mins

Should biologics be shaken before use?

Don't shake medicine

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

True

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

What's rheumatoid arthritis?

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