Chapter 59: Rheumatoid Arthritis Flashcards
RA
Pt presents with pain and joint stiffness. Worse in the morning, s/sx improve as the day progresses
Progressive joint deterioration
Autoimmune inflammatory disorder
RA tx
Relieve symptoms
Maintain joint function
Minimize systemic involvement
Delay progression of disease
Nondrug measures
Classes of anti arthritic drugs
NSAIDs
Nonsteroidal antiinflammatory drugs
Give rapid relief of s/sx
DMARDs
Disease-modifying antirheumatic drugs
Nonbiologic DMARDs (traditional DMARDs)
Biologic DMARDs
Reduce joint destruction and slow progression of disease
Glucocorticoids
Adrenal corticosteroids
Provide rapid relief of s/sx
Have long-term SE, limited to short tern usage
Drug selection for RA
Protocol
Overseen by rheumatologist
Recommend aggressive tx, DMARDs on early
Want dx an tx started within 3m –want to interrupt degenerative process
Takes these drugs several weeks to see effect
NSAIDs brought on early
NSAIDs for RA
First-generation NSAIDs: Inhibit COX-1 and COX-2
Second-generation NSAIDs (coxibs): Selectively inhibit COX-2 (Celecoxib)
Safety: All prescription-strength NSAIDs carry a boxed warning regarding risk of thrombotic events and gastrointestinal (GI) ulceration and bleeding
Glucocorticoids for RA
Generalized symptoms: Oral glucocorticoids
One or two joints are affected: Intra-articular injections
Adverse effects
Weigh gain, fluid retention, irritability, etc.
Prednisone and prednisolone
Relief s/sx quick and may delay progression of dz
d/c NSAIDs when glu started
DMARDs I: Major Nonbiologic DMARDs
Methotrexate
Sulfasalazine
Methotrexate
Most rapid-acting DMARD
Therapeutic effect: 3 to 6 weeks
Adverse effects
Hepatic fibrosis
Bone marrow suppression
GI ulceration
Pneumonitis
Require close follow up of pt
Sulfasalazine
Used to treat inflammatory bowel disease (IBD); now used for RA as well
Antiinflammatory and immunomodulatory actions
Can slow progression of joint deterioration
GI side effects may be intolerable
Other DMARDs I: Major Nonbiologic DMARDs
Leflunomide [Arava]
Hydroxychloroquine [Plaquenil]
Also anti-malarial drug
Full therapy in 3-6m
Can combo with methotrexate
Minocycline [Minocin]
Penicillamine
Azathioprine [Imuran]
Cyclosporine
Prosorba column
Less costly
DMARDs II: Major Biologic DMARDs
Tumor necrosis factor (TNF) inhibitors
Suppress immune function
Pose risk of serious infection
Work by neutralizing TNF
Etanercept [Enbrel]
Adalimumab [Humira]
Certolizumab pegol [Cimzia]
Golimumab [Simponi]
Golimumab [Simponi Aria]
Infliximab [Remicade]
More expensive
Targeted biological
Etanercept (enbrel)
Action
Inactivates TNF
Use
Moderate to severe RA
Adverse effects
Serious infections
Severe allergic reactions
Heart failure
Hematologic disorders
Liver injury
Central nervous system (CNS) demyelinating disorders
Not prescribed in primary care
Drug interaction
Decrease effectiveness of vaccines
Should not get live vaccines
Using with other immunosuppressants increases risk for serious infections
Other Biologic DMARDs
Infliximab [Remicade]
Adalimumab [Humira]
Golimumab [Simponi]
Certolizumab pegol [Cimzia]
Rituximab [Rituxan]
Reduces the number of B lymphocytes
Reduces symptoms of RA and slows disease progression
Adverse effects: Infusion reactions, monocutaneous reactions, hepatitis B reactivation, progressive multifocal leukoencephalopathy (PML), others
Abatacept [Orencia]
First-in-class T-cell activation inhibitor
Reduces symptoms of RA and disease progression
Adverse effects: Headache, upper respiratory infection, nasopharyngitis, nausea, serious infections
Vaccines
Decrease effective’s of vaccines
Should not receive live vaccines
