Chapter 59: Rheumatoid Arthritis

Question 1

goal of treatment for RA

Answer 1

1) relieving symptoms
2) maintaining joint function and range of motion
3) minimizing systemic involvement
4) delaying disease progression

Question 2

RA symptoms

Answer 2

joint stiffness and pain- most intense in the morning and abate as the day advances…swollen tender warm joints

can also be systemic with fever, multiple joints, etc

Question 3

nondrug treatment for RA

Answer 3

PT

exercise

surgery

Question 4

classes of antiarthritic drugs

Answer 4

NSAIDS
Glucocorticoids
DMARDs (Disease- modifying antirheumatic drugs)

Question 5

NSAIDS and glucocorticoids provide ______ in RA treatment

Answer 5

rapid relief

Question 6

Differences in NSAIDS vs. glucocorticods in treating RA

Answer 6

NSAIDS provide rapid relief of symptoms but do not prevent joint damage and do not slow disease progression

Glucosteroids can slow disease progression as well as provide rapid relief of symptoms

Question 7

DMARDS MOA

Answer 7

reduce joint destruction and slow disease progression

Question 8

Major Drugs of focus Conventional DMARDs

Answer 8

Methotrexate
Leflunomide (arava)
Hydroxychloroquine (Plaquenil)

Question 9

Targeted DMARDs- Janus Kinase Inhibitor

Answer 9

Tofacitinib (Xeljanz, Xeljanz XR)

Question 10

DMARDS are contraindicated in

Answer 10

pregnancy and breastfeeding

Question 11

when should DMARD therapy be started

Answer 11

ASAP, close to diagnosis the better but deff within three months

Question 12

While waiting for DMARDs to start to work what is usually given?

Answer 12

NSAIDS

Question 13

What is given for short term flare ups related to RA

Answer 13

Glucocorticoids

Question 14

GI effects from NSAIDS occur due to inhibition of what?

Answer 14

COX-1 (causes GI ulceration etc)

Question 15

what must be supplemented when giving methotrexate

Answer 15

Folate at least 5mg/week

Question 16

MTX MOA for RA

Answer 16

B and T lymphocytes

Question 17

AE effects of MTX

Answer 17

hepatic fibrosis, bone marrow suppression, GI ulceration and pneumonitis

Question 18

what labs should be followed when a patient is taking mtx

Answer 18

liver, kidney function, and cbc

Question 19

caution use of mtx in patients with hx of

Answer 19

renal/ liver impairment

Question 20

if taking mtx what kind of vaccine do you have to have?

Answer 20

inactivated

Question 21

second line use if mtx is not effective is

Answer 21

leflunnomide (Arava) - but is usually more hazardous and more expensive

Question 22

Leflunnomide (arava) can cause fetal effects due to

Answer 22

liver injury- avoid in patients with hx of liver impairment

Question 23

Leflunnomide (arava) AE:

Answer 23

diarrhea, infection, alopecia, and rash. Pancytopenia, Stevens- Johnson Syndrome, peripheral neuropathy, interstitial lung disease and severe hypertension, immunosuppression

Question 24

Before starting Leflunnomide patients should be screened for

Answer 24

TB

Question 25

Before getting pregnant a patient must stop Leflunnomide (Arava) and do what?

Answer 25

take cholestyrammine 8g tid for 11 days (without this it may take two years for it to clear)

verify drug levels are less than 20ug/L

men who wish to father a child should do the same thing.

Question 26

Leflunomide can inhibit the metabolism of what drugs?

Answer 26

NSAIDS -causing their levels to rise

Question 27

Leflunomide can cause liver damage when used in combination to other hepatic toxic drugs

Answer 27

like mtx

Question 28

rifampin can raise leflunomide levels by

Answer 28

40%- causing risk for toxicity

Question 29

Hydroxychloroquine (Plaquenil) usually used in combination with what drug for RA?

Answer 29

MTX

Question 30

onset of symptom management for Hydroxychloroquine include

Answer 30

a 3-6 month time period while NSAIDS and steroids are being used to manage symptoms until effects begin to work

Question 31

most common risk with hydroxychloroquine (plaquenil)

Answer 31

Retinal damage, patient should receive eye exam prior to start and annually after. should d/c if any issues, not common with low doses but more common with higher doses

Question 32

Hydroxychloroquine AE

Answer 32

cardiac arrthythmias including prolonged QT interval

hypoglycemia, proximal myopathy and neuropathy, and worsening psoriasis

may cause GI distress take with milk or food

Question 33

Hydroxychloroquine half life

Answer 33

is extremely long, about 40 days

Question 34

Tofacitinib (Xeljanz, Xeljanz XR) MOA

Answer 34

prevents activation of the STAT pathway by preventing JAK enzyme signaling

Question 35

When is Tofacitinib used?

Answer 35

after methotrexate is tried and other trials of DMARDS are complete but not working, this is because the medication is newer and long-term safety has not been established

Question 36

Tofacitinib AE

Answer 36

infections developing due to immunosuppression, bradycardia, prolonged PR interval, intersitial lung disease, GI perforations, drug induced liver injury, hyperlipidiemia, and increase occurence of malignancies

Question 37

Tofacitinib drug interactions

Answer 37

CYP enzymes can increase/decrease levels

DMARDS have additive toxic effect do NOT combine DMARDs with tofacitinib

Question 38

Tofacitinib black box warning

Answer 38

potential for developing fatel infections including TB

Question 39

when should you get vaccines when starting DMARDs

Answer 39

2 weeks prior to start of medication, once started live viruses must be avoided.

Question 40

Baseline data for drugs:

MTX:

Hydroxychloroquine:

Leflunomide:

Answer 40

M: CXR, pulmonary and GI

H: opthalamologic exam, cardiac and exam with ECG if indicated

L: Consider CXR, emphasis on BP and pulmonary status. s/s of peripheral neuropathy

Question 41

non pharmacological RA interventions

Answer 41

heat or cold applied to the joint

pt

combine with meds for best outcomes

Question 42

If the patient is having multiple joints involved/ pain your going to want to treat with what?

Answer 42

systemic corticosteroids

Question 43

If only one joint is involved you could possibly just give what kind of steroid?

Answer 43

intra articular steroid to local area