DMARDs Flashcards
RA management NICE: Initial therapy
Monotherapy with cDMARD within 3 months
Escalated to dose that can be managed.
RA management NICE: DAS28 scoring
Multiple measures of disease activity to make a decisions on treatment
RA management NICE: Short-term bridging treatment
Glucocorticoids. Steroids used with initial cDMARD, as cDMARD does not work straight away and get rid of symptoms.
Where is the steroid bridging treatment used?
Use intramuscular (muscle), or intraarticular (joint). Avoid oral
Why Avoid oral steroids for bridging treatment?
Have lots of side effects
Systemic, change to blood glucose, osteoporosis, GI irritation, suppression of the adrenal system and physiocratic effects
What are side effects that may be experienced with IM and IA steroids?
Thinning of skin and pain at injection site.
What are Specific targeted therapies?
Oral drugs like Janus Kinase inhibitors (expensive)
RA management NICE: Ineffective initial DMARD therapy (4)
Step up
Try different
Biological DMARD
Specific targeted therapies.
RA management NICE: Symptom control
Analgesia Physio OT Lifestyle advice (exercise) CBT
RA management NICE: target achieved for >1 year without glucocorticoids
Consider stepdown
RA management NICE: First line drugs? (3)
Oral methotrexate, leflunomide or sulfasalazine
RA management NICE: Consider hydroxychloroquine for first line
If patient has mild disease or palindromic disease
Issue with DMARD?
Takes a while to work so patients may not notice any changes.
They do not treat symptoms.
What do DMARD do?
Prevent progression and destruction of the joints over time.
What are biological DMARDs?
Monoclonal antibodies that target cytokines like Anti-TNF
What are RA patients more at risk of?
Strokes and CVD
What do NSAIDs increase the risk of?
CVD particularly COX-2 inhibitors.
What is mild disease or palindromic disease
Flare ups the normal joint function. Not much damage or long term progression to the joint.
What does the DAS-28 score look at? (3)
How many tender and swollen joints out of 28.
ESR/CRP
Patients feeling 1-100
DAS-28 score = very active disease
> 5.1
DAS-28 score = active disease
5.1-3.2
DAS-28 score = remission
<2.6
DAS-28 score = response to treatment
A change of 0.6
ESR
Erythrocyte sedimentation rate
How quickly RBC settle in a test tube.
CRP
C-reactive protein
Increases when inflammation in the body
Normal ESR
0 to 22 mm/hr for men and 0 to 29 mm/hr for women
High ESR?
Inflammation
Normal CRP
Less than 10 mg/L
CS-DMARD
Classical synthetic
B-DMARD
Biologic
Ts-DMARD
Targeted
CS-DMARD examples
Methotrexate, sulfasalazine, hydroxychloroquine, leflunomide, azathioprine
B-DMARD examples
Etanercept, adalimumab, golimumab, abatacept, rituximab
Ts-DMARD examples
Tofacitinib, baricitinib
Prescribing principles cDMARD: shared-care arrangements
Initiated in hospital by a HCP. Once patient stable, care transferred to GP.
Prescribing principles cDMARD: Chicken pox
Due to impaired immune function need to avoid contact. Must seek medical advice immediately.
Prescribing principles cDMARD: Intercurrent illness
Stop DMARD
Prescribing principles cDMARD: Monitoring trends and blood results.
Need to interval for each drug. More than one drug, monitor using minimal interval period. (shortest frequency of monitoring?)
Use multiple blood results.
What is monitored in blood results for cDMARDs?
Neutrophils, platelets.
Prescribing principles cDMARD: Vaccines
Flu, pneumococcal and COIVD 19.
Prescribing principles cDMARD: Live vaccines
Contraindicated. More prone to develop disease. Varicella zoster is the exception.
What is methotrexate never prescribed with?
Trimethoprim
Why is methotrexate and trimethoprim not prescribed together?
Anti-folate effect
What do with cDMARDs, JAK inhibitors or bDMRADs when COIVD 19 infection?
Temporarily stop with consultant advice
