DMARDS Flashcards
What are DMARDS for?
RA
What do you they aim to do?
For remission or low-disease activity
Why is it started as monotherapy?
Risk of toxicity
What are the 1st line options?
Methotrexate
Leflunomide
Sulfasalazine
When is treatment started?
Within 3 moths of onset of persistent symptoms
= better outcomes when quicker to treat
When is hydroxychloroquine considered 1st line?
Palindromic (occasional/flare ups)
What is the dose given?
What the patient can tolerate
Why is S/C methotrexate good?
More tolerated = often don’t feel sick
BUT PO 1st because it’s cheaper
What can you consider to bride the gap for DMARDs to work?
Short course of glucocorticoids
How is DAS-28 scored?
Count number of swollen + tender joints
Then a biochemical test = ERS/CRP
Patient global health = how the patient feels
What are cs-DMARDS?
Classic synthetic
eg. methotrexate, leflunomide
What are B-DMARDS?
Biologic
eg. Etanercept, adalimumab, rituximab
What are Ts-DMARDS?
Targeted
eg. Tofacitinib
What is the risk of DMARDS?
Alter immune system so become very susceptible to infections = sepsis
When are you more at risk?
1st year of treatment = monitored frequently by the hospital
What happens when you get an infection?
Steroid tablets = continue
DMARDS + biologics = STOP
How does methotrexate work?
Anti-folate medication
= interferes with folate metabolism
= growing cells depend on reduced folate for DNA synthesis
= competitively inhibits dihydrofolate reductase
How do you take methotrexate?
ONCE WEEKLY
In 3x tablets all at once
Also need folic acid but must be taken on different day
Why do you need to monitor kidneys?
Renally excreted
How do methotrexate work?
Dihydrofolate reductase inhibited
= dihydrofolate can’t be converted to tetrahydrofolate
= inhibits production of purines + DNA synthesis
Methotrexate can cause foetus damage, so what must happen?
Contraception (men + women) during + 6 months after
How is methotrexate monitored?
1-2 weekly then every 2-4months once stabilised
What needs to be monitored with methotrexate?
Blood count
LFTs
U&Es
What are signs of methotrexate toxicity?
Stomatitis
Immunosuppression = fever, cough, tachycardia, sweat, sore throat
Pulmonary toxicity = dry cough 3 weeks = chest x-ray
Hepatic (cirrhosis) = yellowing of skin/eyes. RUQ pain, urine (brown) + poo (pale)
What is Sulfasalazine?
Prodrug - 5-ASA
Anti-inflammatory effects
What is the counselling for Sulfasalazine?
Signs of infection
May discolour urine
What are the side effects of Sulfasalazine?
GI intolerance
Rashes
Blood disorders
Pneumonitis
What is the dosing for Sulfasalazine?
Target dose 1g BD
Gradual dose titration
What does Leflunomide do?
Inhibit pyrimidine synthesis
Prodrug
What does Leflunomide interact with?
Clopidogrel
Omeprazole
Diazepam
Cholestyramine
What is the therapeutic effect of Leflunomide?
After 4-6 weeks
When is Leflunomide a good option?
Methotrexate + Sulfasalazine cannot be used
What are the adverse effects of Leflunomide?
Gi disturbances
Weight loss
Allergic reaction
Reversible alopecia
Hypertension
What is Hydroxychloroquine?
Anti-malarial
What are the side effects of Hydroxychloroquine?
GI
Skin rash
Vision disorders
Headaches
