DMARDS

Question 1

How would you start DMARD therapy?

Answer 1

Small molecules such as METHOTREXATE

Question 2

How can methotrexate be administered?

Answer 2

IM, SC, oral

give IV if greater than 15mg/week

Question 3

What can methotrexate be used for?

Answer 3

Many forms of inflammatory arthritis, other autoimmune diseases, cancer

Question 4

What drug can increase adenosine level?

Answer 4

Methotrexate

Question 5

What drug causes apoptosis of Cd4 and Cd8 activated T cells?

Answer 5

Methotrexate

Question 6

What drug inhibits dihydrofolate reductase?

Answer 6

Methotrexate

Question 7

What is dihydrofolate reductase involved in?

Answer 7

purine and thimidylate biosynthesis

Question 8

If you inhibit dihydrofolate reductase what will this cause?

Answer 8

Impaired DNA synthesis of rapidly dividing cells

Give lower doses of this drug when used in RA so as not to cause adverse effects to these cells

Question 9

What should you evaluate before starting someone on Methotrexate?

Answer 9

Renal, Acute or Chronic Liver Disease, alcohol abuse, leukopenia, thrombocytopenia, untreated folate deficiency

Question 10

What drugs should you avoid with someone taking methotrexate?

Answer 10

Trimethoprim
Coadmin of NSAIDS is common but liver function tests should be closely monitored
Probenacid

Question 11

Common side effects of Methotrexate?

Answer 11

Mucosal ulcerations, fog, nausea

Cytopenias, Liver Cirrhosis, Acute Pneumonia like syndrome

Question 12

What drug can you administer a day after methotrexate to reduce the toxicities?

Answer 12

Folic acid supplementation or leucovorin

Question 13

What routine monitor tests should you order with methotrexate?

Answer 13

CBC, liver profile. serum albumin and creatinine

Question 14

If treatment of methotrexate fails, what drug can you try next?

Answer 14

Leflunomide

-Can be combined with methotrexate if you monitor liver

Question 15

What drug inhibits dihydroorotate dehydrogenase, causing arrest of autoimmune lymphocytes and thus blocks pyrimidine synthesis?

Answer 15

Leflunomide

Question 16

Is lefluonomide a prodrug? metabolite?

Answer 16

Yes A77-126

Question 17

Admin of lefluonomide?

Answer 17

Oral

Question 18

Side effects of leflunomide?

Answer 18

HA, diarrhea, and nausea
weight loss, allergic reactions, skin rash, alopecia, hypokalemia
CAUTION with liver disease

Question 19

What drug can you give with leflunomide to hep clear out the drug?

Answer 19

Cholestyramine - binds bile acids and interrupts the enterohepatic circulation

Question 20

Monitoring for Leflunomide?

Answer 20

CBC and liver function tests- early in beginning then every 2 months

Question 21

What drug(s) are not very effective for RA and should be limited to use with mild or nonerosive disease? In addition, used when NSAIDS are unresponsive?

Answer 21

Chloroquine and Hydroxychloroquine

Question 22

MOA for chroloquine and hydroxychloroquine

Answer 22

UNKNOWN

Question 23

What drug may cause ocular toxicity and therefore requires opthalmological exam every 6-12 months?

Answer 23

Chloroquine and Hydroxychloroquine

Question 24

What nonbiologic shows NO evidence that it alters bony erosions?

Answer 24

Chloroquine and Hydroxychloroquine

AND Minocycline

Question 25

What drug was shown to be relatively safe in pregnancy?

Answer 25

Hydroxychloroquine | Methotrexate and Leflunomide are def CONTRAINDICATED

Question 26

Whats Sulfasalazine's metabolite?

Answer 26

Sulfapyridine- cleaved by bacteria in the drug

Question 27

What is the "triple therapy" for RA

Answer 27

Methotrexate, Hydroxychloroquine and Sulfasalazine | Good for people who don't respond to methotrexate alone

Question 28

MOA of Sulfasalazine

Answer 28

UNKNOWN

Question 29

Side effects of sulfasalazine

Answer 29

With sulfa allergies: hypersensitivity and allergic rxns | Mild GI complaints, mild cytopenias

Question 30

What screening tests do you do before administering Sulfasalazine?

Answer 30

Deficiency of G6PD - would predispose them for hemolysis and anemia

Question 31

What drug is recommended for people who have liver disease, Hep B or C?

Answer 31

Sulfasalazine

Question 32

What drug works by inhibiting janus kinase 3?

Answer 32

Tofacitinib

Question 33

Admin of Tofacitinib?

Answer 33

Oral

Question 34

What screening test do you need to do before administering Tofacitinib?

Answer 34

TB test for latent TB

Question 35

Side effects of Tofacitinib?

Answer 35

Increased risk for opportunistic or other serious infections

Question 36

What drug do you give for low disease activity and without features of poor prognosis? This drug has low adverse effects.

Answer 36

Minocycline

Question 37

What drug is a purine analog that can cause bone marrow suppression and lowering of blood counts?

Answer 37

Azathioprine | SE more common with renal insufficiency, allopurinal or ACEI

Question 38

What screening test should you do before Azathioprine administration?

Answer 38

test for enzyme thiopurine methyltransferase (metabolizes 6-mercaptopurrine?)

Question 39

How do you monitor someone on Azathioprine?

Answer 39

CBC and liver function

Question 40

What drug is used for preventing renal and liver transplant rejection, psoriasis, and other autoimmune disease?

Answer 40

Cyclosporine

Question 41

What drug inhibits T cell function and inhibit transcription of IL2 ?

Answer 41

Cyclosporine

Question 42

SE of Cyclosporine?

Answer 42

Infection, Renal Insufficiency | Increase in BP common!! - may give BP meds when starting

Question 43

What do you monitor with Cyclosporine?

Answer 43

Renal function and BP

Question 44

What drug do you use for refractory RA or with manifestations such as vasculitis?

Answer 44

Cyclophosphamide

Question 45

Used to treat lupus and vasculitis?

Answer 45

Cyclophosphamide

Question 46

What drug is an alkylating agent?

Answer 46

Cyclophosphamide

Question 47

Toxicities of Cyclophosphamide?

Answer 47

Bone marrow suppresion hemorrhagic cystitis, premature ovarian failure, infection, risk for bladder cancer

Question 48

What is Cyclophosphamides metabolite? How do you neutralize its carcinogenic effect?

Answer 48

Acrylline? treat with MESNA

Question 49

What is Mycophenolate mofetil metabolite?

Answer 49

Mycophenolic acid

Question 50

What drug inhibits the enzyme inosine monophasphatase dehydrogenase (IMPDH), depleting guanosine analgoues which will inhibit B and T cell activation and proliferation. It may also induce apoptosis.

Answer 50

Mycophenolate mofetil

Question 51

What drug has no well controlled data regarding efficacy for RA treatment?

Answer 51

Mycophenolate mofetil

Question 52

Side effects of Mycophenolate mofetil

Answer 52

N,D, abdominal pain hepatotoxicity, leukopenia, thrombocytopenia, and anemia increased infections

Question 53

What drug is used for lupus nephritis?

Answer 53

Mycophenolate mofetil

Question 54

What drug is an analog of amino acid cysteine?

Answer 54

d-Penicillamine

Question 55

What drug is primarily reserved for aggressive disease that doesn't respond well to other DMARDS?

Answer 55

d-Penicillamine

Question 56

SE of d-Penicillamine

Answer 56

severe rash, renal function effects, lupus like illness or other autoimmune disease

Question 57

What should you monitor for d-Penicillamine

Answer 57

Renal function

Question 58

MOA of this drug is that macrophages take it up and it suppresses phagocytosis and lysosomal enzyme activity?

Answer 58

GOLD

Question 59

Admin of gold?

Answer 59

IV and oral, but oral is less efficacious

Question 60

What should you do prior to gold injection?

Answer 60

CBC and urine protein

Question 61

SE for gold?

Answer 61

``` Rash (mild to severe) Ulcerations and mucositis Membranous glomerulanephropathy Immune thrombocytopenia, granulocytopenia, aplastic anemia Blue skin ```

Question 62

What drug can be given to people who have an inadequate response to DMARDS such as methotrexate and TNF inhibitors? Its a CTLA4 antibody

Answer 62

Abatacept

Question 63

What drug do you not combine with TNF inhibiors and Anakinra?

Answer 63

Abatacept

Question 64

How do you administer abatacept?

Answer 64

IV once a month

Question 65

SE of abactacept

Answer 65

increased infections and mild infusion reactions

Question 66

How do B cells contribute to RA?

Answer 66

Activate T cells, produce autoantibodies (anti-CCP and RF), release TNFa and IL1

Question 67

What drug(s) can be used in RA only AFTER they have failed TNF antagonists?

Answer 67

Rituximab, Tocilizumab

Question 68

What drug is a monoclonal antibody that binds to CD20 antigen found on B Cells?

Answer 68

Rituximab

Question 69

What dug is used for non Hodgkins lymphoma?

Answer 69

Rituximab

Question 70

How long does Rituximab effect last?

Answer 70

anywhere from 6 months-2 years

Question 71

Admin of Rituximab?

Answer 71

IV for 3-4 hrs, 2 weeks apart | Given with corticosteroids, and diphenhydramine and acetominophen

Question 72

What should you make sure patient has before starting Rituximab?

Answer 72

Immunizations- tell them not to do live virus vaccinations

Question 73

SE of Rituximab?

Answer 73

Increased infections, Infusion reactions | Reactivation of viral infections that were dormant like HEP B

Question 74

What drug binds to IL6 receptors?

Answer 74

Tocilizumab

Question 75

What drug restores CYP450 and should readjust certain medications because of it?

Answer 75

Tocilizumab

Question 76

What group of drugs have limited use due to cost and insurance reimbursement?

Answer 76

TNF inhibitors

Question 77

What should you test before starting TNF inhibitors? What should you continue to monitor?

Answer 77

Latent TB Don't use with demyelinating diseases and CHF Check for infections continuously

Question 78

Standard therapy of RA by experts?

Answer 78

Methotrexate plus TNF inhibitor

Question 79

Admin of Entanercept?

Answer 79

SubQ 1/2 times per week

Question 80

SE of Entanercept

Answer 80

Virtually none, may see local inflammation with injection

Question 81

What is a chimeric immunoglobun Gk monoclonal antibody to TNF a?

Answer 81

Infliximab

Question 82

Admin of Infliximab?

Answer 82

IV over 2 hours

Question 83

What is a consequence of chronic use of infliximab?

Answer 83

development of anti-infliximab antibodies, unless givne with methotrexate

Question 84

How can you reduce the infusion reactions with infliximab?

Answer 84

Give corticosteroids, diphenhydramine, or acetaminophen with infusion

Question 85

Admin of Adalimumab?

Answer 85

SubQ every week or 2 weeks

Question 86

What are the human and humanized antibody to TNFa?

Answer 86

Golimumab and Certolizumab

Question 87

What drug is administered by injection pen doses of 50 mg given monthly by SC injection?

Answer 87

Golimumab

Question 88

Admin of Certolizumab?

Answer 88

SC injection

Question 89

What cytokine (that leads to stimulation of osteoclasts) do we have an endogenous blocker of?

Answer 89

IL-1

Question 90

What DMARD has a DAILY subq injection?

Answer 90

Anakinra

Question 91

What DMARD should NOT be used with TNF inhibitors?

Answer 91

Anakinra

Question 92

What drug can be given additionally for IBD?

Answer 92

Sulfasalazine

Question 93

What drug can you use in RA if the patient has significant liver disease of Hep B and C?

Answer 93

Sulfasalazine