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MSS > DMARDS > Flashcards

DMARDS Flashcards

1
Q

How would you start DMARD therapy?

A

Small molecules such as METHOTREXATE

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2
Q

How can methotrexate be administered?

A

IM, SC, oral

give IV if greater than 15mg/week

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3
Q

What can methotrexate be used for?

A

Many forms of inflammatory arthritis, other autoimmune diseases, cancer

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4
Q

What drug can increase adenosine level?

A

Methotrexate

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5
Q

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

A

Methotrexate

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6
Q

What drug inhibits dihydrofolate reductase?

A

Methotrexate

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7
Q

What is dihydrofolate reductase involved in?

A

purine and thimidylate biosynthesis

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8
Q

If you inhibit dihydrofolate reductase what will this cause?

A

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

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9
Q

What should you evaluate before starting someone on Methotrexate?

A

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

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10
Q

What drugs should you avoid with someone taking methotrexate?

A

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

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11
Q

Common side effects of Methotrexate?

A

Mucosal ulcerations, fog, nausea

Cytopenias, Liver Cirrhosis, Acute Pneumonia like syndrome

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12
Q

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

A

Folic acid supplementation or leucovorin

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13
Q

What routine monitor tests should you order with methotrexate?

A

CBC, liver profile. serum albumin and creatinine

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14
Q

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

A

Leflunomide

-Can be combined with methotrexate if you monitor liver

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15
Q

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

A

Leflunomide

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16
Q

Is lefluonomide a prodrug? metabolite?

A

Yes A77-126

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17
Q

Admin of lefluonomide?

A

Oral

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18
Q

Side effects of leflunomide?

A

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

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19
Q

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

A

Cholestyramine - binds bile acids and interrupts the enterohepatic circulation

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20
Q

Monitoring for Leflunomide?

A

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

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21
Q

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?

A

Chloroquine and Hydroxychloroquine

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22
Q

MOA for chroloquine and hydroxychloroquine

A

UNKNOWN

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23
Q

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

A

Chloroquine and Hydroxychloroquine

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24
Q

What nonbiologic shows NO evidence that it alters bony erosions?

A

Chloroquine and Hydroxychloroquine

AND Minocycline

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25
Q

What drug was shown to be relatively safe in pregnancy?

A

Hydroxychloroquine

Methotrexate and Leflunomide are def CONTRAINDICATED

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26
Q

Whats Sulfasalazine’s metabolite?

A

Sulfapyridine- cleaved by bacteria in the drug

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27
Q

What is the “triple therapy” for RA

A

Methotrexate, Hydroxychloroquine and Sulfasalazine

Good for people who don’t respond to methotrexate alone

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28
Q

MOA of Sulfasalazine

A

UNKNOWN

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29
Q

Side effects of sulfasalazine

A

With sulfa allergies: hypersensitivity and allergic rxns

Mild GI complaints, mild cytopenias

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30
Q

What screening tests do you do before administering Sulfasalazine?

A

Deficiency of G6PD - would predispose them for hemolysis and anemia

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31
Q

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

A

Sulfasalazine

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32
Q

What drug works by inhibiting janus kinase 3?

A

Tofacitinib

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33
Q

Admin of Tofacitinib?

A

Oral

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34
Q

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

A

TB test for latent TB

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35
Q

Side effects of Tofacitinib?

A

Increased risk for opportunistic or other serious infections

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36
Q

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

A

Minocycline

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37
Q

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

A

Azathioprine

SE more common with renal insufficiency, allopurinal or ACEI

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38
Q

What screening test should you do before Azathioprine administration?

A

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

39
Q

How do you monitor someone on Azathioprine?

A

CBC and liver function

40
Q

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

A

Cyclosporine

41
Q

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

A

Cyclosporine

42
Q

SE of Cyclosporine?

A

Infection, Renal Insufficiency

Increase in BP common!! - may give BP meds when starting

43
Q

What do you monitor with Cyclosporine?

A

Renal function and BP

44
Q

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

A

Cyclophosphamide

45
Q

Used to treat lupus and vasculitis?

A

Cyclophosphamide

46
Q

What drug is an alkylating agent?

A

Cyclophosphamide

47
Q

Toxicities of Cyclophosphamide?

A

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

48
Q

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

A

Acrylline? treat with MESNA

49
Q

What is Mycophenolate mofetil metabolite?

A

Mycophenolic acid

50
Q

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.

A

Mycophenolate mofetil

51
Q

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

A

Mycophenolate mofetil

52
Q

Side effects of Mycophenolate mofetil

A

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

53
Q

What drug is used for lupus nephritis?

A

Mycophenolate mofetil

54
Q

What drug is an analog of amino acid cysteine?

A

d-Penicillamine

55
Q

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

A

d-Penicillamine

56
Q

SE of d-Penicillamine

A

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

57
Q

What should you monitor for d-Penicillamine

A

Renal function

58
Q

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

A

GOLD

59
Q

Admin of gold?

A

IV and oral, but oral is less efficacious

60
Q

What should you do prior to gold injection?

A

CBC and urine protein

61
Q

SE for gold?

A 
Rash (mild to severe)
Ulcerations and mucositis
Membranous glomerulanephropathy
Immune thrombocytopenia, granulocytopenia, aplastic anemia 
Blue skin
62
Q

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

A

Abatacept

63
Q

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

A

Abatacept

64
Q

How do you administer abatacept?

A

IV once a month

65
Q

SE of abactacept

A

increased infections and mild infusion reactions

66
Q

How do B cells contribute to RA?

A

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

67
Q

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

A

Rituximab, Tocilizumab

68
Q

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

A

Rituximab

69
Q

What dug is used for non Hodgkins lymphoma?

A

Rituximab

70
Q

How long does Rituximab effect last?

A

anywhere from 6 months-2 years

71
Q

Admin of Rituximab?

A

IV for 3-4 hrs, 2 weeks apart

Given with corticosteroids, and diphenhydramine and acetominophen

72
Q

What should you make sure patient has before starting Rituximab?

A

Immunizations- tell them not to do live virus vaccinations

73
Q

SE of Rituximab?

A

Increased infections, Infusion reactions

Reactivation of viral infections that were dormant like HEP B

74
Q

What drug binds to IL6 receptors?

A

Tocilizumab

75
Q

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

A

Tocilizumab

76
Q

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

A

TNF inhibitors

77
Q

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

A

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

78
Q

Standard therapy of RA by experts?

A

Methotrexate plus TNF inhibitor

79
Q

Admin of Entanercept?

A

SubQ 1/2 times per week

80
Q

SE of Entanercept

A

Virtually none, may see local inflammation with injection

81
Q

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

A

Infliximab

82
Q

Admin of Infliximab?

A

IV over 2 hours

83
Q

What is a consequence of chronic use of infliximab?

A

development of anti-infliximab antibodies, unless givne with methotrexate

84
Q

How can you reduce the infusion reactions with infliximab?

A

Give corticosteroids, diphenhydramine, or acetaminophen with infusion

85
Q

Admin of Adalimumab?

A

SubQ every week or 2 weeks

86
Q

What are the human and humanized antibody to TNFa?

A

Golimumab and Certolizumab

87
Q

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

A

Golimumab

88
Q

Admin of Certolizumab?

A

SC injection

89
Q

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

A

IL-1

90
Q

What DMARD has a DAILY subq injection?

A

Anakinra

91
Q

What DMARD should NOT be used with TNF inhibitors?

A

Anakinra

92
Q

What drug can be given additionally for IBD?

A

Sulfasalazine

93
Q

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

A

Sulfasalazine

MSS (3 decks)

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