Drugs in Rheumatoid Arthritis Treatment

Question 1

What drugs are used to reduce acute pain in RA?

Answer 1

Analgesics (Acetaminophen, Capsacin, Opioids)

NSAIDS

Glucocorticoids (dexamethasone)

Question 2

What drug classes prevent or control joint damage in RA?

Answer 2

DMARDs = Disease Modifying anti-Rheumatic Drugs

BRMs = Biological Response Modifiers

Question 3

General MOA for DMARDs

Answer 3

Reduce or prevent joint damage

Inhibit the overactive immune system

Question 4

In general, how long do DMARDs take to work?

Answer 4

Weeks-months

Question 5

Hydroxychloroquine

Indication and type of drug

Answer 5

DMARD

Anti-malarial drug that is moderately effective for mild RA

Question 6

Hydroxychloroquine

Rare side effect

Answer 6

Ocular toxicity that may result in permanent visual loss

Question 7

What DMARDs may be used during pregnancy and lactation?

Answer 7

Hydroxychloroquine

Sulfasalazine

Question 8

Hydroxychloroquine

How long does it take to work?

Answer 8

3-6 months

Question 9

Sulfasalazine

Adverse Effect

Answer 9

Agranulocytosis within 2 weeks

Hepatotoxicity

Question 10

Sulfasalazine

Indication

Answer 10

Decreases signs/symptoms of disease and slows joint destruction

Question 11

Methotrexate

Indication

Answer 11

DOC for pts with active moderate/severe RA

Decreases appearance of new bone erosions

Improves LT clinical outcome

Question 12

How long does Methotrexate take to work?

Answer 12

4-6 weeks

Question 13

Methotrexate

MOA

Answer 13

Indirectly increases adenosine production, which leads to immunosuppression

Question 14

Methotrexate

AEs (common and rare)

Answer 14

Common:
Dose-related hepatotoxicity (do NOT drink alcohol with methotrexate)

Rare:

• Pulm toxicity
• Bone marrow suppression
• Increased risk lymphoma

Question 15

Methotrexate

Elimination

Answer 15

Renally excreted

So adverse effects are more common in renal impaired patients

Question 16

Methotrexate

Contraindications

Answer 16

Pregnancy/Breast Feeding

Pre-existing liver disease

Renal impairment

Question 17

Leflunomide

Indication

Answer 17

Used in pts with RA who can’t take or are nonresponsive to Methotrexate

Question 18

Leflunomide

MOA

Answer 18

Inhibits dihyroorotate dehydrogenase, which synthesizes uridine

Causes G1 cell cycle arrest, inhibiting T cell proliferation and production of autoantibodies by B cells

Question 19

Leflunomide

Contraindications

Answer 19

Pregnancy/Breast feeding

Preexisting liver disease (risk of hepatotoxicity)

Question 20

Describe how TNF-alpha plays a role in inflammation of RA

Answer 20

Joint inflammation

Cartilage breakdown

Bone erosion

Question 21

List the anti-TNF-alpha drugs

Answer 21

Etanercept
Infliximab
Adalimumab

Question 22

Anti-TNF-alpha drugs

MOA

Answer 22

Bind TNF-alpha and prevent it from binding its receptor, thus preventing inflammation

Question 23

Anti-TNF-alpha drugs
Administration
Clinical Use

Answer 23

Given subQ or IV weekly or biweekly

Used in monotherapy or in combo with methotrexate

Question 24

Anti-TNF-alpha drugs

AEs

Answer 24

Increased risk of opportunistic infection (fungal/bacterial)

Potential reactivation of latent TB and latent HBV

Question 25

Before starting Anti-TNF-alpha drugs, you should screen the patient for....

Answer 25

Latent TB infection Latent HBV infection

Question 26

Abatacept What is it? Clinical Use

Answer 26

Recombinant fusion protein of CTLA4 and human IgG Used in pts non-responsive to TNF-alpha inhibitors

Question 27

Abatacept | MOA

Answer 27

It's CTLA4 domain inhibits T cell activation by blocking delivery of CD28 costimulatory signals

Question 28

Abatacept | AEs and Contraindications

Answer 28

Increased risk for serious infections Should NOT be given in combo with a TNF-alpha blocker

Question 29

Rituximab | MOA

Answer 29

Binds CD20 on B cells and depletes B cells from blood

Question 30

Rituximab | How long does it last?

Answer 30

Effects not seen for 3 months, though the effects may last 6 months - 2 years after one infusion

Question 31

Rituximab | AEs

Answer 31

Increased infections | Risk of PML

Question 32

Anakinra | MOA

Answer 32

IL-1 receptor antagonist Competitively inhibits pro-inflammatory effects of Il-1

Question 33

Anakinra | AEs

Answer 33

Neutropenia Infection risk increases Never given to patients with an acute/chronic infection Bad when given with an anti-TNF-alpha drug

Question 34

Tocilizumab | MOA and Clinical Use

Answer 34

IL-6 receptor antagonist Used in patients who are non-responsive to TNF inhibitors May be used in combo with methotrexate

Question 35

Tocilizumab | AEs

Answer 35

Bone marrow suppression (lymphocytopenia, neutropenia, anemia) Increased infection risk Hepatotoxicity

Question 36

Tofacitinib | MOA

Answer 36

Small molecule inhibitor of JAK tyrosine kinases involved in immune cell cytokine signaling