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PR3154 > IC16 RA > Flashcards

IC16 RA Flashcards

1
Q

main goal of treatment

A

Achieve disease remission
- at least 6 months
- Boolean 2.0 criteria (remission)
- Index based classification

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2
Q

pharmacotherapy approach in RA

A
  • Glucocorticoid (ST use; bridging to DMARD)
  • DMARDs (LT use)
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3
Q

non-pharmacological management strategies of RA

A
  • physical activity & exercise (avoid high-intensity weight-bearing)
  • PT/OT
  • healthy diet to reduce CV risk & inflammation e.g. fish oil,
  • weight management
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4
Q

what is RA

A

Chronic autoimmune INFLAMMATORY systemic disease

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5
Q

Prevalence of RA - age, gender

A
  • Can occur at any age, peak at 40-50 y/o
  • 3x more common in women
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6
Q

Genetic predisposition to RA

A
  1. HLA-DR1 or HLA-DR4 typing
  2. Parents are RF+
  3. Twin have RA
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7
Q

Clinical presentation of RA (KEY FEATURES)

A
  • Inflammation (pain, swelling, redness, warmth)
  • Early Morning stiffness > 30 mins
  • Symmetrical polyarthritis
  • Systemic sx (fever, aching/stiffness, etc)
  • Extra-articular complications
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8
Q

Clinical presentation in CHRONIC RA

A
  • deformities
  • loss of physical fn & inability to carry out ADL
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9
Q

Radiologic finding - in late course of RA

A
  • Narrowing of joint space
  • Erosion (around margin of joint)
  • Hypertrophic synovial tissue
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10
Q

Diagnosis of RA

A

At least 4 of the following:
- Early Morning Stiffness >/= 1 hour for > 6 weeks
- Swelling of >/= 3 joints for > 6 weeks
- Swelling of wrist/ MCP/ PIP joints for > 6 weeks
- Rheumatoid nodules
- +ve RF and/or anti-CCP tests
- Radiographic changes

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11
Q

Lab findings for RA - all stages of RA

A
  • Autoantibodies (RF +ve, anti-CCP +ve)
  • Acute phase response (Incr ESR & incr CRP)
  • FBC (decr haematocrit, incr WBC & incr platelets)
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12
Q

Examples of csDMARD

A
  • methotrexate
  • sulfasalazine
  • leflunomide
  • hydroxychloroquine
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13
Q

Examples of tsDMARD (JAK inhibitor)

A
  • tofacitinib, baricitinib
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14
Q

Examples of TNF-alpha inhibitor (bDMARD)

A

Etanercept, infliximab, adalimumab

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15
Q

Examples of IL6-receptor antagonist (bDMARD)

A

tocilizumab

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16
Q

Examples of anti-CD20 B cell depleting monoclonal antibody (bDMARD)

A

rituximab

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17
Q

Why is glucocorticoid not recommended for LT use?

A

Side effects

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18
Q

Indication for glucocorticoid

A
  1. Low dose bridging therapy when initiating/changing csDMARD (for moderate-high disease activity)
  2. Low-dose continuous therapy for difficult to control patients (but not recommended)
  3. Control flares (up to 2-3 injection per joint/ yr, q3 months)
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19
Q

MOA of glucocorticoid

A

anti-inflammatory & immunosuppressive ppty

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20
Q

Side effects of glucocorticoid

A
  • osteoporosis, osteonecrosis
  • impaired glucose metabolism, insulin resistance, beta cell dysfunction
  • gastric ulcer (if concomitant NSAID)
  • incr CV risk
  • cataract, glaucoma
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21
Q

Do DMARDs alter disease progression?

A

Yes

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22
Q

Onset of DMARDs

A

Slow onset (weeks to months)

23
Q

When to adjust tx for DMARD

A
  1. No improvement aft 3 months
  2. Target not reached aft 6 months
24
Q

Monitoring frequency active disease

A

Every 1-3 months

25
Q

DMARD therapy for moderate-severe RA disease activity

A

MTX + folic acid 5mg / week

+/- short-term GC

26
Q

Dose for glucocorticoid

A

PO prednisolone < 7.5mg/day

27
Q

DMARD therapy for low RA disease activity

A

In order of preference:
- Hydroxychloroquine (better tolerated)
- Sulfasalazine (less immunosuppressive)
- MTX (low cost)
- Leflunomide

28
Q

MTX dose (initiation, increment, target, max)

A
  • Initiation: 7.5mg once weekly
  • Dose increment: 2.5-5mg every 4-12 wks based on response
  • Target: 15mg/week (within 4-6 wks of initiation)
  • Max dose: 25mg/week
29
Q

MTX tablet strength

A

2.5mg

30
Q

How long is GC added to DMARD for bridging

A

up to 3 months

31
Q

Can GC be used in bDMARD/tsDMARD?

A

No

32
Q

Renal/ liver dose adj: MTX

A
  • AST/ALT > 3xULN: 75% of dose
  • CrCl < 50 ml/min: 50% of dose
  • CrCl < 30 ml/min: avoid use
33
Q

Monitoring (sx & labs): MTX

A

Infection -like sx, jaundice, skin blisters;
FBC, LFT (AST,ALT,albumin, bilirubin), SCr

34
Q

csDMARD C/I pregnancy

A

MTX, leflunomide

35
Q

Which csDMARD could cause retinopathy?

A

Hydroxychloroquine

36
Q

Drugs to use when not at target with MTX

A
  • Add bDMARD or tsDMARD (maximise improvements)
    or
  • Add Sulfasalazine & leflunomide (triple therapy; less adverse effects & lower cost)
37
Q

Approach when patients with bDMARD/ tsDMARD but not at target

A

Switch to bDMARD or tsDMARD of a different class

38
Q

General MOA of bDMARD

A

Binds to cytokine or their receptors to downregulate / inhibit their fn -> reduce immune & inflammatory responses

39
Q

Administration route of bDMARD

A

SC inj/ IV infusion

40
Q

Administration route of tsDMARD

A

Oral

41
Q

C/I sulfasalazine

A
  • sulfonamide allergy
  • G6pd deficiency
42
Q

C/I hydroxychloroquine

A
  • pre-existing retinopathy
  • g6pd deficiency
43
Q

MOA of tsDMARD

A

Binds to JAK proteins inside cells to prevent JAKs from transphosphorylating the associated cytokine & growth factor receptor

44
Q

JAK MEANING

A

Janus kinase (small molecule kinase)

45
Q

-cept meaning

A

fusion of receptor to Fc region of IgG1

46
Q

Which DMARDs cannot be used tgt

A

bDMARD and tsDMARD

47
Q

Which DMARD to avid in HF (NYHA class III & IV)

A

TNF-alpha inhibitors

48
Q

Anti-drug antibodies (ADA) may occur with ____, leading to loss of efficacy

A

TNF-𝛼 inhibitor

49
Q

bDMARD or tsDMARD is preferred? why

A

bDMARD; tsDMARD more adverse effects (MACE, malignancy)

50
Q

Pre-tx screening prior bDMARD/tsDMARD initiation

A
  • TB
  • HepB & C
51
Q

Vaccination required prior bDMARD/tsDMARD initiation

A
  • Pneumococcal
  • Influenza
  • Hepatitis B
  • Varicella zoster
52
Q

Lab screening/ monitoring prior starting ts/bDMARD

A
  • CBC w differential white count & platelet count
  • LFT(ALT,AST,bilirubin,ALP)
  • Lipid panel
  • SCr
53
Q

When is RA considered low disease activity or remission

A

patients at target for >/= 6 months

PR3154 (19 decks)

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