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C. Year 3: Core Drugs > Immunosuppressants - DMARD, Antimetabolites > Flashcards

Immunosuppressants - DMARD, Antimetabolites Flashcards

1
Q

Disease-modifying antirheumatic drugs (DMARDs) are typically the 1st line treatment for patients with a confirmed diagnosis of RA as they can reduce or prevent joint damage and to use preserve joint integrity and function.
How long do these drugs take before these drugs are effective?

1 - immediately
2 - 1-2 week
3 – 4-6 weeks
4 - 4-12 weeks

A

3 – 4-6 weeks

Some patients may stop taking them as they dont work straight away

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2
Q

Disease-modifying antirheumatic drugs (DMARDs) are typically the 1st line treatment for patients with a confirmed diagnosis of RA. Are they always used in isolation?

A
  • No

Can be used as a as a single agent or as a combination

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3
Q

Disease-modifying antirheumatic drugs (DMARDs) are typically the 1st line treatment for patients with a confirmed diagnosis of RA. Which of the following is the least important to check at baseline before starting the DMARDs?

1 - FBC
2 - Cardiac enzymes
3 - Serum Creatinine
4 - Aminotransferases (liver enzymes)
5 - ESR and CRP

A

2 - Cardiac enzymes

  • FBC = DMARDs can suppress bone marrow activity and can cause neutropenia and increased risk of infection
  • Serum Creatinine = DMARDs can cause renal toxicity
  • Aminotransferases (liver enzymes) = DMARDs can cause hepatoxicity
  • ESR and CRP
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4
Q

When starting DMARDs for a patient with RA, the following are measured at baseline:

  • FBC
  • Serum Creatinine
  • Aminotransferases (liver enzymes)
  • ESR and CRP

How often are these monitored in the 1st 6 weeks?

1 - daily
2 - every 72h
3 - weekly
4 - every 2 weeks

A

4 - every 2 weeks

Then monthly for 3 months
Then every 3 monthly afterwards

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5
Q

What is generally the 1st line treatment for RA?

1 - Disease-modifying anti-rheumatic drugs (DMARDs) - Methotrexate
2 - non-steroidal drugs
3 - aspirin
4 - corticosteroids

A

1 - Disease-modifying anti-rheumatic drugs (DMARDs) - Methotrexate

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6
Q

The first line treatment for RA is the disease-modifying anti-rheumatic drug (DMARDs) Methotrexate, typically prescribed SC, hut can be given orally as well. How often is this prescribed?

1 - daily 7.5 – 15mg SC
2 - daily 25mg orally
3 - weekly 7.5 – 15mg SC
4 - weekly 25mg orally

A

3 - weekly 7.5 – 15mg SC

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7
Q

When starting methotrexate, what supplement are patients advised to take?

1 - Calcipotriol (vitamin D)
2 - Folic acid
3 - Omeprazole
4 - Vitamin C

A

2 - Folic acid
- given at 5mg/wk

Folic acid taken as methotrexate impairs folic acid synthesis

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8
Q

Which of the following is NOT a common adverse event of methotrexate?

1 - GI problems – Nausea, Stomach upset
2 - Stomatitis (oral mucosa inflammation)
3 - Weight loss
4 - Hair loss
5 - Abnormal liver enzymes

A

3 - Weight loss

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9
Q

Which of the following is NOT a common serious adverse event of methotrexate?

1 - cardiac toxicity
2 - hepatotoxicity
3 - nephrotoxicity
4 - pulmonary toxicity
5 - myelosuppression

A

1 - cardiac toxicity

Myelosuppression
1 - Anaemia
2 - Leukopenia
3 - Thrombocytopenia
4 - Pancytopenia

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10
Q

Is methotrexate safe to take during pregnancy?

A
  • no

Contraindicated in pregnancy as used as an abortifacient that can also induce congenital anomalies if taken during pregnancy

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11
Q

Methotrexate is contraindicated in pregnancy as it is used as an abortifacient that can also induce congenital anomalies if taken during pregnancy. Prior to becoming pregnant, how long must patients have stopped taking it by?

1 - 24h
2 - 1 week
3 - 4 weeks
4 - 3 months

A

4 - 3 months

At least 3 months prior to coneption

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12
Q

Which of the following is NOT an indication for the use of Methotrexate according to the BNF?

1 - RA
2 - Urticaria
3 - Psoriasis
4 - Crohn’s disease
5 - Neoplastic diseases

A

2 - Urticaria

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13
Q

Leflunomide is a DMARDs used in rheumatology at a dose of 10-20mg/d. Which of the following is NOT a common side effect of this drug?

1 - GI - Diarrhoea, Nausea
2 - Hepatic – transaminitis
3 - Hypotension
4 - Pulmonary (ILD)
5 - Skin – rash, alopecia,
6 - Haematological – leucopoenia
7 - Drug interaction – warfarin

A

3 - Hypotension
- Causing hypertension

  • BP monitoring during the first 3 months of treatment recommended

Monitoring is the same as methotrexate

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14
Q

Leflunomide is a DMARDs used in rheumatology at a dose of 10-20mg/d. Is this a safe drug to take during pregnancy and lactation?

A
  • no

Even when stopping, it can remain at low levels for up to 2 years

Cholestyramine, which binds to bile salts and prevents enterohepatic recirculation of Leflunomide

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15
Q

Which 2 of the following are indications for the use of Leflunomide according to the BNF?

1 - RA
2 - Urticaria
3 - Psoriasis
4 - Crohn’s disease
5 - Neoplastic diseases

A

1 - RA
]3 - Psoriasis (must be active)

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16
Q

Hydroxychloroquine is a DMARD that can be used to treat RA. What is the most important mechanism of action of Hydroxychloroquine in treating inflammatory conditions such as RA?

1 - inhibit COX1 and 2
2 - lysosomotropic actions
3 - inhibit prostoglandins
4 - inhibit immunoglobulin formation

A

2 - lysosomotropic actions

Accumulate in lysosomes, organelles that can degrade proteins, carbs, nucleic acids, lipids etc..

  • can inhibit MHC-II auto-antigen presentation so body doesn’t attack itself
  • interfere with autophagy, disrupt membrane stability and alter signalling pathways and transcriptional activity.
  • inhibition of immune activation by reducing Toll-like receptor signalling and cytokine production and, in T cells, reducing CD154 expression, essentially resulting in anti-inflammatory response
17
Q

What is the maximum dose of Hydroxychloroquine?

1 - 1mg/day
2 - 5mg/kg
3 - 3g/day
4 - 50mg/kg

A

2 - 5mg/kg

18
Q

Which of the following is NOT an adverse effect of Hydroxychloroquine?

1 - GI upset
2 - hepatotoxicity
3 - hyperpigmentation
4 - nephrotoxicity
5 - retinal toxicity
6 - cardiotoxicity
7 - neuromuscular toxicity

A

4 - nephrotoxicity

Does not cause this, but CKD must be monitored, as it is cleared by kidneys

Baseline examination within a year of starting treatment, subsequent screening in 5 years and yearly thereafter.
More frequent screening required in patients on higher doses of HCQ, presence of renal disease, presence of macular disease and concomitant use of tamoxifen

19
Q

Although Hydroxychloroquine can be used in RA, which of the following is it also used as 1st line treatment for?

1 - pericarditis
2 - rosacea
3 - SLE
4 - giant cell arteritis

A

3 - SLE

20
Q

Which 2 of the following are indications for the use of Hydroxychloroquine according to the BNF?

1 - RA
2 - Urticaria
3 - Psoriasis
4 - SLE

A

1 - RA
4 - SLE

Can also be used for dermatological conditions irritated by the sun

21
Q

If a patient has RA and is already on disease-modifying anti-rheumatic drugs (DMARDs), namely Methotrexate. What drugs can be given to help with flare ups?

1 - paracetamol
2 - non-steroidal drugs
3 - aspirin
4 - corticosteroids

A

2 - non-steroidal drugs for short periods

22
Q

The 1st line treatments for RA are disease-modifying anti-rheumatic drugs (DMARDs). The core drug is methotrexate, but other drugs include sulfasalazine, hydroxychloroquineand leflunomide. If DMARDs are not successful patients can be prescribed Biologic Agents, such as anti-B, anti-T and anti-TNF-a. How many DMARDs do patients need to have tried prior to being prescribed Biologic Agents?

1 - can go straight to Biologic Agents
2 - >4 drugs
3 - >3 drugs
4 - >2 drugs

A

4 - >2 drugs

23
Q

Which of the following are are the major side effects of Disease Modifying Anti-Rheumatic Drugs?

1 - bone marrow suppression
2 - increased risk of infection
3 - liver dysfunction
4 - all of the above

A

4 - all of the above

24
Q

When should treatment for RA be started?

1 - as soon as the patient asks for it
2 - if the suspicion of RA is high
3 - clinical experience only
4 - immediately once the diagnosis is confirmed

A

4 - immediately once the diagnosis is confirmed

25
Q

If a patient presents to the GP with symptoms of RA, what is the time frame from when treatment should be started?

1 - 3 days
3 - 3 weeks
3 - 3 months
4 - 3 years

A

3 - 3 months

26
Q

Mycophenolate Mofetil is another DMARD that can be used to treat SLE. What is the mechanism of action of this drug?

1 - inhibition of COX1 and 2
2 - prevents T and B cell proliferation
3 - inhibits all WBCs
4 - all of the above

A

2 - prevents T and B cell proliferation

Active metabolite of mycophenolate, mycophenolic acid, prevents T-cell and B-cell proliferation and the production of cytotoxic T-cells and antibodies

Dose 500mg – 1500mg twice a day

27
Q

Mycophenolate Mofetil is another DMARD that can be used to treat SLE. Which of the following is NOT an adverse event of Mycophenolate Mofetil?

1 - Bone marrow suppression,
2 - GI upset
3 - Infections
4 - Lymphoproliferative diseases
5 - Seizures
6 - Pure Red cell aplasia

A

5 - Seizures

28
Q

Is Mycophenolate Mofetil safe in pregnancy and breastfeeding?

A
  • no

Planned 6 weeks after stopping the medication

29
Q

How often should Is Mycophenolate Mofetil be monitored by FBC to assess renal and liver function?

1 - weekly during first month
2 - fortnightly during second and third month
3 - monthly for the first year
4 - all of the above

A

4 - all of the above

30
Q

Azathioprine is another DMARD that can be used to treat SLE. Azathioprine reduces intracellular purine synthesis, which results in which of the following?

1 - decreased numbers of circulating B and T lymphocytes
2 - reduced immunoglobulin synthesis
3 - diminished interleukin (IL) 2 secretion
4 - all of the above

A

4 - all of the above

31
Q

Azathioprine can be haematologic toxicity due to AZA and6-mercaptopurine(6-MP). What must be measured prior to using Azathioprine?

1 - pancreatic lipase
2 - thiopurine methyltransferase
3 - reductase
4 - RNA polymerase

A

2 - thiopurine methyltransferase
-TPMT

TPMT is an enzyme that breaks down (metabolizes) a class of drugs called thiopurines

32
Q

The starting dose of Azathioprine is 25 to 50 mg/day. How often should FBC be measured initially to assess for haematologic toxicity?

1 - daily
2 - weekly
2 - every 2 weeks
4 - monthly

A

2 - every 2 weeks

Can increase the daily dose by 50 mg (or approximately 0.5 mg/kg/day) every four weeks to 1.5 mg/kg/day.

Maximum of 3 mg/kg/day

33
Q

Which of the following is NOT an adverse effect of Azathioprine?

1 - GI upset
2 - anorexia
3 - eye inflammation
4 - myelosuppression
5 - infection

A

3 - eye inflammation

myelosuppression = bone marrow suppression, both RBCs and WBCs

34
Q

All of the following drugs are safe in pregnancy, EXCEPT which one?

1 - Hydroxychloroquine
2 - Methotrexate
3 - Sulfasalazine
4 - Azathioprine
5 - Low dose steroids (5 – 15mg)

A

2 - Methotrexate

35
Q

Which of the following can be used selectively in pregnancy?

1 - Steroids
2 - NSAIDs
3 - TNF alpha inhibitors
4 - Ciclosporin
5 - Tacrolimus
6 - all of the above

A

6 - all of the above

36
Q

All of the following drugs should NOT be used in pregnancy, EXCEPT which one?

1 - Mycophenolate mofetil
2 - Leflunomide
3 - Hydroxychloroquine
4 - Methotrexate
5 - Cyclophosphamide

A

3 - Hydroxychloroquine

C. Year 3: Core Drugs (125 decks)

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