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CDM 2 Exam 2 > Lecture 9 - Rheumatoid Arthritis > Flashcards

Lecture 9 - Rheumatoid Arthritis Flashcards

1
Q

Meds most effective for acute pain relief in RA?

A

NSAIDs

Ibuprofen, also prednisone

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2
Q

Which meds have most risk of re-activating Hep B?

A

Rituximab, -mabs are immunosuppressive

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3
Q

Which med required periodic eye exams for RA?

A

Hydroxychloroquine

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4
Q

Med with highest risk for infections?

A

Etanercept

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5
Q

Which RA med is safe for pregnancy?

A

sulfasalazine

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6
Q

Meds most appropriate for someone with kerato-conjunvitis related to RA?

A

Restasis

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7
Q

RA risks

A

Associated with HLA DR4 MHC II Antigen
women 3-4X > men
Smokers are 4x > non-smokers

Caucasians higher risk than AA, native Americans 5-6X > Caucasians

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8
Q

Some Interleukin and Cytokine factors for RA?

A

IL-1, TNF-a, IL-6, IL-8, PGE2, IL-17

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9
Q

which factors important in RA? Psoriasis?

A

RA = TNF, IL-1/IL-6

Psoriasis = lL-17

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10
Q

Pathologic effects characteristic of RA?

A

tends to be more peripheral joints

inflamed synovial membrane

cartilage in bone is broken down and soften

soft and spongey

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11
Q

Criteria for RA?

A

Need to have 4 out of 7

Morning stiffness
3 or more joints involved
Arthritis of hand joints
Symmetrical arthritis
Rheumatoid nodules
Positive serum rheumatoid factor
Radiographic changes
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12
Q

Goal of Arthritis therapy

A

Improve & Maintain functional status to inc QOl

Control of disease activity and joint pain

Slow progression of disease activity and reduce deformities

improve extra-articular manifestations ( = outside joints)

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13
Q

Poor predictor of outcomes for RA

A 
young age at time of dx
Elevated ESR
High titer of Rheumatoid factor
Swelling founding > 20 joints
Female
Extra-articular manifestations
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14
Q

ARC 20

A
  1. Pt experiences a 20% improvement in tender joint count and swollen joint count
  2. Plus a > 20% improvement in at least 3 of 5 criteria…
    Patient pain assess, global assess, physical global asses, self-asses, acute case reactant
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15
Q

40-50% of individuals with psoriatic arthritis have genotype for…

A

HLA-B27

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16
Q

Median onset of Psoriatic Arthritis?

A

30-50yrs old

Men/women effected equally

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17
Q

Oligoarticular Psoriatic Arthritis

A

70% of pts and is generally mild, and usually only involves fewer than 3 joints

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18
Q

Polyarticular Psoriatic Arthritis

A

25% of cases, and effects 5 or more joints on both side of the body simultaneously

most similar to RA and is disabling in ~ 50% of all cases

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19
Q

Arthritis mutilans Psoriatic Arthritis

A

Less than 5% and is severe, deforming and destructive

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20
Q

Spondyloarthritis Psoriatic Arthritis

A

Stiffness of the neck or sacroiliac joint of the spine

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21
Q

Distal interphalangeal predominant Psoriatic Arthritis

A

5% of pts, characterized by inflammation and stiffness in the joints nearest to the ends of fingers/toes

nail changes often marked

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22
Q

Psoriatic Arthritis treatment for core pain management

A

NSAIDs and COX-2 inhib

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23
Q

Psoriatic Arthritis drugs that are specifically for it

A

Stelara (Ustekinumab)
Otezla (Apremilast)

commonly used but not specifically for….Adalimumab, Entanercept

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24
Q

Non-Pharma Treatment for RA

A

Primary: OT/PT, Smoking cessation, Weight loss, Massage, Exercise

Secondary: Emotional support & ed, assistive devices, surgical procedures, mediterranean diet

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25
Q

Approach to RA treatment

A

Get aggressive early

  1. DMARD or Biologic agent + NSAID
  2. 2nd line Biologic agent
  3. Combining Biologica agents
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26
Q

Preferred ARC 2021 agents

A

DMARDs: Methotrexate

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27
Q

Which RA DMARDs cant be used together?

A

Leflunamaide & Methotrexate

Have same MOA

also -nibs/mabs can only use one at a time

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28
Q

Starting therapy for RA?

A
  1. Establish dx and evaluate severity
  2. Initiate therapy therapy ( TB screen, Vaccines, Patient Ed, pain control, OT/PT)
  3. periodically assess disease activity
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29
Q

Early RA w/ low disease activity and no poor prognosis factors therapy

A

DMARD monotherapy = preferred (MTX drug of choice, quicker onset and less toxicity)

If poor response after 3 months, can do either…

  1. add sulfasalazine or hydroxychloroquine
  2. anti-TNF agent or tofacitinib
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30
Q

Early RA w/ moderate to high disease activity and poor prognosis therapy

A
  1. DMARD monotherapy preferred
  2. biologic agent +/- methotrexate
  3. Triple therapy usually MTX, sulfasalazine, hydroxycholorquine
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31
Q

When should you re-assess pts in Early RA management?

A

3 months if inadequate response

6 months for Non-TNF biologics

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32
Q

Labs to check for drugs?

A

CBC, creatinine for Methotrexate and Sulfasalazine

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33
Q

Special Pops for RA

A

Hep B = no changes
Hep C = cant do biologics
Cancer (Melanoma) = DMARD > Biologic/Tofacitinib
Cancer (Treated solid tumor) = same as others
Cancer (Treated Lymphoma) = rituximab > non-TNF
CHF 3-4 = no anti-TNF rec
Latent TB = treat 1 month before starting biolgoic
Active TB = complete course for TB

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34
Q

Recommended Vaccinations prior to starting biologic therapy or a DMARD

A 
Pneumococcal vaccine
Influenza vaccine
Hep B vaccine
HPV
*may be given before or concurrently with DMARD or biologic agent therapy

Herpes zoster = given before starting

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35
Q

NSAIDs, COX-II inhibitors, Salicylates Role in therapy & Efficacy

A

Role in therapy:

  1. Symptomatic tx of mild RA
  2. Doesn’t alter course of disease
  3. if no effect, add DMARD
  4. can be used with DMARD to manage until DMARD takes effect

Efficacy:
If no effect in 2-4 wks, inc dose or switch to another agent

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36
Q

COX non-specific

A

Ibuprofen
naproxen
indomethacin

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37
Q

COX-2 preferential

A

Etodolac
Diclofenac
Nabumetone
Meloxicam

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38
Q

COX-2 specific

A

Celecoxib, concern about inc CV risk

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39
Q

NSAIDs monitoring

A

SCr, CBC

BP, wt, electrolytes, stool color

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40
Q

NSAIDs toxicity

A

GI, renal,

Dont need to put everyone on PPI, only if at risk for GI bleeding

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41
Q

NSAID patient info

A

Take w/ food, report GI symptoms, black stools, SOB, edema, wt gain or dizziness

Salicylate specific = ringing in ears

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42
Q

Methotrexate MOA

A

Antimetabolite, inhibiting dihydrofolate reductase

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43
Q

Methotrexate Role in Therapy

A

Considered DMARD of choice & gold standard

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44
Q

Methotrexate Dosing

A

2.5mg po or IM q12hr X 3 doses per week
inc by 2.5mg per wk q6-8 weeks to max of 20-25mg/wk

Goal: atleast 15mg/wk by week 6-8, 20-25mg/week later

** Can give as 1 dose per week when tolerated **
If CrCl < 50, decrease dose by 50%

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45
Q

Methotrexate Efficacy

A

Most predictable long-term benefit

Onset of effect is 2-4 weeks

46
Q

Methotrexate toxicity

A 
GI = N/V/D, stomatitis
Hematolgic
Folic Acid deficiency = take FA to reduce GI tox
Hepatic = inc LFTs, cirrhosis (rare)
Pulmonary = fibrosis (rare)
Teratogenic
47
Q

Methotrexate monitoring

A

BL: LFTs, Hep B/C studies, CBC w plt, SCr

Every 1-2months: CBC w/ plt, AST, Albumin

48
Q

Methotrexate Patient education

A

Counsel about weekly dosing

Ask about SOB, infections, GI symptoms, mouth sores

49
Q

Methotrexate CI

A 
Pregnancy
Chronic liver disease
Immunodeficiency
CrCl < 10ml/min
Effusion
Leukopenia
Thrombocytopenia
50
Q

Leflunomide Dosing

A

Loading: 100mg QD X 3 days
Maintenance: 20mg QD, dec to 10mg if not tolerated

51
Q

Leflunomide Role in Therapy

A

alternative in pts who fail or don’t tolerate MTX or sulfasalazine

can be used with NSAIDs or Steroids

52
Q

Leflunomide notable Adverse effects

A

rare reports of hepatotoxicity, liver failure and death

53
Q

Leflunoamide monitoring

A

LFTs at BL, Q month for 6 months, then Q6-8wk

IF 2-X ULN, dec to 10mg/day, if 3 X ULN = D/c

CBC & put at BL, monthly for 6 months, then Q6-8wk

54
Q

Leflunoamide Patient education

A

maintain adequate hydration
report GI symptoms or jaundice
report signs/symptoms of infection

55
Q

Hydroxychloroquine MOA

A

Antimalarial

Inhibit lysosome function leading to decreased immune function and TLR blockade

56
Q

Hydroxychloroquine Role in therapy

A

Use in mild RA in pts who dont tolerate, respond or have CI for MTX

57
Q

Hydroxychloroquine efficacy

A

up to -12 weeks to see effect, can take 6 months

58
Q

Hydroxychloroquine Dosing

A

200mg sulfate = 155 mg base

200-300mg BID X 1-2 months, then dc to 200mg QD-BID (Max 400mg/day)

59
Q

Hydroxychloroquine Toxicity

A

GI = N/V/D
Ocular = night blindness, loss of vision, retinal damage
Neurologic (mild) = headache, vertigo, insomnia
Dermatologic = inc skin pigment, rash, hair loss

60
Q

Hydroxychloroquine monitoring

A

BL eye exam, then q 6-12 months

61
Q

Hydroxychloroquine patient education

A

wear sunglasses in bright light = dec accommodation
caution night driving = dec night vision
report vision changes
take with food or milk

62
Q

Sulfasalazine MOA

A

Production of 5-ASA, NF-kB inhibition

63
Q

Sulfasalazine Role in Therapy

A

mild disease, women who plan to have children

64
Q

Sulfasalazine efficacy

A

effects seen in 1-2 months

65
Q

Sulfasalazine Dosing

A

500mg BID, inc to 1gm BID

66
Q

Sulfasalazine Toxicity

A

Myelosuppresion
Rash
increased LFTs
GI

67
Q

Sulfasalazine Monitoring

A

CBC w/ plt at BL & q wkly for 1 month, then q1-2 months

68
Q

Tofacitinib Indications

A

Moderate to severe RA w/ inadequate response or intolerance to MTX

monotherapy or combo with MTX or other Non-biologic DMARDs

69
Q

Tofacitinib Caution

A

Dont use w/ biologic DMARDs, Azathioprine or cyclosporine

70
Q

Tofacitinib warnings (also relevant to other -inibs/ - imabs)

A

Serious infections

If serious infection develops, hold therapy until controlled

before starting, test for TB…treat TB prior to tarting, and monitor all pts for active TB during treatment

Avoid live vaccines during therapy

DI = CYP3A4

71
Q

Upadacinitinib (Rinvoq) Indication & Dosing

A

15mg PO daily

PA after Anti-TNF agent
RA after prior anti-TNF agent

72
Q

Upadacinitinib (Rinvoq) warning

A

Inc risk of thromboembolism

Higher rates of CV death, MI and Stroke vs other anti-TNF agents

73
Q

Baracitinib Indication & Dosing

A

2mg PO daily

RA after prior anti-TNF therapy

74
Q

Baracitinib (Olumiant) Warnings

A

Inc risk of thromboembolism

Myelosuppression

75
Q

Common issues with Biologics

A 
ADR:
Serious infections
Lymphoma and skin cancers
Worsening CHF
Neutropenia
Hep B reactivation

Pt ed:
Updated vaccines before treatment
teach pt proper injection technique

76
Q

Entanercept (Embrel) Role in Therapy

A
  1. used for refractory RA in pts with inadequate response to DMARDs
  2. approved for use early in disease
  3. cab be combo with MTX, steroids, or NSAIDs
77
Q

Entanercept (Embrel) Dosage

A

25mg Sq twice weekly or 50mg once weekly

keep in fridge

78
Q

Entanercept (Embrel) formulation

A

Sureclick

pre-filled syringe

79
Q

Adalimumab (Humira) Dosing

A

40 mg SQ every other week, weekly if not on MTX

80
Q

Adalimumab (Humira) Dosage forms

A

Prefilled syringes

Pen formulation

81
Q

Adalimumab (Humira) Role in therapy

A

used in pts who had an inadequate response to 1 or more DMARDs

82
Q

Adalimumab (Humira) ADR addition to typical

A

Headache & rash

83
Q

Golimumab (Symphonic) Dosing

A

50mg SQ q monthly

84
Q

Golimumab (Symphonic) toxicities

A

Upper resp tract infection
LFT increases
Hypertension
Injection site erythema

85
Q

Certolizumab (Cizmia) dosing

A

400mg SQ every 4 weeks can be considered, dosed monthly

86
Q

Certolizumab (Cizmia) Indication

A

monotherapy or combo with MTX

87
Q

Certolizumab (Cizmia) Toxicity

A

Normal ones +
Upper resp tract infection
Hypertension
back pain

88
Q

Infliximab (Remicade) Role in therapy

A

used in combo with MTX in pts who have had inadequate response to MTX alone

89
Q

Infliximab (Remicade) Dosage

A

3mg/kg by IV infusion, q2wks/q6wks/q8wks

May inc to 10mg/kg, do Q 4 weeks

infuse over 2hrs

90
Q

Infliximab (Remicade) ADR

A

URIs, headache, N, sinusitis, rash, cough
Other common issues listed
Neurologic = guillan barre

Dont give live vaccines

91
Q

Abataceot (Orencia) Role in therapy

A

more second line

pts w/ moderate+severe RA who had inadequate response to 1 or more DMARDs or TNF-a

can be used as monotherapy or w/ DMARDs

* Dont give with TNF-a or anakinra

comes in prefilled syringe

92
Q

Abataceot (Orencia) Dosing

A

most do 125mg Q weekly without loading dose

93
Q

Abataceot (Orencia) Adverse effects

A

common symptoms listed

Headache, URIs, sore throat, nausea

Don’t take live vaccines during and 3 months after treatment

**COPD have inc respiratory symptoms

94
Q

Tocilizumab (Actemra) MOA

A

IL-6 receptor inhib

95
Q

Tocilizumab (Actemra) indication

A

RA pts who have inadequate response to atleast 1 DMARD

use w/ or w/o MTX

96
Q

Tocilizumab (Actemra) Black Box warning

A

Risk for serious infections, TB reactivation/new infection, fungal infection

97
Q

Tocilizumab (Actemra) Dosing

A

infusion

4mg/kg IV every 4 weeks

98
Q

Rituximab Role în therapy

A

in combo w/ MTX in pts with moderate-severe RA with inadequate response to 1 or more TNF-a

99
Q

Rituximab Dosing

A

1000mg IV X 2 doses 2 weeks apart

pretreat w/ 100mg methylprednisolone

100
Q

Rituximab Adverse effects

A

infusion reactions, infections, arrhythmias, renal toxicity,bowel obstruction

CHF

Risk of Demylenating Syndrome

101
Q

Anakinra (Kineret) Role in therapy

A

Dont use with TNF-a, not as effective as TNF-a

can be used alone or in combo

used in pts who have failed 1 or more DMARDs

102
Q

Anakinra (Kineret) Dosing

A

not used much

100mg SQ QD

103
Q

Anakinra (Kineret) Supplied

A

Prefileld syringes

104
Q

Last resort for refractory patients?

A

Steroids

wants to add Vit D and Calcium therapy if choosing to do so

105
Q

Corticosteroids Doses

A

PO = lowest dose possible < 10mg = low, >10mg = high dose

IA= no more than 2-3 shots/joint/yr

106
Q

Corticosteroids Toxicity

A

HPA suppression
Myopathies
shit load

107
Q

Corticosteroids Pt education

A
  1. report signs and symptoms of infection
  2. take Calcium and Vit D
  3. Regular opthalmologic exams
108
Q

Corticosteroids monitoring

A 
BP
BG
electrolytes 
IOP
BMD
109
Q

How to treat vasculitis?

A

Corticosteroids, NSAIDs

110
Q

How to treat ocular issues from RA?

A

Artificial tears

Restasis

111
Q

How to treat Sjogrens syndrome (Xerostomia) Dry mouth

A

Cevimeline 30mg po TD (Evoxac)

pilocarpine 5mg po QID (Salagan)

112
Q

How to treat nodules from RA?

A

no treatments

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