Management of Rheumatoid Arthritis Flashcards
What is the key to RA therapy
Early and aggressive intervention is the key to obtaining optimal outcomes in the management of RA
What is the aim of RA therapy
Effective suppression of inflammation
What will Effective suppression of inflammation achieve in RA treatment
It will improve symptoms and prevent joint damage and disability
What are the treatment options available in RA
Medicines
Therapies
o Physio/pysch/pharma etc
Surgery
What are the therapeutic categories available in RA
NSAID
DMARD - Disease Modifying anti Rheumatic drugs
Biologics
Corticosteroids
What are Disease Modifying anti Rheumatic drugs generally
A group of structurally unrelated, typically small molecule drugs which have been demonstrated to have slow onset effect (weeks/months) on disease activity and retard disease progression
What are the DMARDs
Methotrexate
Sulfasalazine
Hydroxychloroquine
Leflunomide
How does methotrexate work
Methotrexate works by interfering with the metabolism of folate and suppressing certain components of the immune system
How is methotrexate taken?
It is taken by injection or tablet once a week.
What is also prescribed with methotrexate
.Folic acid5mg is also prescribed once a week to betaken on a different dayto the methotrexate.
What are side effects of methotrexate
- Mouth ulcers and mucositis
- Liver toxicity
- Pulmonary fibrosis
- Bone marrow suppression and leukopenia (low white blood cells)
- It isteratogenic(harmful to pregnancy) and needs to be avoided prior to conception in mothers and fathers
How does Leflunomide work
Leflunomide is an immunosuppressant medication that works by interfering with the production ofpyrimidine. Pyrimidine is an important component of RNA and DNA.
What are side effects of Leflunomide
- Mouth ulcers and mucositis
- Increased blood pressure
- Rashes
- Peripheral neuropathy
- Liver toxicity
- Bone marrow suppression and leukopenia (low white blood cells)
- It isteratogenic(harmful to pregnancy) and needs to be avoided prior to conception in mothers and fathers
How does Sulfasalzine work
Sulfasalazine works as an immunosuppressive and anti-inflammatory medications. The mechanism is not clear but may be related to folate metabolism.
What are side effects of Sulfasalzine
- Temporary male infertility (reduced sperm count)
* Bone marrow suppression
How does Hydroxychloroquine work?
Hydroxychloroquine is traditionally an anti-malarial medication. It acts as an immunosuppressive medication by interfering withToll-like receptors, disrupting antigen presentation and increasing the pH in the lysosomes of immune cells
What are side-effects of Hydroxychloroquine
- Nightmares
- Reduced visual acuity (macular toxicity)
- Liver toxicity
- Skin pigmentation
What are the biologics generally
Typically these are large complex proteins which need to be given parenterally. Compared to traditional DMARD, they work rapidly, are generally well tolerated although with important toxicities (eg infection and come at high cost.
What type of biologics are there
TNFa inhibitors (x5)
IL-1 inhibitors (Anakinra)
Anti B Cell therapies (CD20, Rituximab)
Anti T Cell therapies (Abatacept)
IL-6 inhibitors (Tocilizumab)
Other
What is TNF
Tumour necrosis factoris a cytokine involved in stimulating inflammation
How do TNF inhibitors work
Tumour necrosis factoris a cytokine involved in stimulating inflammation. Blocking TNF reduces inflammation.
What are some TNF inhibitors
Adalimumab Infliximab Golimumab Certolizumab pegol Etanercept
What are the monoclonal antibodies to TNF
Adalimumab, infliximab, golimumab and certolizumab pegol
What are the side effects of anti-TNF drugs
Vulnerability to severe infections and sepsis
Reactivation of TB and hepatitis B
What is a popular Anti B Cell therapies
Rituximab
What is Rituximab and how does it work
Rituximab is amonoclonal antibodythat targets theCD20 proteinon the surface ofB cells. This causes destruction of B cells. It is used for immunosuppression for autoimmune conditions such as rheumatoid arthritis and cancers relating to B cells.
What are side effects of Rituximab
Vulnerability to severe infections and sepsis
Night sweats
Thrombocytopenia (low platelets)
Peripheral neuropathy
Liver and lung toxicity
What is first line treatment for RA
Methotrexate
Sulfasalazine
Leflunomide
(monotherapy)
What is 2nd line treatment for RA
2 of:
Methotrexate
Sulfasalazine
Leflunomide
What is 3rd line treatment for RA
Methotrexate and biological therapy
What is 4th line treatment for RA
Methotrexate and Rituximab
