medical management Flashcards
what are the key features of RA?
-symmetrical - ie affect both joints
-pain in small joint of hands
-swelling
-morning stiffness more than 1 hr
-rheumatoid factor / CCP
what are the main causes of death of patients w/ RA?
-main cause is heart attacks and stroke
-Rx reduces this risk
what is a disease activity score?
numerical tool for quantifying and assessing disease activity in rheumatoid arthritis (RA)
-asseses 28 joints, takes into account a blood marker of inflammation eg CRP or ESR & patients are asked to rate their disease activity and overall health on numerical scale (0-10)
what values of DAS indicate remission, low activity, moderate and high activity?
-remission - less than 2.6
-2.6-3.1 - low disease state
-3.2-5.1- moderate
more than 5.1= high disease activity
what enzyme do NSAIDS target ?
they inhibit cyclooxygenase
what are the main hand joints affected in RA?
the PIP and MC joints
not DIP (that’s OA)
what drugs are prescribed to treat symptoms for RA?
-NSAIDS - symptomatic relief
-low dose prednislone (steroid) - risk of OP w/ long term use - so add Ca, vit D or biophosphonates
-intraarticular / parenteral steroids- for flare ups
why do NSAIDS cause gastric side effects?
because NSAIDS reduce prostaglandins by blocking COX-1, thereby impairing mucus and bicarbonate production and adversely affecting acid secretion and blood flow in the stomach
what conditions does glucocorticoids treat?
-used in almost all inflam cond eg RA, gout, asthma, IBD etc
what are examples of Side effects of glucocorticoids?
-glucose intolerance
-HTN
-obesity
-thinning of skin
-osteoporosis
-infection
-cataract formation
-peptic ulcer disease
what drugs can be used to reduce the need for NSAIDS and steroids?
DMARDS & biologics
what are DMARDS?
-disease modifying anti-rheumatic drugs
-they modify the course of the disease, reduce joint damage & deformity, reduce long term disability
what is the therapeutic strategy for DMARDS?
-start with mono therapy - methotrexate
-if mono therapy dosent work, combinations of DMARDS +/- biologic agents
what are examples of DMARDS?
-methotrexate
-sulfasalazine
-hydroxychloroquine
-leflunomide
why is methotrexate normally given with a folic acid supplement?
as the med blocks folic acid metabolism
what cells does methotrexate affect?
cells that rapidly turnover
eg mucosal cells, hair follicles, immune cells
hence the side effects
what are examples of side effects of methotrexate?
-alopecia
-mouth ulcers
- GI problems eg nausea
-hepatotoxicity
what is the dose of methotrexate?
once a week
what are things that need to be avoided with methotrexate?
-alcohol consumption needs to be reduced
-needs to be stopped at least 3 months before conception / pregnancy
what is an example of a biologic used for RA?
-anti TNF therapy
-target tumour necrosis factor
what are the side effects of TNF therapy?
-infection (patients w/ co-morbidities)
-TB
-antibody formation - autoimmune disease eg SLE
-neuro - MS, seizures, inflammation
how does B cell depletion therapy work?
- B cells cannot act as an antigen presenting cell to activate T cells
-they can’t produce RF
-they cant release cytokines
what is an example of anti b cell therapy?
rituximab
what are the main principles of RA management?
-patient education
-symotomatic relief
-turn off inflammation
-early use of DMARDs
-measure of inflammation and disease activity
-treat to target if remission or low disease state
-minimise medication
