Medications for Rheumatoid Arthritis Flashcards
What is rheumatoid arthritis?
chronic autoimmune disorder that causes painful inflammation in the joints.
What is the end result wanted for treatment of rheumatoid arthritis?
controlling the painful inflammation, decrease swelling, decrease joint stiffness, increase joint mobility.
Will any of the medications discussed cure rheumatoid arthritis?
NO
they are used to relieve symptoms and slow progression
What are DMARDS?
disease-modifying antirheumatic drugs
these are a variety of medications use to treat rheumatoid arthritis
How are DMARDS classified?
based on the order in which they are prescribed
Describe DMARDS I.
these are usually the first DMARDS prescribed
Consist of:
Immune suppressant - methotrexate (rheumatrex) – (lower doses decrease cytotoxic effect like when used for chemotherapy)
antimalarial agent - hydroxychloroquine (Plaquenil) – (has been shown to decrease inflammation)
tetracylcline antibiotic - minocycline (Minocin) – (controls inflammatory response)
Describe DMARDS II.
Usually used when DMARDS I are not effective
Consist of Tumor necrosis factor antagonists:
- — These directly target cytokines responsible for inflammatory process— have more adverse effects
- etanerecept (Enbrel)
- Infliximab (Remicade)
- adalimumab (Humira)
Describe DMARDS III.
these are not frequently prescribed, used when DMARDS II are not effective
Consist of:
- gold salts - auranofin (Ridaura)
- penicillamine (Depen) (decreases inflammation)
- Immune suppressants - cyclosporine (Neoral) (suppress immune respone)
What do gold salts do?
block cellular molecules that are responsible for inflammatory process.
What are two other drug classes that are used in conjunction with DMARDS to treat rheumatoid arthritis? Why?
NSAIDS and glucocorticoids
both of these suppress the inflammatory response
THESE ARE THE FIRST THING PRESCRIBED WHEN DIAGNOSED WITH RHEUMATOID ARTHRITIS BECAUSE OF THEIR FASTER ONSET OF ACTION IN COMPARISON TO DMARDS
DMARDS take months to reach full effect
NSAIDS are pretty immediate
glucocorticoids may take a couple days to take effect
What is the pharmacological action of DMARDS?
slow joint degeneration and progression of rheumatoid arthritis (maintenance of joint function, slow/delay worsening of disease, management of inflammatory bowel disease as well)
What is the pharmacological action of glucocorticoids for treatment of rheumatoid arthritis?
provide symptomatic relief of inflammation and pain (analgesia for pain swelling and joint stiffness, slow/delay worsening of disease, short-term therapy until long-acting DMARDS take effect, prevention of organ rejection in transplants, and management of inflammatory bowel disease as well)
What is the pharmacological action of NSAIDs for treatment of rheumatoid arthritis?
provide rapid symptomatic relief of inflammation and pain (analgesia for pain swelling and joint stiffness, short-term therapy until long-acting DMARDS take effect)
What are immunosuppressants also used for?
management of inflammatory bowel disease and prevention of organ rejection in transplant
What drugs in the DMARDS classes cause bone marrow suppression and what would be some nursing considerations for it?
methotrexate
etanercept
infliximab
cyclosporine
gold salts
monitor CBC, WBC, platelets and patients need to get a CBC, WBC every 3-6 months
also report bruising, bleeding gums, bleeding in general (reduction of platelets)
report signs of infection (sore throat, fever)
COMMON ADVERSE EFFECT, ALL DMARDS GROUPS CAN CAUSE THIS
What drugs in the DMARDS classes (and one other drug not in DMARDS for rheumatic arthritis treatment) cause a risk for infection and what would be some nursing considerations for it?
methotrexate
etanercept
infliximab
cyclosporine
gold salts
glucocorticoids
SAME DRUGS AS BONE MARROW SUPPRESSION EXCEPT ADD GLUCOCORTICOIDS
report signs of infection (sore throat, fever)
What drugs in the DMARDS classes are nephrotoxic and what are some nursing considerations for it?
methotrexate
cyclosporine
gold salts
MONITOR LABS
What drugs in the DMARDS classes are hepatotoxic and what are some nursing considerations for it?
gold salts
cyclosporine
MONITOR LABS AND EDUCATE ABOUT SIGNS OF DYSFUNCTION
What drug in the DMARDS I class can cause retinal damage and what are some nursing considerations for it?
hydroxychloroquine (antimalarial agent)
REMEMBER THIS
baseline eye exam and follow-up every 6 months with opthalmologist
What drugs in the DMARDS classes can cause skin reactions/rashes?
gold salts
etanercept
infliximab
OTHER DMARDS II (injected subcutaneously) like adalimumab
REPORT THIS EFFECT
What are some other adverse effects of glucocorticoids other than risk for infection and what are some nursing considerations for them?
fluid retention, hypokalemia, hyperglycemia – monitor for these and report symptoms.
osteoporosis (long term use)– take calcium supplements, vitamin D, and biphosphonates
What drugs in the DMARDS classes cause heart failure and what are some nursing considerations for this?
etanercept
infliximab
MONITOR (tachycardia, decreased CO, signs of left and right sided heart failure)
What pregnancy category is methotrexate?
cat X (two forms of birth control)
What is something to watch out for when administering infliximab IV, what do we do if it happens?
an IV infusion reaction
stop the infusion, notify provider, monitor patient for 2 hours after the IV infusion (with or without the occurence of an infusion reaction)
What can methotrexate do to the GI tract and what is a nursing consideration for this reason?
stomatitis/ GI ulcerations
take medication with food
How are etanercept and adalimumab adminstered and what is a nursing consideration for this reason?
subcuntaneous
we need to monitor the site for any skin rashes/reaction after injection
also make sure that the solution to be injected is clear and without particles (this is supposed to be done with any injections)
How should we give the first dose of cyclosporine? why? and what should be done during and after infusion?
administer the first dose over 2-4 hours because of the infusion reaction that can happen
monitor for a reaction during and after infusion is done
When are glucocorticoids contraindicated?
systemic fungal infections
live virus vaccines
Do we stop glucocorticoids suddenly if long term use, what is considered long term use? why?
NO NO NO
7-10 days is considered long term use
adrenal insufficiency can happen
Do DMARDS have many drug-drug interactions?
YES YES YES
What are some patient teaching points for DMARDS?
report signs of illness - avoid illness and crowds (bone marrow suppression and glucocorticoids)
keep lab appointments - renal, liver, CBC, every 3-6 months
avoid grapefruit juice with cyclosporine
take NSAIDS and methotrexate with food
monitor for signs of bleeding (methotrexate, etanercept, infliximab, cyclosporine, gold salts) (bone marrow suppression)
take medications as directed - dont stop glucocorticoids suddenly
many drug-drug interactions
3-6 months to reach full effectiveness (except glucocorticoids and NSAIDS)
avoid alcohol (gold salts, cyclosporine) (hepatotoxicity)
baseline eye exam and follow-up every 3-6 months (hydroxychloroquine)
methotrexate is a pregnancy category X
What DMARD should be taken with food and what other adjunct drug should be taken with food as well?
methotrexate (stomatitis/GI ulcers)
NSAIDS (peptic ulcers)
What DMARD should you avoid taking grapefruit juice with?
cyclosporine (increases risk of toxicity)
`Why should we avoid alcohol with gold salts and cyclosporine?
because of the hepatotoxicity
Why do we need to get a baseline eye exam and follow-up every 6 months for patients on hydroxychloroquine?
because of the possible retinal damage the drug can cause
