MSK RA Therapeutics

Question 1

What is the pathophysiology of RA?

Answer 1

For now, refer to ur own notes… haha trying to think how to put it here succintly

Question 2

What are the symptoms of RA? (physical, systemic)

Answer 2

Physical:
* Symmetrical polyarthritis (may start w unilateral joint at first)
* Pain, swelling, erythema, warm
* Early morning stiffness >30min

Systemic symptoms:
* Generalised aching/ stiffness, fatigue, fever, weight loss, depression
* Esp for those with acute/ >60yo onset

Question 3

List out 3 extra-articular complications of RA

Answer 3

Sjogren’s syndrome, CAD, Felty’s syndrome, rheumatoid nodules/ vasculitis

I included those that YKZ coloured/ highlighted in her slides only, there are many other complications

Question 4

List out 2 deformaties of advanced RA disease

Answer 4

Swan neck, boutonniere, Z-shaped thumb, rheumatoid nodules (skin), popliteal cyst (knee), MTP subluxation (toes)

Question 5

What are the diagnostic labs of RA?
____ESR, ____CRP
Auto-Abs: +ve ____, +ve ____ (____ assays)
FBC: ____hematocrit/Hg, ____platelets, ____WBC

Answer 5

↑ESR, ↑CRP
Auto-Abs: +ve RF, +ve ACPA (anti-CCP assays)
FBC: ↓hematocrit/Hg, ↑platelets, ↑WBC

ACPA: Anti-cyclic citrullinated peptide antibody
CCP: cyclic citrullinated peptide

Question 6

What are the criteria for diagnosing RA?

Answer 6

Must have ≥4 of the following:
* Early morning stiffness ≥1hr x ≥6w
* Swelling of ≥3 joints x ≥6w
* Swelling of wrist/ metacarpophalangeal (MCP)/ proximal interphalangeal (PIP) joints x ≥6w
* Rheumatoid nodules
* +ve RF and/or anti-CCP tests
* Radiographic changes

Question 7

When is imaging used in RA?

Answer 7

Is not used as part of diagnosis (not observable in early stages), usually occur at later stages to monitor disease progression

Question 8

What are the risk factors for RA? (4)

Answer 8

• Family hx
• Genetics (HLA-DRB1 gene in MHC region)
• Female > Male
• Smoking

Question 9

What are the Boolean Criteria for Remission? How long (e.g. no. of weeks or months) must it be before it is counted as remission of RA?

Answer 9

Boolean 2.0 criteria (remission):
* Tender joint count ≤1
* Swollen joint count ≤1
* CRP ≤1mg/dL
* PGA using 10cm VAS: ≤2cm

At least 6m

Question 10

What drugs are used for acute flares of RA?

Answer 10

NSAIDs, glucocorticoids

Question 11

How long does it take for NSAIDs to have an effect?

Answer 11

1-2 weeks

Question 12

Glucocorticosteroids should only be used for ____, need to ____ when discontinuing. It can be used as a bridging agent for ____DMARDs tx, but should be discontinued immediately if ____DMARD are started due to risk of ________

Answer 12

Glucocorticosteroids should only be used for 3m, need to taper when discontinuing. It can be used as a bridging agent for cDMARDs tx, but should be discontinued immediately if b/tsDMARD are started due to risk of additive and immunosuppressant effects

Question 13

Intra-articular glucocorticoid injections are used to control flare and sx relief, should not be relied on
May be repeated ____
But limit to ________ (risk of tendon atrophy and accelerated joint destruction)

Answer 13

May be repeated Q3m
But limit to ≤2-3 times per year per joint (risk of tendon atrophy and accelerated joint destruction)

Question 14

When initiating DMARDs, what are the drugs recommended for low RA disease acitivty? List them in order, and include adjuncts if any

Answer 14

1st line: hydroxychloroquine
Others (preference in order): sulfasalazine (↓immunosuppressive), MTX (↑dosing flexibility and↓cost), leflunomide
Adjunct: NSAIDs

Question 15

When initiating DMARDs, what are the drugs recommended for moderate RA disease acitivty? List them in order, and include adjuncts if any

Answer 15

1st line: methotrexate
Others: sulfasalazine/ hydroxychloroquine/ leflunomide
Adjuncts:
* Folic acid 5mg one day after MTX
* Low-dose bridging short-term glucocorticoids when initiating/ changing DMARDs

Question 16

In a patient with moderate RA disease activity, cDMARDs r initiated. But patient is not at the target. What should the next course of action be?
Also include what to do if target is not reached subsequently, and also what to do in the event that target is reached.

Answer 16

Add bDMARD/ tsDMARD, bDMARD is more preferred (because tofacitinib has ↑risk for MACEs and malignancy)
Others: Add hydroxychloroquine/ sulfasalazine (triple therapy, ↓risk of adverse events)

If target still not reached, switch to a diff class of b/tsDMARD, keep cDMARD. Do not use >1 b/tsDMARD at the same time

If target is reached: Consider dose reduction/ ↑interval
Do not discontinue DMARD abruptly, may result in flares!
Continuation of all DMARDs highly recommended, but…
* Triple tx: gradual discontinuation of sulfasalazine recommended over hydroxychloroquine (for lower adverse events and better tx persistence)
* MTX + b/tsDMARDs: gradual discontinuation of MTX recommended (for better disease control)

Question 17

In RA

Anti-drug antibodies may occur with ____ → loss of efficacy ∴ MONITOR for ____

Answer 17

Anti-drug antibodies may occur with TNF-α inhibitors → loss of efficacy ∴ MONITOR for antibodies

Question 18

List out 3 risk factors that needs to be taken note of when initiating b/tsDMARDs?

Answer 18

• CVS: >65yo, hx/ current smoking, obesity, PMH of DM/HTN
• Hx/ current malignancy
• Thromboembolic events: immobility, major surg, use of contraceptives/ hormonal replacement therapy, PMH of MI/ HF/ blood clots/ inherited blood clotting disorders
• GI: diverticulitis, >65yo, GC/ NSAID use

Question 19

List out 3 things to check before initiating b/tsDMARDs

Answer 19

• Discontinue glucocorticoid use (if any)
• Pre-DMARD screening for infections
• TB: start after completing anti-TB tx
• Avoid if untreated hepatitis B/C detected
• Complete vaccinations: pneumococcal, influenza, hepatitis B, varicella/ herpes zoster
• Labs screening/ monitoring: CBC, LFT, lipid panel, SCr

Question 20

List out 3 non-pharmacological treatment for RA

Answer 20

Education
* Manage pt’s expectations, correct misconceptions

Psychosocial Interventions
* e.g. CBT (Enhance self-efficacy and QoL)

Rest/ Use splinters
* Caution against promoting rest, encourage physical activity when possible (May lead to sedentary lifestyle)

Exercise
* Range of motion exercises (Preserve joint motion)
* Exercises that ↑muscle strength → avoid contractures and muscle atrophy (Prevent joint instability and improve function)
* Aerobic exercises (↓Fatigue/ pain, improve sleep)
* Avoid high-intensity weight-bearing exercises (Prevent further injury)
* PT/ OT referral for supervised tailored exercises by trained experts

Nutrition and Diet
* * Overcome anorexia and poor dietary intake
* Weight management if obese (↓stress on weight-bearing joints)
* Dietary interventions for ↓inflammation (e.g. fish oil)