OA and RA treatment Flashcards
OA nonpharm treatment
Weight loss
Low impact exercise
Physical therapy
Reasonable expectations
OA topical medications
Capsaicin
NSAIDs
Topical NSAIDs recommended for
over oral NSAIDs for patient >75 years old
Topical Capsaicin pain reduction
Reduces pain in approximately 2 weeks but has a burning sensation side effect
Acetaminophen use OA
First line for mild osteoarthritis
Max dose 4g/day
Less effective than NSAIDs but safer
NSAIDs use OA
More effective than acetaminophen
Less favorable adverse events
How should NSAIDs be used if GI bleed in last 12 months
COX2 inhibitor + PPI
What happens when COX2 is inhibited
vasoconstriction and platelet aggregation
Warnings with NSAIDs
CVD
Renal
GI
Opioid use in OA
Do not use routinely
High risk and severity of adverse events outweigh benefit potential
Tramadol safety
lower seizure threshold
Limit dose to 50mg every 12 hours in patient with cirrhosis
Avoid ER formulation
Increased risk of serotonin syndrome
BBW: Addiction/Abuse/Misuse
Glucosamine and Chondroitin OA
Not routinely recommended
Invasive interventions OA
No more than a steroid injection every 3 months
Hyaluronic acid benefit not observed until 4 weeks after injections
RA supportive care
NSAIDs and corticosteroids
NSAIDs efficacy RA
Do not modify the destruction or progression of RA
CS efficacy RA
Short term, low doses, effective for symptom flares
CS adverse effects
Hyperglycemia
Hypertension
Weight gain
osteoporosis/fracture risk
What to prescribe with corticosteroids long term
Start calcium and vit D
Consider bisphosphonates
Synthetic DMARDs
Methotrexate and Hydroxychloroquine
Methotrexate for RA
First choice for DMARD therapy
Add folic acid
Leflunomide efficacy
Comparable to methotrexate
Can add to methotrexate to further improve symptoms
Leflunomide safety
Decreased defense against malignancy
Women planning pregnancy or men planning to father children - discontinue drug
Preexisting liver disease and LFTs 2x upper limit should not receive leflunomide
Leflunomide adverse effects
Alopecia
Sever hepatotoxicity
Sulfasalazine patients to avoid
Platelet count <50,000/mm3
LFTs >2x upper limit of normal
Acute Hep B/C
Benefit of sulfasalazine
Alternative for pregnant women or women planning to become pregnant
Hydroxychloroquine efficacy
Decreases pain and swelling
Improvement in symptoms in 1-2 months
May take 6 months to see full benefit
Hydroxyxhloroquine safety
Best safety profile out of all synthetic DMARDs
Potential rare maculopathy
Biologic DMARDs
Adalimumab (Humira)
Certolizumab Pegol (Cimzia)
Etanercept (Enbrel)
Golimumab (Simponi)
Infliximab (Remicade)
TNF inhibitor indications
RA
Psoriatic arthritis
Ankylosing spondylitis
TNF inhibitor efficacy
First line choice biologic DMARD based on ability to improve physical function and delay radiographic changes
Combination with methotrexate yields better outcomes than monotherapy
TNF inhibitors adverse effects
HA
Injection site reactions
ACR recommendations for TNF inhibitors
Recommends biologic DMARD after insufficient response to nonbiologic DMARDs
Clinical Pearl infliximab
Should only be used in combination with methotrexate
TNF inhbitor nonadherence concern
Increased risk of antibody development leading to loss of effectiveness and/or adverse reactions
How long for TNF to work
Weeks to months; need additional pain management first 3 months
Vaccines and TNF inhibitors
Live attenuated not recommended
Anakinra (Kineret) efficacy
decreases RA symptoms
Not as effective as TNF inhibitors
Anakinra safety
High dose associated with serious infection
Tofacitinib (Xeljanz) efficacy
reduce RA symptoms 20-70%
Tofacitinib safety
Bone marrow suppression
Hepatotoxicity
Tofacitinib adverse effects
Increased infection risk
Biologic DMARD + Synthetic DMARD
Safe and acceptable
Synthetic DMARD + Synthetic DMARD
Safe and acceptable
Biologic DMARD + Biologic DMARD
Increased risk of severe immunosuppression
RA optimizing outcome of treatment
Early diagnosis
Goal is remission - no joint symptoms
Corticosteroids to be used as bridge to effective DMARD therapy
