OA, RA Flashcards
1st line for osteomyelitis empiric
Vanc + cefepime/ ceftriaxone
targets of RA treatment
Targets immune components involved: T lymphocytes, cytokines, B lymphocytes, kinases
do NSAIDs treat underlying dz?
no
MOA: Inhibits phospholipase A2. Inhibits cytokines and inflammatory mediators
“Prednisone
Methylprednisolone”
steroids for RA
“Prednisone
Methylprednisolone”
glucocorticoid interaction
NSAIDs (also thin stomach lining – use caution)
which class? Do not initiate during active infx. Consult rheumatology about holding during severe infx, surgery.
DMARDs
considerations before starting DMARDs
All patients must be screened for Hep B, Hep C AND latent TB before starting DMARDs. Give any needed live vaccines before initiating DMARDs
MTX dose frequency
1x/wk
MOA: Inhibitor of dihyrofolate reductase enzyme which is essential for DNA replication (making new cells quickly!)
MTX
non-bio DMARDs for RA
Methotrexate PO, SC, IM, dosed once weekly
Hydroxychloroquine (Plaquenil)
Sulfasalzine
Leflunomide (Arava®)”
1st line for RA
MTX
MTX contras
pregnancy (BBW), lactation, severe liver dz (BBW), use of Bactrim. Avoid in renal impairment, skin cancer
AEs: rash, liver/lung/bone marrow toxicity (BBW), folic acid deficiency, n/v/d, gastric ulcer, anorexia, pulm fibrosis, pneumonitis, anemia, leukopenia, thrombocytopenia, pancytopenia, opportunistic infx (BBW), alopecia.
MTX
MTX interactions
Bactrim, probenecid, NSAIDs (BBW)
pts must take what if on MTX
must take folate 1mg QD
AEs: Nausea, vomiting, diarrhea (less than MTX), QTc prolongation. Retinal damage and vision changes (due to highly protein binding of ocular tissue)
Hydroxychloroquine (Plaquenil)
monitoring for Hydroxychloroquine (Plaquenil)
MUST HAVE A BASELINE EYE EXAM AND THEN ANNUALLY ON THIS MEDICATION.
Sulfasalzine
contras
sulfa allergy, hepatic dysfunction
AEs: HA, n/v, dyspepsia, fever, rash, photosensitivity, oligospermia. Rare: leukopenia, aplastic/hemolytic anemia, agranulocytosis, pancreatitis, hepatitis
sulfasalazine
pt counseling for sulfasalazine
men must stop 3 mo before trying to conceive
monitoring for sulfasalazine
Monitor CBC and LFTs before starting therapy then routinely Q3 mo
on the mitochondrial level – inhibits RNA and DNA synthesis. Decreases T and B cell proliferation
”
Leflunomide (Arava®)”
”
Leflunomide (Arava®)”
contras
pregnancy, lactation
AEs: Nausea, diarrhea, abdominal pain, HTN, HA. BBW: Hepatotoxicity. When combined with MTX, there is a dramatic rise in hepatotoxicity
”
Leflunomide (Arava®)”
Leflunomide (Arava®)”
monitoring
LFTs
main types of biologic DMARDs for RA
TNF-alpha inhibitors, IL-1 and IL-6 antagonists
5 TNF-alpha inhibitors to treat RA
Etanercept (Enbrel®)
Infliximab (Remicade®) IV only
Adalimumab (Humira®)
Golimumab (Simponi®)
Certolizumab (Cimzia®)
indications: maintaining remission in CD, UC, RA, psoriasis and psoriatic arthritis, hidradenitis suppuritiva, juvenile RA, ankylosing spondylitis
TNF-alpha inhibitors
AEs: “HA, sinusitis, URI, injection site reaction.
BBW: Increases risk of serious infections (possibly fatal). Worse if also on MTX or steroids. risk for listeria, invasive fungal dz. BBW: lymphoma / skin cancer in kids”
TNF-alpha inhibitors
pt counseling for TNF-alpha inhibitors
rotate injection sites, apply cold pack after administration and 1% hydrocortisone cream. Must get periodic skin exams
Anakinra (Kineret®) class
Interleukin-1 Antagonist
Interleukin-1 Antagonist indications
Adults who have failed non-biologic DMARDs. Systemic RA and continued disease activity after trial of NSAIDs and glucocorticoids. Not FDA-approved for JIA. alone or in combo w/ MTX
AEs: Injection site reaction. Increased risk of infection (rare; URI). Neutropenia. Increased risk of malignancy
Interleukin-1 Antagonist: Anakinra (Kineret®)
monitoring for Interleukin-1 Antagonist: Anakinra (Kineret®)
neutrophils
AEs: Rash. BBW: Fatal infusion related reactions, Mucocutaneous reactions (SJS, TEN)
Rituximab (Rituxan®)
class: Tocilizumab (Actemra®)
Sarilumab (Kevzara®)
IL-6 Antagonist:
class: “only PO options
Tofacitinib (Xeljanz®)
Tofacitinib extended release (Xeljanz XR®)
Upadacitinib (Rinvoq®)”
Janus-Kinase Inhibitors
contras: Janus-Kinase Inhibitors
Hx of VTE/DVT/PE
AEs: GI perforation. Esophageal candidiasis. Risk of skin cancer and lymphomas. Altered lipid profile. increases risk of herpes zoster (so must get vax). BBW: serious infx (URI, UTI most common), malignancies, thrombosis
Janus-Kinase Inhibitors
Janus-Kinase Inhibitors interactions
biologic DMARD (due to increased immunosuppression and risk of infection). CYP3A4
Janus-Kinase Inhibitors monitoring
lipid profile
1st line for mod-severe OA
NSAIDs
MOA: induces release of substance P (primary chemomediator of pain impulses from peripheral sensory neurons to CNS)
“topical capsaicin OTC
apply 3-4x/d”
AEs: “application site edema and pain
Decreased sensory function (patch)
PAIN if gets into eyes or genitals”
“topical capsaicin OTC
apply 3-4x/d”
pt counseling for capsaicin
wash hands well after application or use gloves
intra-articular Corticosteroids for OA
(methylprednisolone; triamcinolone)
indications: 2nd line to PO and topical agents for pain. Does NOT reverse dz progression, only relieves symptoms
corticosteroid injections
