OA/RA Flashcards
OA, Clinical Presentation
Joint pain
-hips, knees, hands
-resolves with motion, recurs with rest
-limited motion, may be related to weather
OA, Non Pharm
-Exercise
-Self efficacy/man programs
-Weight loss, tai chi, cane
-1st cmc orthosis for hand
-Knee brace
~heat, cooling, CBT, acupuncture
TX Strategy for OA
ALL: oral NSAIDS
Knee: topical NSAIDS, I-A steroids
Hip: I-A steroids
~cond for all: tylenol, tramadol, duloxetine
NSAIDs: OA
Topical > Systemic
*Initial oral med of CHOICE!
AE: renal, GI
-PPI, H2, COX2 selective
CV risk
-Avoid in pts with ID, CVD, CHF
DDIs:
-Lithium, Warfarin
-Hypoglycemics
-ACEI, Diuretics
Sulfa allergy: DONT use celecoxib
Other NSAID Options: OA
-Diclofenac
-Capsaicin, irritant
-Glucosamine/Chondroitin, caution with shellfish allergies
-Acetaminophen if NSAID CI
-Duloxetine
-Tramadol
RA, Clinical Presentation
-Joint pain, stiffness, tenderness, swell, warmth
-Fatigue, weak, LOA
-Sym joint distribution
-RF 60-70%, elevated ESR/CRP
-Increased WBC, joint changes in radiography
OA VS RA
RA
-30-60 yrs, autoimmue
-over weeks/months
-symmetrical
-extra articular manifestations
-females >
OA
-after 40 yrs, loss of cart, over years
-unilateral or bilateral
-larger joints
-no extra articular
-males = females
Goals of TX: RA
- Remission/low disease activity
- Improve functional status
- Improve quality of life
- Reduce symptoms
- Slow progression
- Delay disability
Non-pharmacologic Treatment: RA
- Rest
- Physical therapy
- Occupational Therapy
- Assistive devices
- Heat/cold therapy
- Weight loss
- Surgical correction
- Anti-inflammatory diet
Treatments for Rheumatoid Arthritis
csDMARDs
-MTX, HCQ, sulfasalazine, leflunomide
Biologic
-MABs, cept
tsDMARD
-small mol anti rheum drug
Adj tx
-NSAIDs, GC
Treatment for Moderate-Severe RA
- MTX preferred, use first before adding other dmards
- bDMARD and tsDMARD
- Class switch
Glucocorticoids for RA
SX TX
-bridge for dmard
-acute flares
-chronic use: inadequate response to dmards
-Low dose < 10 mg/day prednisone
-Short term < 3 mo
-Long term, taper if > 2 weeks, monitor
AE:
-Psych, round face, eyes
-Diabetes, neutrophilia, IS, insomnia
-Stomach, osteo, Na/water retention, endocrine (HPA)
Traditional DMARDs for RA
MTX, HCQ, sulf, lef
Monotherapy, first line
Slow onset, 6-12 wk
Methotrexate
Needs folic acid supplementation, 1 mg a day or 5 mg weekly
DDI: salicylates (nsaids), pheny, cipro, thiazide, vit c, SNP CTV
BBW: nephrotoxicity, BMS, derm, GI, hepatoxicity, infections, malignancy (HIM BD GN)
Pregnancy X, teratogen
-avoid pregnancy for 3 mo male patients, 1 ovulatory cycle for female patients
Hydroxychloroquine
Preferred agent for patients with low disease activity
AE: NVD, HA, myopathy, ototoxicity, retinopathy (monitoring), NM HOR
CI: retinal/visual changes
Sulfasalazine
AE: NV, LOA, HA, oligospermia, yellow discoloration, decrease folic acid abs, NhAY F
CI: sulfa and salicylate allergy, intestinal/urinary obstruction, porphyria
Leflunomide
AE: NVD, increase LFTs, alopecia, rash, HTN, resp tract infections
CI: Pregnancy X
-BBW for embryofetal toxicity, contraception during tx
-BBW for hepatotoxicity
PH GAL RRH
csDMARD Monitoring
Guidelines recommend monitoring CBC, LFT, SCr based on length of treatment received
Summary of csDMARD Place in Therapy
LOW severity
-HCQ > sulf > MTX > leflu
MOD-HIGH
-MTX 1st line (FA supp)
If MTX naive and on other agent, start MTX as monotherapy before moving to others
TNF- α Inhibitors (biologics)
Adalimumab, Certolizumab, Etanercept, Golimumab, Infliximab
*Mod-severe cases
AE: HI IM A
-Infections: TB/HB test prior
-Malignancy
-AI conditions
-Heart failure
-Immunologic rxns
Refrigderate, no freezing, RT before injecting (do not shake, pens are single use)
Infliximab has high potential for infusion-related rxns (use AH, APAP, CS), longer infusion times > 2
NON TNFI: Abatacept
AE: nausea, HA, antibody development, infection, COPD flare ups
CINAH
NON TNFI: Rituximab
AE: edema, HTN, fatigue, chills, neuropathy, HA, insomnia, NVD, rash, itching, night sweats, hematologic, infection, antibody, cough, epistaxis (nose bleeds)
BBW
-fatal infusion rxns
-mucocutaneous rxns
-hbv reactivation
-multifocal leukoencephalopathy
IM HiM
NON TNFI: Tocilizumab and Sarilumab (same)
AE:
-HLD, infusion rxns
-high liver enzymes (NO if alt/ast > 1.5 unl)
-hematologic
BBW: infections, TB
HHHIIT
NON TNFI: Anakinra
AE:
-NVD
-HA
-Thrombocytopenia & neutropenia
reduce to every other day if CrCl < 30 ml/min
