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Fall Therapeutics > OA/RA > Flashcards

OA/RA Flashcards

1
Q

OA, Clinical Presentation

A

Joint pain
-hips, knees, hands
-resolves with motion, recurs with rest
-limited motion, may be related to weather

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2
Q

OA, Non Pharm

A

-Exercise
-Self efficacy/man programs
-Weight loss, tai chi, cane
-1st cmc orthosis for hand
-Knee brace

~heat, cooling, CBT, acupuncture

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3
Q

TX Strategy for OA

A

ALL: oral NSAIDS

Knee: topical NSAIDS, I-A steroids

Hip: I-A steroids

~cond for all: tylenol, tramadol, duloxetine

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4
Q

NSAIDs: OA

A

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

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5
Q

Other NSAID Options: OA

A

-Diclofenac
-Capsaicin, irritant
-Glucosamine/Chondroitin, caution with shellfish allergies

-Acetaminophen if NSAID CI
-Duloxetine
-Tramadol

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6
Q

RA, Clinical Presentation

A

-Joint pain, stiffness, tenderness, swell, warmth
-Fatigue, weak, LOA
-Sym joint distribution
-RF 60-70%, elevated ESR/CRP
-Increased WBC, joint changes in radiography

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7
Q

OA VS RA

A

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

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8
Q

Goals of TX: RA

A
  • Remission/low disease activity
  • Improve functional status
  • Improve quality of life
  • Reduce symptoms
  • Slow progression
  • Delay disability
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9
Q

Non-pharmacologic Treatment: RA

A
  • Rest
  • Physical therapy
  • Occupational Therapy
  • Assistive devices
  • Heat/cold therapy
  • Weight loss
  • Surgical correction
  • Anti-inflammatory diet
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10
Q

Treatments for Rheumatoid Arthritis

A

csDMARDs
-MTX, HCQ, sulfasalazine, leflunomide

Biologic
-MABs, cept

tsDMARD
-small mol anti rheum drug

Adj tx
-NSAIDs, GC

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11
Q

Treatment for Moderate-Severe RA

A
  1. MTX preferred, use first before adding other dmards
  2. bDMARD and tsDMARD
  3. Class switch
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12
Q

Glucocorticoids for RA

A

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)

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13
Q

Traditional DMARDs for RA

A

MTX, HCQ, sulf, lef

Monotherapy, first line

Slow onset, 6-12 wk

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14
Q

Methotrexate

A

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

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15
Q

Hydroxychloroquine

A

Preferred agent for patients with low disease activity

AE: NVD, HA, myopathy, ototoxicity, retinopathy (monitoring), NM HOR

CI: retinal/visual changes

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16
Q

Sulfasalazine

A

AE: NV, LOA, HA, oligospermia, yellow discoloration, decrease folic acid abs, NhAY F

CI: sulfa and salicylate allergy, intestinal/urinary obstruction, porphyria

17
Q

Leflunomide

A

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

18
Q

csDMARD Monitoring

A

Guidelines recommend monitoring CBC, LFT, SCr based on length of treatment received

19
Q

Summary of csDMARD Place in Therapy

A

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

20
Q

TNF- α Inhibitors (biologics)

A

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

21
Q

NON TNFI: Abatacept

A

AE: nausea, HA, antibody development, infection, COPD flare ups

CINAH

22
Q

NON TNFI: Rituximab

A

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

23
Q

NON TNFI: Tocilizumab and Sarilumab (same)

A

AE:
-HLD, infusion rxns
-high liver enzymes (NO if alt/ast > 1.5 unl)
-hematologic

BBW: infections, TB

HHHIIT

24
Q

NON TNFI: Anakinra

A

AE:
-NVD
-HA
-Thrombocytopenia & neutropenia

reduce to every other day if CrCl < 30 ml/min

25
Q

Biologics (both) Monitoring

A

Prior to Initiation:
* TB screening
* HBV screening
* Up-to-date vaccinations
* Risk assessment for cancer
* CBC, LFT

Throughout therapy:
* Sx improvement
* Assessment of physical function
* S/sx of infection

26
Q

Janus Kinase Inhibitors (JAKinibs)
-Tofacitinib, Baricitinib, Upadacitinib

A

AE:
-Infection risk, HLD, LFTs, BMS

Do not initiate in patients with:
* Absolute lymphocyte count <500 cells/mm3
* ANC <1,000 cells/mm3
* Hb <8 g/dL

DDI: CYP3A4 inhibitors

BBW: infections, mortality (CV death), malignancy, pulmonary embolism and thrombosis = PIC of TiM

27
Q

Treatment Success

A
  • If disease activity = low: continue all treatments
  • If disease = in remission: consider tapering treatment
    -Decrease dose or frequency, 1 treatment at a time
    -Do NOT discontinue all DMARDs
28
Q

Special Populations

A

-HF: non TNF, tsDMARD

-Lympho: Rituximab

-HBV: Rituximab

-Infection: csDMARD multitx

-Skin cancer: csDMARD

Fall Therapeutics (34 decks)

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