OA/RA Flashcards
Osteoarthritis is a disease of the ?
What’s our goal?
Clinical presentation ?
Cartilage
Pain relief!
Joint pain in hips, knees, hands that resolves with motion, recurs with rest.
Usual duration < 30 mins
May be related to weather . Can have limited joint motion .
Non Pharm Tx
Highlight some Strongly recc therapies
Waht about conditionally recommended?
Exercise, self efficacy and self management programs
for knee and hip : Weight loss, tai chi, cane, Knee brace
Heat, therapeutic cooling, acupuncture, kinesiotaping, balance training
Pharm Tx
- What tx should u try to use first?
- Strongly recommended for hand, knee and hips ?
- Strongly rec for knee and hip and conditionally rec for hands?
- for all , the following drugs r conditionally recommended
Topical nsaids (knee and hand)
oral nsaids
Intra-articular steroids
Tylenol, tramadol, duloxetine
NSAIDS
If possible use which formulation over which?
Great for __
WHy do hips and hands have limitations?
-Initiate oral med of choice, regardless of ___ (Lowest and shortest dose possible)
What can you use to diffuse the GI and renal AE’s of NSAIDS?
-Note AE of Fluid retention +Incr BP
Cardiovasc risk –> Avoid in patients?
Topical > systemic
knees!
handwashing, depth of hip joint
location!
PPI’s,H2, COX2 selective agents
with known active ischemic disease, CVD, and moderate/severe CHF
NSAIDS DDI’s
(5) and
Likely less risk if u use a topical
Sulfa Allergy beware of?
Lithium, warfarin bleeding risk, oral hypoglycemics, ACEI, diuretics
Celecoxib (sulfonamide)
Other TX options ? (3)
Diclofenac Gel (AAA 4x daily)
Capsaicin (irritant )
Glucosamine/chondroitin (caution with shellfish allergy + no evidence it actually works)
Rheumatoid Arthritis : Autoimmune Disease
-Describe the inflammation
Sx’s : Joint pain/stiffness
Fatigue, weakness, loss of appetite
RF 60-70% , elevated ESR /CRP, warm tender and swollen
-Might have normocytic anemia
Chronic, systemic inflammation
progressive symmetrical joint damage
Difference between RA and OA
-Onset
-What happens
Develops over?
Pattern ?
Which joints
Morning stiffness?
Manifestations?
Gender?
RA : Onset 30-60 years
* Autoimmune joint
destruction
* Develops over
weeks/months
* Symmetrical
* Primarily small joints
* Morning stiffness (>1 hr)
* Extra-articular
manifestations
* More common in females
OA : Onset after age 40
* Biomechanical loss of
cartilage
* Develops over many years
* Unilateral or bilateral
* Primarily larger joints
* Minimal morning stiffness
* No extra-articular
manifestations
* Males = females
Goals of Tx
R___
Improve __ and __
Reduce ___
Slow __
Delay ___
remission/low disease activity
functional status, quality of life
sx’s
progression
disability
Non Pharm for RA
R,P,O,A,H,W,S,A
rest, PT, OT, assistive devices, heat or cold therapy, weight loss, surgical correction , anti inflamm diet
TX Strategy in General : Which 3 categories of drugs ?
csDMARD : Conventional synthetic disease modifying antirheumatic drug
Biologics : TNF/non TNF
tsDMARD : targeted synthetic DMARD
csDMARDS : 4
Biologics TNFI : 5
Biologics Non TNF : 5
Adjunctive therapy of nsaids and glucocorticoids name an example of each
MTX, Hydroxychloroquine, sulfasalazine, leflunomide
adalimumab, certolizumab, etanercept, golimumab, infliximab
Abatacept, rituximab, tocilizumab, sarilumab, anakinra
ASA
Cortisone
Glucocorticoids AE’s
P
R
E
D
N
I
S
O
N
E
psychiatric (mood change and jitters)
round face
eyes (glaucoma and cataracts)
diabetes
neutrophilia
immunosuppression, insomnia
stomach (GI upset and ulcer)
Osteoporosis
Na/H2O retention
Endocrine (HPA suppression)
MTX
-It is the ___ initial DMARD therapy for most pt’s with mod/high disease activity
Dosing ?
What can u do to reduce ae’s?
Titrate up gradually to optimal response
When can u see initial vs full effects?
What must be supplemented ?
PREFERRED
15 mg weekly; oral preferred
May divide dose to reduce side effects (daily); transition to subQ
May take 3-6 weeks to see initial effects, 12+ weeks for full effect
Folic acid : 1 mg daily or 5 mg weekly (Day after MTX) to reduce SE
MTX DDI
-ALbumin binding interactions with ? (5)
-Reduction of renal elimination of drug (with Acidic drugs such as? )
salicylates, phenytoin, SMZ/TMP, ciproflox, thiazide diuretics
Salicylates or vitamin C
For salicylates –> includes NSAIDS But u dont have to avoid NSAIDS. u can be cautious and use diclofenac or mobic
MTX : BBW
Never bake diet goods , humans only prefer sugar
Nephrotoxicity (Renally elim)
Bone marrow suppression
dermatologic rxns
GI (N/V/D)
Hepatotoxic
opportunistic infxn
pneumonitis
Secondary malig (lymphomas)
MTX Monitoring parameters? 6
MTX and pregancy?
Scr, CBC, LFTS, baseline chest xray, if needed, hepB/c testing, liver biopsy
Preg category X. Abortifacient, teratogen
-Following tx, avoid preg for 3 months w/male patients, 1 ovulatory cycle for females
Maintenance monitoring of MTX : CBC, LFT, Scr Frequency
If < 3 month therapy
if 3-6 months
if >6 months
2-4 weeks, 8-12 wks, 12 weeks
Biologics : TNF Alpha Inhibitors
-Immune suppression, reduce inflammation
AE’s : I,M,A,H, I (I might actually hate it)
Infection Risk : Tb, must test before therapy.
Invasive fungal infxns
Atypical/opportun bact/viral infxns
reactivation HepB
Malignancy : lymphoma or skin cancer
Autoimmune conditions : Worsening or new onset, MS, drug induced lupus like syndromes
HF : Worsening or new onset
Immunologic rxns : ANA titer, Ab devel
For each TNFAlphaI name the route
- Adalimumab (Humira)
- Certolizumab (cimzia)
- Etanercept (Enbrel)
- Golimumab (Simponi)
(combo w/ MTX) - Infliximab (Remicade)
(combo w/ MTX
Subq
Subq
subq
IV / subq
IV
Counseling for TNFAI
-Dont __, ___. before injecting, bring to ___
Don’t __
Pens and synringes are ___
What varies with product?
Which product has antigenic potential? (Infusion related rxns)
-Premedicate with __,__ and or __
Infusions less than ___ not recc first line
freeze, refridgerate. ROOM TEMP
Shake
Single use
Injection site! (thigh, lower abd, upper arm)
Infliximab
-Antihist, APAP, corticosteroids
2 hrs
Biologics : NON TNF
Abatacept (Orencia) -> route?
Ae’s? (5)
-Competes w/CD80/CD86 binding to prevent costum signal required for T cell activation
Rituximab (Rituxan)
-Route?
AE’s?
BBW? (4)
-mab binds CD20 on B lymphocytes
IV, subq
Nausea, headache, antibody devel, infection, COPD exacerbations
IV
edema, HTN, fatigue, chills, neuropathy,
headache, insomnia, N/V/D, rash, itching, night sweats, hematologic, infection, antibody development, cough, epistaxis
Fatal infusion reactions – monitor closely!
* Severe mucocutaneous reactions
* HBV reactivation
* Progressive multifocal leukoencephalopathy (PML)
Tocilizumab (ACtemra)
-Humanized IL6 receptor inhib
Route?
AE’s?
BBW?
IV or SubQ
HLD, infusion rxns
-Elevated liver enzymes. If AST/ALT>1.5 UNL, dont start. If 5xULN, discontinue
-Hematologic effects : Neutropenia, thrombocytopenia
Dont start if ANC< 2000 or Plt <100K
Discontinue if ANC <500 or Plt <50k
INFECTIONS + TB
Sarilumab (Kevzara)
-IL6 maB
route?
AE’s ?
BBW?
Subq
HLD
-Elevated liver enzymes. If AST/ALT>1.5 UNL, dont start. If 5xULN, discontinue
-Neutropenia, Thrombocytopenia
Dont start if ANC< 2000 or Plt <150K
Discontinue if ANC <500 or Plt <50k
INFECTIONS + TB
Anakinra (Kineret)
-IL1 receptor antag
Route?
AE’s ?
Subq
N/V/D, HA, Thrombocytopenia, and neutropenia
Biologics Monitoring
Prior to Initiation ? (5)
Throughout therapy?
TB screening
* HBV screening
* Up-to-date vaccinations
* Risk assessment for cancer
* CBC, LFT
Sx improvement
* Assessment of physical
function
* S/sx of infection
* Agent specific concerns
Targeted Synthetic DMARDS (JAKS)
Name the 3 drugs, dose? and route
What is it metabolized by? Need dose adj for?
Tofacitinib (xeljanz) IR 5 mg po bid, ER 11 mg po daily
Baricitinib (Olumiant) : 2 mg po daily
Upadacitinib (rinvoq) 15 mg po daily
CYP3A4 . CYP3a4 inhibs
JAKS AE’s (4) ?
Monitoring Baseline+Periodically?
Dont initiate in pt’s with ??
Baseline in general ?
infection risk, hyperlipidemia, LFT
elevations, bone marrow suppression
CBC, LFT, lipids
Absolute lymphocyte count <500 cells/mm3
* ANC <1,000 cells/mm3
* Hb <8 g/dL.
screen for viral hepatitis, tuberculosis
BBW for all RA JAKS
Incr risk of serious bact, fungal, viral and opport infxns leading to ?
-Higher rate of all cause __ including ___
Higher rate of __ and __
Higher rate of ___
Incr incidence of ___ venous and arterial thrombosis
hospitalization or death including Tb
mortality, sudden cardiovasc death
lymphomas, lung cancers
MACE
pulmonary embolism
KIM : print out Special Pop
ALSO pt’s can receive any vaccine just not live ones
print out
