OA, RA, PSA: i don't want to study anymore Flashcards
Difference between OA and RA: age
- OA: in pts > 50
- RA: variable age (most commonly in 50+, juvenille RA occurs in pts < 16)
Difference between OA and RA: onset
- OA: gradula onset
- RA: variable onset
Difference between OA and RA: joint s/s
- OA: localized s/s that usually only last 30 min and occur with joint use
- RA: general malaise/prodromal s/s tht can last over an hour and are present with use and at rest
Difference between OA and RA: joint involvement
- OA: larger, weight-bearing joints; unilateral involvement
- RA: b/l small jonts of hands, wrists and feet
Difference between OA and RA: auto-Ab involvement
- OA: no auto-Ab involement
- RA: auto-Ab present
OA
failure of the jont and surrounding tissues
OA signs
not syptoms
- usualy just one joint or oligoaricular (asymmetrical joints)
- local tenderness
- limted motion with passive/active movement
- bone proliferation or synovitis
OA symptoms
not signs
- pain
- deep aching
- stiffnes in affected joint
- usually < 30 min duration
- often related to weather
- limited joint movement
OA goals of dx
- distinguish between primary and secondary
- Primariy: no identifiable cause; idiopathic
- Secondary: associated with known cause - inflammation, trauma, metabolic/endocrine disorders, or congenital factors
- clarify which joints are involved and seveirty
- assess response to prior therapies
OA risk factors
- obesity - esp knees
- sex
- More common in men if <45 y/o
- More common in women if >45 y/o
- occupation
- certain sports
- hx of joint injury or surgury
- genetics: black men
Hand OA: non-pharm
strongly recommended
- exercise
- CMC orthosis
conditionally
- Heat, therapeutic cooling
- CBT
- acupuncture
- kinesiotaping
- other hand orthoses
- paraffin
don’t forget pt educaton
Knee OA: non-pharm
strongly recommended
- exercise
- wt losss
- tai chi
- cane
- knee brace
conditionally
- Heat, therapeutic cooling
- CBT
- acupuncture
- kinesiotaping
- balance training
- PF knee brace
- yoga
- RFA
don’t forget pt education
Hip OA: non-pharm
strongly recommended
- exercise
- wt loss
- taichi
- cane
conditionally
- Heat, therapeutic cooling
- CBT
- acupuncture
- balance training
don’t forget non-pharm
Hand OA: pharm
strongly recommended
- PO NSAIDs
conditionally
- Topical NSAIDs: diclofenac 2gm QID
- I-A steroid
- APAP
- Tramadol
- Duloxetine
- Chondroitin (NOT glucosamine, recommended against)
Knee OA: pharm
strongly recommended
- PO NSAIDs
- Topical NSAIDs: diclofenac 4gm QID
- I-A steroid
conditionally
- APAP
- Tramadol
- Duloxetine
- Topical capsaicin
Hip OA: pharm
strongly recommended
- PO NSAIDs
- I-A steroid with US guidance
conditionally
- APAP
- Tramadol
- Duloxetine
Which NSAIDs have a lower risk of GI tox and lower risk of plt inhibition
- celebrex
- valdecoxib
I-A steroid onset and duration and admin OA
- Give Q3 months
- Onset 2-3 days
- lasts 4-8 weeks
I-A relative CI
- ctive superficial skin or soft tissue infections
- Suspected joing infection
- Unstable coaguloapthy
- Uncontrolled DM
- Broken skin at injection site
Duloxetine OA dose and osnet
- 60mg QD
- onset: 4 wks
Duloxetine AE
- N/V
- Constipation
Capsaicin counselingn points
- may initially cause more pain befoe helping
- must be used regularly for efficacy
- onset 2 wks
RA dx
- Dx
- Early dx is difficult
- Lab findings:
- ESR/CRP: inflammatory factors
- Rheumatod factor
- ACPAs: peptide antibodies
- ANAs: antinuclear Ab
- Dx scoring system: based on 4 domains
- Joint involvement
- Serology
- Acute phase rectants
- Duration of s/s
RA flare: most common trigger
virus
RA signs
not symptoms
- symmetric swelling of hands, wrists, ankles, feet
- Synovitis
- Erthematous and warm over affected joints
- Rhematod nodules present
- Potential grip weakness, deformity and muscle atrophy
RA symptoms
not signs
- Occur with use AND at rest
- Joint pain and stiffness lasting > 6 weeks
- Prodromal symptoms
- Fatigue
- Fever
- Weakness
- Wt less
- Decreased bood
- Myalgias
- Joint swelling
- Decresed range of motion
- Joint deformity (late in disease
RA extra-articular involvement
RA is a multi-system inflammatroy disease
- Rheumatoid nodules: subq manifestations of macrophages surrounded by lymphocytes and fibroblasts; commonly found in forearms, elbows, and hands
- Pulmonary complications: intersitital lung disease is most common, may sometimes see pleural effusions
- Vasculitis: invasion of arterila walls by inflmamtory cells → narrow vessels
- Ocular manifestations: decreased tear formation → dry itchy eyes
- Cardiac involvement: RA is a risk factor for CAD and incraesed CV mortality
- Hematologic involvement: neutropenia
- Lymphadenoopathy
- Amyloidosis: protein buildup in organs → renal, GI complications
- Osteoporoiss
What are the available guidelies for RA treatment
- merican College of Rheumatology (ACR)
- National Institute for Health and Care Excellence (NICE)
- European League Againt Rheumtism (EULAR)
Goals of treatment: RA
- Improve/maintain functional status: decrease pain, joint mobility, maintain daily activities
- Slow destructive joint chages
- Achieve diesase remission or low activity
RA: non-pharm
- Rest
- Wt loss
- Pain coping
- Physica and occupational therapy
- Assistive devices
- Exercise
- Physiotherapy
- Biofeedback
- Surgery
RA: non-disease modifyig pharm
- NSAIDs: decrease pain and inflammation
- NOT MONOTHERAPY
- CS: decrease pain and inflammation
- NOT MONOTHERAPY
- Low dose for chronic or refractory
- High dose for short course during flares
RA: disease modifying drug types
DMARDs (Disease Modifying AntiRheumatic Drugs)
- csDMARDs: conventional synthetic
- bDMARDs: biolgoics (TNF and non-TNF)
- tsDMARDs: target synthetics (JAKi)
List the csDMARDs
- MTX
- leflunomide
- sulfasalzine
- HCQ
MTX MOA
folate atag with anti-inflammatory properties
MTX admin RA
start 7.5mg PO QW and titrate to 15mg PO QW withun 4-6 weeks
If pt unable to tolerate PO dose:
- split oral dose over 24H
- switch to subq
Take a folic acid 1-5mg QD, or if not taking every day, to at least take the day after MTX to reduce AE
MTX monitorring
CBC, LFTs, SCr
- Q2-4 W during first 3 months
- Q8-12 W during month 3-6
- Q12 W from month 6 onwards
Preggers test before starting
Chest x-ray before starting
MTX AE
BBW
- GI tox
- derm reaction
- pneumonitis
- pulmonary fibrosis
- myelosuprresion
- icnreased LFTs
Stomatis
Dyspepsia
Immunosuppression
Bone marrow suppression
Hepatotox
Nephrotox
MTX CI
BBW
- preggers
- breast feeding
- renal disease
- liver disease
- myelosuppression
Immunodeficiency
Leflunomide MOA
inhibit pyriidine synthesis → decrease lymphocyte proliferation
Leflunomide admin RA
loading dose of 100mg PO QD 3D then 20 mg QD (can decrease to 10mg QD if 20mg no tolerated)
Leflunomide monitoring
CBC, LFTs, SCr
- Q2-4 W during first 3 months
- Q8-12 W during month 3-6
- Q12 W from month 6 onwards
Preggers test before starting
Leflunomide AE
- N/V/D
- Reversible alopecia
- Rash
- Peripheral neuropathy
- HTN
- Hepatotox
Leflunomide CI
BBW
- preggers - if pt wants to become preggers, cholestyramine and verify plasma levels are < 0.02 mg/L by 2 seperate tests at least 14 days apart
- breast feeding
- hepatotoxicity: dc if ALT 3x ULN, take cholestyramine if hepatotox is d/t leflunomide
long half life, may be detectable for up to 2 yrs after cessation
- eliminate: cholestyramine 8mg TID 11D
Leflunomide DDI
- CYP2C8 inhibitor
- Warfarin: decrease INR
- CYP1A2 inducer
- OAT3 inhibitor: many ABX [ ] go up
- BCRP and OATP1B1/1B3 inhibitor:
- if pt on crestor, crestor dose =/< 10mg
- also dose adjust, lipitor, pravastatin, simvatatin
Sulfasalazie MOA
relative to RA
unknown, however, its active meetabolites do have anti-inflammatory properties
Sulfasaline admin RA
- 500-1000mg QD
- if no effect after 12 W can titrate up to 3g
Sulfazalzine monitoring
CBC, LFTs, SCr
- Q2-4 W during first 3 months
- Q8-12 W during month 3-6
- Q12 W from month 6 onwards
Rule out G6PD deficiency before starting
Sulfasalzine AE
N/V
Abdominal pain
HA
Wt loss
Reversible oligospermia (low sperm count)
Rash, pruitis, urticaria
Hemolytic anemia
Sulfasalazine CI
- Interstitital or urinary obstruction
- Porphyria
- Sulfa allergy
HCQ MOA
relative to RA
unknown MOA for RA, but it’s a cytokine production inhibitor
CAN BE USED IN PREGGERS
HCQ admin
- initial: 400-600mg QD
- maintenance: TDD of 200-400mg
RA and SLE
HCQ monitoring
- RA: Eye exam at baseline and Q3 months
- SLE: baseline, in 5 years, then annually
HCQ AE
- N/V/D
- QT prolongation → do NOT exceed MDD
- avoid if already at risk for arrhythmias
- Serious skin reactions
- Irreversible retinal damage; higher risk if
- low TBW
- renal or hepatic impairment
- previous retinal or macular disease
- on med for 5+ years
- flu-like s/s
- allergic skin eruption
- skin and hair pigment changes
- hematologic changes
- myopathies, palsis, CNS
- cardiomyopathy
- hearing loss
When to use bDMARDs
- n combo with MTX if possible
- Moderate/high disease activity desptie DMARD monotherapy
- Unable to tolerate /has CI to csDMARD
bDMARD BBW
- malignancy and serious infecgtion leading to hospitalization or death
- Get TB test before starting
- Latent TB: pt can start RA agent after 1 month of TB tratment
- Active TB: pt can start RA agent after completing TB treatment
- Get TB test before starting
also get a HepB test before starting
Adquate trial for bDMARDs
- TNF inhibitors: 3 months
- non-TNF inhibitors: 6 months
bDMARD TNF inhibiors monitoring
- CBC at bseline ad periodically
- if on infliximab: get LFT at baseine and then again after 4-8 W
List the bDMARD TNF inhibitors
- etanrecept
- infliximab
- adalimumab
- golimumab
- certolizumab
etanerecept admin
- 50mg SQ QW or 25mg SQ 2xW
- +/- MTX
etanerecept AE
- infection
- inj site reaction
- diarrhea
- rash
infliximab admin
- 3mg/kg IV QW for 3 doses then 3-10 mg/kg IV Q4-8W
- WITH MTX only
infliximab AE
- URTI
- inf related rx
- HA
- abdominal pain
Adalimumab admi
- with MTX: 40mg SQ Q2W
- without MTX: 40mg SQ QW
adalimumab AE
- infection (sinusitis, URTI)
- HA
- rash
- inj site reaction
golimumab admin
- SQ: 50mg SQ Q mo.
- IV: 2mg/kg IV Q4W for 2 doses then 2mg/kg Q8W
- WITH MTX only
Golimumab AE
- URTI
- SQ
- nasopharyngitis
- inj site reaction
- IV
- LFT elevation
- HTN
- Rash
- Decreased neuutrophil count
certolizmumab admin
- 400mg SQ Q2W for first 3 doses then 200mg SQ Q2W
- +/- methotrexate
supposedly don’t need to know dose….
certolizumab AE
- URTI
- rash
- UTI
List the bDMARD non-TNF inhibitors
- abatacept
- rituximab
- tocilizumab
- anakinra
- sarilumab
abatacept target
T cells
abatacept admin
- SQ: 125mg SQ QW
- IV: wt based dose Q2W for 3 doses then Q4W
abatcept monitoring
CBC at baseline and periodically
abatacept AE
- HA
- URTI
- Nasopharyngitis
- Nasuea
rituximab target
anti-CD20 Ab
Rituximab admin
- 1g IV Q2W for 2 doses
- repeat prn Q16-24 W
- WITH MTX only
supposedly don’t need to know dose….
rtiuximab monitoring
CBC at baseline adn with each dose
rituximab AE
- URTI
- UTI
- Nasopharyngitis
- Inf related rx: pre medicatie with antihistamines, APAP, and GC
tocilizumab target
IL-6 inhibitor
tocilizumab admin/dose
-
SubQ
- < 100kg: 162mg SQ QOW
- > 100kg: 162g SQ QW
-
IV: 4mg/kg IV Q4W
- can increase to 8mg/kg Q4W
supposedly don’t need to know dose….
tocilizumab monitoring
- ANC: at baseline
- CBC: at baseline, after 4-8 weeks, then Q3mo
- LFTs: at baseline, after 4-8 weeks, then Q3mo
- FLP: at baseline, after 4-8 weeks, then Q6mo
tocilizumab AE
- URTI
- Nasopharyngitis
- HA
- HTN
- Inj site reaction
- Increased ALT
anakira target
- IL-1 inhibitor
- less effective than the other non-TNF inhibitors
anakira admin
100g SQ QD
anakira monioring
CBC at abaseline an Q3mo.
anakira AE
- URTI
- Rash
- Pyrexia
- Flu-like s/s
- Gastroenteritis
sarilumab target
IL6 inhibior
sarilumab admin
200mg SQ Q2W
sarilumab monitoring
- ANC: at baseline
- CBC: at baseline, after 4-8 weeks, then Q3mo
- LFTs: at baseline, after 4-8 weeks, then Q3mo
- FLP: at baseline, after 4-8 weeks, then Q6mo
tsDMARD MOA
inhibit janus kinase enzymes expressed by inflammatory cytokiens
tsDMARD BBW
- Risk of opportunistic infections (TB)
- Get TB test bebfore iitation
- Latent TB: pt can start RA agent after 1 month of TB tratment
- Active TB: pt can start RA agent after completing TB treatment
- Get TB test bebfore iitation
- Malignancy
- Thrombosis (DVT, PE, arterial thrombosis)
List the tsDMARDs
- tofacitinib
- baricitinib
- upadacitinib
tofacitinib admi
- IR: 5mg PO BID
- XR: 11mg PO QD
tofacitinib AE
- Increased HDL, LDL
- HA
- UTI
- URTI
- GI perforation
- Anemia
- Neutropenia
- Skin cancer
- PE
- Infections
baricitinb admin
2mg PO QD
baricitinib AE
- Increased LFTs
- Nausea
- Herpes zoster and other infections
- GI perforation
- Thrombosis
upadacitinib admin
15mg PO QD
upadacitinib AE
- Increased HDL, LDL, TC
- Increased LFTs
- Nausea
- URTI
- Skin cancer
- GI perforation
- Thrombosis
- Anemia
- Neutropenia
- Infections
What vaccines are recommnded to pts with RA
- pneumococcal
- inactive flu
- HepB
- HPV
- live herpes zoster - do NOT give during biologics therapy, give before
Treatment for pts who are DMARD naive and have had RA < 6 months (early symptoamtic RA)
- DMARD monotherapy (HCQ if low disease acctivity, MTX if moderate to severe)
- If pt has moderate or high disese therapy desptie DMARD, can try one of the following: can use short term CS to bridge onto these
- Combo csDMARDs
- bDMARD with methotrexate
- tsDMARD with methotrexte
- If pt has moderate or high disese therapy desptie DMARD, can try one of the following: can use short term CS to bridge onto these
Treatment for pts who are DMARD naive and have had RA > 6 months (established RA)
- DMARD monotherapy (HCQ if low disease acctivity, MTX if moderate to severe)
- If pt has moderate or high disese therapy desptie DMARD, can try one of the following: can use short term CS to bridge onto these
- Combo csDMARDs
- bDMARD with methotrexate
- tsDMARD with methotrexte
- If pt has moderate or high disese therapy desptie DMARD, can try one of the following: can use short term CS to bridge onto these
RA treatment specific considerations: pt has moderate to high disease actiivty that persists and has had prior csDMARD but NOT MTX
Swtich to MTX
RA treatment specific considerations: pt has moderate to high disease actiivty that persists and is currently on PO MTX
switch to SQ MTX or add antoher DMARD
RA treatment specific considerations: pt has moderate to high disease actiivty that persists and does NOT have poor prognostic factors
add an additional csDMARD
subejct to pt preference
RA treatment specific considerations: pt has moderate to high disease actiivty that persists and HAS poor prognostic factors
add tsDMARD or bDMARD
subject to pt preference
What is/are considered poor prognostic factors in RA
- High disease activity
- Early presence of erosion
- autoAb positivity
RA therapy efficacy monitoring and when to consder lowering dose or dc
- Assess efficacy Q3mo
- Can consider tapering to dc after being at target for 6 months - but we would rather you continue
- Would prefer dose reduce over complete dc
- If on triple therapy (HCQ + MTX + sulfasalazine) - get rid of sulfasalazine
- If on MTX + bDMARD or tsDMARD - get rid of MTX
RA comorbiditties to consider
- Preggers: no MTX or LEF
- HF NYHA Class III-IV: use non-TNFi or tsDMARD
- Lymphoproliferative disorder: rituximab preferred
- HepB: caution sue with biologics and JAKi
- Liver disease: avoi MTX and LEF
