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15. Rheumatoid Arthritis > Patho > Flashcards

Patho Flashcards

1
Q

NSAIDs

- Indication

A
  • DO NOT prevent or slow joint destruction

- Provide some sx relief, not appropriate for monotherapy & should only be used in conjunction w/ DMARDs

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2
Q

Corticosteroids

- Indication

A
  • Potent anti-inflammatory agents that can slow down the progression of joint damage in RA
  • Due to its SEs when use in long term
    => Reserved for brief periods of active disease

Bridge therapy use until DMARDS take effect
- Low dose Prednisone 5-10mg

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3
Q

Rayos

  • Formula
  • Administration
A

Prednisone Delayed-Release

  • F: 1, 2, 5 mg tab
  • Take w/ FOOD = incr absorption
  • The shell breaks open= releases ~ 4H after adm

=> RayOs => O => take w/ FOOD

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4
Q

Ridaura

  • Form
  • Dose
  • SEs
  • Monitor
A

Auranofin = gold salt

  • Form: PO
  • Dose: 3mg BID or 6mg QD PO
  • SEs: Itchy rash, mouth ulcers, diarrhea, flushing, vasodilation

Monitoring

  • CBC Q3M
  • UA Q3M for PO
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5
Q

Myochrysine

  • Indication
  • Route of adm
  • SEs
  • Monitoring
A

Gold sodium thiomalate = gold salt

  • Indication: RA
  • Dose: IM
SEs IM
- Pruritic rash 20%, Stomatitis
- Proteinuria
- BMS/Leucopenia, thrombocytopenia, anemia
- Nitroid rxn, flushing (vasodilation)
- HypoTN => tachycardia
  => gOld => O => hypOtn

Monitoring

  • CBC Q3M
  • UA Q3M for PO
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6
Q

Rheumatrex
Trexall

  • Form
  • Indications
A

Methotrexate

  • Form: PO

Indications:

  • Ectopic pregnancy
  • Psoriasis
  • Chemotherapy
  • RA
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7
Q

Arava

A

Leflunomide

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8
Q

Imuran

A

Azathioprine

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9
Q

Cuprimine

A

D- Penicillamine

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10
Q

Plaquenil

A

Hydroxychloroquine

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11
Q

Azulfidine
Azulfidine EN-tabs
Sulfazine
Sulfazine EC

  • Indication
A

Sulfasalazine

  • UC
  • RA
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12
Q

Xeljanz

A

Tofacitinib

Toe fa SYE tin nib

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13
Q

Kineret

  • Indication
A

Anakinra

  • Indication: RA, Neonatal-onset multisystem inflammatory disease (NOMID)
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14
Q

Enbrel

A

Etanercept

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15
Q

Remicade

A

Infliximab

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16
Q

Humira

A

Adalimumab

A da LIM YOO mab

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17
Q

Simponi

A

Golimumab

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18
Q

Cimzia

A

Certolizumab

Cer to LIZ u mab

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19
Q

Orencia

A

Abatacept

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20
Q

Rituximab

A

Rituxan

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21
Q

Actemra

A

Tocilizumab

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22
Q

Golimumab

  • Form:
A

Simponi-SC

Simponi Aria - IV

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23
Q

Methotrexate

  • MOA
    => what it’s is
    => Work on which phase
  • Indications
A

MOA

  • Antimetabolite chemotherapy (cell cycle specific)
  • S-phase toxin (DNA synthesis phase)
  • Folic acid structural analog
  • Completely inhibits dihydrofolate (DHF) reductase
  • Inhibits de novo pyrimidine synthesis

Indications

  • Cancer Chemo
  • Ectopic pregnancy (terminate pregnancy)
  • Psoriasis
  • RA
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24
Q

Methotrexate

  • Dosing for RA
    => Initial
    => Max
    => Rec take supplement
A

Rheumatrex, Otrexup, Trexall

Dosing
- Initial: 7.5mg PO single dose
- 2.5mg PO Q12H x 3 doses given as a course QW
- Max: 20mg/W
- Supplement: 1mg/d Folate
  => 1mg is Rx. 0.4 and 0.8 mg is OTC
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25
Q

Methotrexate

  • SEs
  • Monitor
A

SEs

  • Oral ulcer & stomatitis
  • GI = N/diarrhea => most common
  • Hepatotoxicity
  • Renal
  • Pulmonary fibrosis (CXR)
  • Hypersensitivity pneumonitis: dry cough, fever, dyspenia. If so, stop MTX, exclude infection and start corticosteroids
  • Myelo-supression/thombo-cytopenia: minimal compare to imuran, cytoxin, sandiummune

Monitor => obtain baseline

  • CBC (WBC & plt Q4W)
  • CXR
  • LFT (Q3-4M)
  • Renal fxn
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26
Q

Methotrexate

  • Absolute CI
  • Relative CI
A

Absolute CI

  • Preg Cat X and lactating W
  • Renal insuffiency SrCr > 1.5
  • Pleural effusion
  • Active stomatitis
  • Diarrhea or any infection
  • Immuno-deficiency

Relative CI

  • Alcohol use or liver disease
  • Age > 70 => as pt age, renal decre
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27
Q

Methotrexate

  • Antidote
A
  • Leucovorin
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28
Q

Leflunomide

  • MOA
  • Dose
  • ADEs
  • Monitor
    => How long?
A

Arava

MOA

  • Inhibits dihydroorotate dehydrogenase
  • Inhibitor of T-cell activation and proliferation

Dose

  • LD: 100 mg PO QD x 3d
  • MD: 10-20mg PO QD

ADEs

  • Nausea
  • Alopecia
  • Increase LFT (CI in imp liver fxn)

Monitor:
- LFT: ALT/ALT QM x 6M.
Then Q8W thereafter (2Months)
- CBC

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29
Q

Leflunomide - Arava
- Wash out period
=> T1/2
=> Antitode

A
  • T1/2 life: 2wks

Wash out period for:

  • Switch to a different DMARD
  • Hepatotoxiciy
  • Wish to have children

Antitode
=> Cholestyramine 8grams TID for 11 days

30
Q

Leflunomide - Arava

C/I

A
  • Impair liver fxn

- Pregnancy Cat X

31
Q

Azathioprine - Imuran

  • MOA
  • Indication
  • Dosing
  • CI
    => Preg Cat
  • DDI
A
  • MOA: Purine analog => antimetabolite converts to 6MP
  • I: RA, renal transplatation
  • D: 100-150 mg PO QD / 1-2.5 mg/kg/d
  • CI: Pregnancy Cat D and lactation
  • DDI: allopurinal (Aloprim, Zyloprim)
32
Q

Azathioprine - Imuran

  • ADEs
    • Cause severe which ADEs?

=> check CBC how often

A

SEs

  • Myelosuppression: thrombocytopenia, anemia, leukopenia
  • Skin rash
  • Hepatotoxicity
  • Flu-like sx, fever
  • GI sx - severe N/V
33
Q

D-Penicillamine - Cuprimine

  • MOA
  • Indication
  • Dose
    => take with what?
  • CI
A
  • MOA: Lowers IgM Rheumatoid factor by unknown MOA

Indication

  • RA: 3rd line DMARD agent)
  • Wilson’s disease (Incr copper): promote excretion of excess copper

Dose

  • Start low, increase slowly
  • Take on EMPTY STOMACH
  • MD:750-1000 mg PO QD

CI: penicillin allergy

34
Q

D-Penicillamine - Cuprimine

  • ADEs
A 
SEs
- GI: Nausea
- Dysgeusia: taste change & metallic taste
- Rash/hypersensitivity, Stomatitis
- Myelosuppression
- Autoimmune disease
    => must d/c if have myasthenia gravis & lupus
- Proteinurea; renal toxicity
35
Q

HydrOxychloroquine - Plaquenil

  • Indication
  • Dose/Administration
A

Indication

  • Early RA
  • Malaria

Dose
- 200-400 mg PO QD with FOOD or milk

36
Q

Sulfasalazine - Azulfidine

  • MOA
  • Indication
  • Dosing for RA
    => Given when?
A
  • MOA: inhibit of folate synthesis

Indication

  • UC: Ulcerative colitis
  • RA (Azulfidine EN only)

Dosing for RA

  • 500 mg EC DR QD-BID after meals
  • Increase to 1g PO BID

Dosing for Colitis
- 500-1000 mg PO QID

37
Q

Sulfasalazine - Azulfidine

  • SEs
  • Monitoring
  • CI
A

ADEs

  • Rash/HA/GI upset
  • Myelosuppression: check CBC
  • Orange-yellow discoloration
  • Fertility impairment

Monitoring
- CBC, LFT, hypersensitivity rxn

CI
- Sulfonamide or salicylate sensitivity

38
Q

Tofacitinib - Xeljanz

  • MOA
  • Indication
    => Do not combine with
  • Dosing route
    => Renal/hepatic imp
  • SEs
    => D/c lymphocyte decr:
    => Check ? B/4 use:
  • DDI
A
  • MOA: Janus kinase inhibitor

Indications
- RA pt decr response to or intolerate to MTX

  • Do not combine w/ ABX or immunosuppressants

Dosing

  • 5mg PO BID
  • Decr to 5mg PO QD in mod/severe renal/hepatic imp or receiving inhibitor 3A4 or 2C9

SEs

  • Infection
  • D/c if lymphocyte count less than 500
  • check TB prior to use

DDI
- 3A4 and 2C9 substrate

39
Q

AnakINra - KineRET

  • MOA
  • Indication
  • Route
  • Storage
  • SEs
    => Do not use in:
  • Monitor

=> RET: Lanh => fridge
=> in = Interleukin

A
  • MOA: interleukin-1 receptor antagonist
  • I: RA, Neonatal-onset multisystem inflammatory disease (NOMID)
  • D: 100 mg SC QD
  • S: refridgerate and protect from light
ADEs
- Infectious: neutropenia
- Pulmonary infections (COPD)
- HA
  => DO NOT use in active infection or w/ TNF blockers etancercept, infiximab, adalimumab, abatacept
- Injection site rash

Monitor
- CBC for neutrophil count

40
Q

Etanercept - Enbrel

  • MOA
  • Indication
  • Route and Frequency
  • ADEs
  • ALLs
A
  • MOA: TNF receptor blocker
    => rapid onset & very effective
    => Good synergic effect w/ MTX

Indications

  • RA => combine w/ MTX of DMARDs
  • Psoristic arthritis
  • Plaque psoriasis

Dosing
- 50 mg SQ QW in thigh, abdomen, upper arm

ADEs
- Potential risk of infection

ALL
- Needle contains latex

41
Q

Etanercept - Enbrel

3 rec SC injection sites

A
  • Front of middle thigh
  • Abdomen
  • Outer area of upper back arms
42
Q 
Infliximab - Remicade
- MOA
- Indication
- Dose
  => route
- Storage
- CI

=> I => given IV

A
  • MOA: Anti-TNF alpha monoclonal antibody

Indications

  • Crohn’s D
  • Ulcerative Colitis
  • Plaque psoriasis
  • Psoriatic arthritis
  • Refractory RA: added to MTX or other agents

Dose for RA

  • Initial 3mg/kg IV at 0 wk, 2 wks, 6 wks
  • MD: 3mg/kg Q8W (6x every year)

S: Refrigerate

CI:

  • TB (check PPD), histoplasmosis, coccidiomycosis
  • Avoid live vaccines
43
Q

Infliximab - Remicade

  • ADEs
A

ADEs

  • *Serious Life threatening infection
  • Fever
  • *May Worsen HF
  • *Increase risk of malignancy
  • HA
  • Dyspnea
  • Nausea
  • Abdominal pain
  • Optic neuropathy
44
Q

Adalimumab - Humira

  • MOA
  • Indication
  • dosing
    => W/ MTX
    => w/o MTX
  • Storage
A
  • MOA: Monoclonal antibody - TNF blocker

Indications

  • RA: alone or w/ MTX
  • Psoriatic arthritis in adults
  • Ankylosing spondylitis (AS) in adults (spine is straight & inflamed)
  • Crohn’s D in adult

Dosing

  • 40 mg SC QOW if on MTX OR
  • 40 mg SC QW if not on MTX

Storage
- Refrigerate and protect from light

45
Q

Adalimumab - Humira

  • ADEs
  • Warning
    => Dont combine w/:
    => May worsen
  • Monitoring
  • Notes
A

SEs

  • Infection: TB, virus, fungi, bacteria
  • BMS: aplastic anemia, thrombocytopenia, leukopenia
  • Cancer
  • HF
  • Lupus like syndrome

Warnings

  • Dont combine w/ Anakinra => serious infection
  • May worsen HF

Monitor
- CBC

Notes
- Avoid live vaccines => true for all TNF blockers

46
Q

Adalimumab - Humira

Rec site to SC

A
  • Front of thighs

- Abdomen (2 inches away from belly button)

47
Q

Golimumab - Simponi SC and Simponi Aria IV

  • Indications
  • MOA
  • BBW
  • Route and Frequency
  • ADEs
A

Indication

  • RA: combine w/ MTX
  • Psoriatic arthritis
  • Ankylosing spondylitis : arthritis of spine

MOA
- Target and neutralizes TNF-alpha

BBW
- BBW risk of TB invasive fungal infection (histo, cocci)

Dose

  • 50 mg SC once a month (self injected)
  • Simponia Aria: 2mg/kg IV over 30 min at weeks 0, 4 and then Q8W

SEs
- URI, sore throat, nasal congestion

48
Q

Certolizumab - Cimzia

  • Indications
  • MOA
  • CI: same as others
  • Route and frequency
  • SEs
A

Indications

  • RA
  • Crohn’s D

MOA
- TNF inhibitor

CI
- Same as other TNF inhibitors

Dose:
- 400 mg SC at wk 0, 4 followed by 200 mg QOW or 400 mg Q4W

SEs

  • Serious infections
  • Malignancies
  • HF
49
Q

Abatacept - Orencia

  • MOA
  • Indications
  • Route
  • SEs
  • avoid

3A => infusion over 30 min

A

MOA
- Inhibits production of tumor necrosis factor, interleukin-2 and interferon-gamma

Indications
- RA: for who don’t response to TNF blockers or DMARDs

Dosing
- 30 min IV infusion

SEs

  • CoPD watch for exacerbation
  • Pulmonary infection
  • Malignancies

=> avoid live vaccine

50
Q

Rituximab - Rituxan

  • MOA
  • Indication
  • Dosing
    => Premedicate
  • Storage
  • CI
A

MOA
- Monoclonal antibody directly against CD20 on B cells

Indications

  • Refractory RA
  • Non-Hodgkins Lymphoma
  • Microscopic polyangiitis (MPA$

Dosings
- RA: 1g IV Q2W x 2 doses
=> Premedicate w/ methylprednisolone 100 mg IV

Storage:
- refrigerate away from light and moisture

CI

  • Live virus vaccines
  • Allergy to murine proteins
51
Q

Rituximab - Rituxan

  • SEs
  • Monitor
A 
SEs
- Severe infusion rxn: infuse w/in 30-120min
  => use methylprednisolone 100 mg IV 30 min prior to infusion
- Tumor lysis syndrome: leading to ARF
- HTN
- Hepatitis B reactivation
- Nephrotoxicity
- URI

Monitoring

  • PPD: before initiating
  • CBC
52
Q 
Tocilizumab - Actemra  => IV Q4W (once a month)
- MOA
- Indication
- Doses
  => Dilute with:
- Warning
  => Dont combine with:
  => Do not start if:
A

MOA

  • Interleukin-6 (IL-6) receptor inhibitor
  • Indication: RA pts w/ inadequate response to 1 or more TNF blockers

Doses

  • Single vials IV => dilute to 100mL 0.9% NaCl
  • 4mg/kg - 8mg/kg Q4W.
  • Max: 800 mg/H IV infusion

Warnings
- Serious infections: don’t combi w/ biological DMARDS
- Anaphylaxis or serious hypersensitivity rxns
- Live vaccines NOT to be given w/ actemra
- Do not start if:
=> ANC Plt ALT/AST > 1.5 x ULN

53
Q

Five TNF blockers are:

A
  • Adalimumab (Humira) 40mg SC QOW
  • Etanercept (Enbrel) 50 mg SQ QW
  • Infliximab (Remicate) IV infusion Q8W
  • Simponi (Golimumab) SC once a month
  • Cimzia (Certolizumab) SQ once or twice a month
54
Q

T cell activator inhibitor

A
  • Abatacept (Orencia): IV infusion once a month
55
Q

CD20 monoclonal antibody

A

Rituxan (Rituximab) TWO 1000 mg IV infusion separate by two weeks

56
Q

When use TNF blockers, always rec

=> Caution
=> CI

A
  • PPD test for TB before start therapy

Caution

  • TNF blocker can worse HF
  • Avoid live vaccines
  • Avoid Interleukin -1 receptor blockers:

CI

  • TB
  • Histoplasmosis
  • Coccidiomycosis
57
Q

For all DMARDS

- Check wat

A

Check CBC for all

58
Q

Monitoring

  • Gold
  • Methotrexate
  • Leflunomide - Arava
  • Azathioprine - Imuran
  • D-Penicillamine - Cuprimine
  • Hydroxychloroquine - Plaquenil
  • Sulfsalazine - Azulfidine
  • Anakinara - Kineret
  • Adalimumab - Humira
  • Rituximab - Rituxan
A

Gold

  • CBC Q3M
  • UA Q3M for PO

Methotrexate

  • CBC: WBC & Plt check Q4W
  • CXR
  • LFT: check Q3-4M
  • Renal fxn

Leflunomide - Arava
- LFTs: QM x 6M. Thereafter Q2M

Azathioprine - Imuran
- CBC & Plt Q1-2W w/ changes of dose & ten Q1-3M thereafter

D-Penicillamine - Cuprimine
- CBC

Hydroxychloroquine - Plaquenil
- Plaque in eye => Eye exam Q6-12M

Sulfsalazine - Azulfidine

  • CBC: Check Q2-4W x 3M then Q3M
  • LFT
  • Hypersensitivity rxn

Anakinara - Kineret
- CBC for neutrophil count

Adalimumab - Humira
- CBC

Rituximab - Rituxan

  • PPD
  • CBC
59
Q

Which medications should worry about latex allergy

A
  • Etanercept - Enbrel

- Needle cover contains latex

60
Q

Need Refrigerate

A
  • Etanercept - Enbrel
  • Infliximab - Remicade
  • Adalimumab - Humira
  • Rituximab - Rituxan
61
Q

Protect from light

A
  • Adalimumab - Humira

- Rituximab - Rituxan => and moisture

62
Q

Cause Lupus like syndrome

A
  • Adalimumab - Humira
63
Q

Worsen HF

A
  • Inflixmab - Remicade
  • Adalimumab - Humira
  • Certolizumab - Cimzia
64
Q

Which has ankylosing spondytitis indication

A
  • Adalimumab - Humira

- Golumumab - Simponi

65
Q

BBW for risk of TB invasive fungal infections

A
  • Golumumab - Simponi
66
Q

Use for Refractory RA

A
  • Infliximab - Remicade
  • Rituximab - Rituxan

=> Abatacept - Orencia => for who don’t respond to TNF blockers or other DMARDs
=> Tocilizumab - Actemra => for pt w/ inadequate response to 1 or more TNF blockers

67
Q

CI in murine proteins allergy

A
  • Rituximab - Rituxan
68
Q

Anaphylaxis Rx

A
  • Tocilizumab - Actemra
69
Q

Rasuvo

  • Indication
  • Form
A

MTX

  • I: RA and severe psoriasis
  • Form: preservative free SQ weekly
70
Q

Otrexup

  • Form
A

MTX

  • Form: auto injection

15. Rheumatoid Arthritis (1 decks)

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