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Musculoskeletal 1 > Pharm - DMARDS > Flashcards

Pharm - DMARDS Flashcards

1
Q

non biologic DMARDS

A
  • methotrexate
  • leflunomide
  • sulfasalazine
  • hydroxychloroquine
  • clyclosporine
  • azathioprine
  • clyclophosphamide
  • mycophenolate mofetil (MMF)
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2
Q

what are the two classes of biologic DMARDs?

A
  • anti-TNF alpha biologics

- non-TNF alpha biologics

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3
Q

anti-TNF alpha biologics

A
  • etanercept (Enbrel)
  • infliximab (remicade)
  • adalimumab (humira)
  • certolizumab (camia)
  • golimumab (simponi)
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4
Q

non-TNF alpha biologics

A
  • abatacept (orencia)
  • rituximab (rituxan)
  • tocilizumab (actemra)
  • BLyS specific inhibitor: belimumab (benlysta)
  • JAK inhibitor: tofacitinib (Xeljanz)
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5
Q

treatment goals of RA

A
  • low dz activity or ideally remission

- aggressive tx in early RA

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6
Q

pretreatment evaluation prior to starting DMARDs

A
  • CBC
  • CMP (serum creatinine and liver fxn tests)
  • ESR and CRP
  • HBV: surface antigen and core antibody
  • HCV
  • if hx of alcohol abuse, chronic hepatitis or sustained elevated LFTs: get baseline liver biopsy
  • latent TB screen
  • HIV status in at-risk pts
  • eye screen for hydroxychloroquine
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7
Q

what two categories of drugs are used for symptomatic tx of RA?

A
  • NSAIDs
  • steroids

**used for rapid relief

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8
Q

what affect do NSAIDs have on disease progression for RA?

A

NONE!

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9
Q

length of tx for NSAIDs and steroids in RA

A
  • use NSAIDs until there is an adequate response to DMARDs
  • if NSAIDs inefficient for control, use steroid bridge
  • DMARDs usually take effect in 4-6 months
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10
Q

indications for use of steroids in the tx of RA

A
  • rapidly reduce sx d/t inflammatory synovitis
  • control sx before DMARDs take effect
  • can also be used to manage acute RA flares as burst therapy
  • should not be used as monotherapy **
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11
Q

place in therapy for methotrexate

A
  • DMARD of choice for initial tx of pts w/ active RA

- approved for use in RA and psoriasis

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12
Q

contraindications for methotrexate

A
  • PREGNANCY: women who are pregnant, contemplating pregnancy, not using adequate contraception, breast feeding, men who’s partners are contemplating pregnant. Avoid it for at least 3 months after drug is stopped
  • hypersensitivity to methotrexate (duh)
  • preexisting blood dyscrasias (bone marrow hypoplasia, leukopenia, thrombocytopenia, significant anemia)
  • lab evidence of immunodeficiency syndromes
  • alcoholism or alcoholic/chronic liver dz
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13
Q

dosing schedule of methotrexate

A

single weekly dose

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14
Q

what supplementation is needed when taking methotrexate

A
  • daily folic acid 1 mg
  • or
  • lecovorin (folinic acid) weekly

*to prevent hematologic ADRs and other side effects

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15
Q

what is the preferred agent for RA if methotrexate can’t be used?

A

leflunomide (arava)

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16
Q

serious ADRs of leflunomide

A
  • serious liver injury
  • severe infections
  • peripheral neuropathy
  • pregnancy category X

*all of these are increased in those who are at high risk

17
Q

what is the serious ADR of leflunomide that is different from methotrexate?

A

peripheral neuropathy

18
Q

monitoring parameters of leflunomide

A
  • CBC (look for bone marrow suppression)
  • aminotransferases
  • creatinine
  • INR if pt is taking Warfarin
19
Q

need for contraception when taking leflunomide

A
  • reliable contraception needed!
  • very teratogenic
  • can stay in system for up to 2 years
20
Q

what biologics are indicated for tx of RA?

A
  • etanercept (enbrel)

- adalimumab (humira)

21
Q

MoA of tocilizumab (actermra)

A

inhibits IL-6 signaling

22
Q

MoA of tofacitinib (xeljanz)

A

Janus kinase (JAK) inhibitor

23
Q

what is the drug of choice for SLE?

A

hydroxychloroquine

24
Q

eye monitoring recommended for pts taking hydroxychloroquine

A
  • complete baseline ophthalmologic exam w/i 1st yr: including retinal exam through dilated pupil and automated visual field testing
  • repeated q 5 yrs
  • if > 60 yo or have retinal dz: need exam every year
25
Q

at what cumulative dose of hydroxychloroquine can retinal toxicity occur?

A

> 6 gm/kg

26
Q

role of NSAIDs in the tx of SLE

A
  • for musculoskeletal complaints
  • don’t suppress dz activity
  • avoid in pts w/ SLE glomerulonephritis
27
Q

role of steroids in the tx of SLE

A
  • low doses used to manage flares not responsive to NSAIDs and antimalarials
  • moderate dose used for moderate to severe flares
  • higher doses for significant organ involvement
28
Q

DMARDs can increase the risk of what two things?

A
  • infection

- cancer

29
Q

what lab marker would indicate the need to dc methotrexate or leflunomide?

A

-WBC <3,000
or
-platelet < 50,000

30
Q

sulfasalazine is contraindicated at what platelet ct?

A

< 50,000

31
Q

what is the LFT indication that would prevent someone from starting or restarting methotrexate, leflunomide or sulfasalazine?

A

if LFTs are > 2 times the upper limits of normal

32
Q

acute hep B or C infection is a contraindication to all DMARDs except which one?

A

hydroxychloroquine

33
Q

contraindications to all DMARDs

A
  • serious bacterial, fungal, or herpes zoster infection
  • febrile URI
  • infected skin ulcer
34
Q

contraindications to TNF alpha blockers

A
  • moderate to severe heart failure (class III or IV and EF < 50%)
  • demyelinating disorders (MS)
35
Q

what is the recommendation for surgery when taking a biologic?

A

with hold biologics one week prior to surgery and one week post op

36
Q

renal insufficiency contraindications

A
  • leflunomide contraindicated in moderate to severe RI

- methotrexate contraindication when CrCl < 30

37
Q

vaccines to administer before starting a DMARD

A
  • hep B
  • influenza (NOT flumist)
  • prevnar 13 and pneumovax
  • HPV
  • herpes zoster (unless already on biologic)
  • NO live vaccines
38
Q

what are the most serious ADRs of TNF and non-TNF alphas?

A
  • infections

- malignancies

Musculoskeletal 1 (14 decks)

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