Pharm - DMARDS Flashcards
non biologic DMARDS
- methotrexate
- leflunomide
- sulfasalazine
- hydroxychloroquine
- clyclosporine
- azathioprine
- clyclophosphamide
- mycophenolate mofetil (MMF)
what are the two classes of biologic DMARDs?
- anti-TNF alpha biologics
- non-TNF alpha biologics
anti-TNF alpha biologics
- etanercept (Enbrel)
- infliximab (remicade)
- adalimumab (humira)
- certolizumab (camia)
- golimumab (simponi)
non-TNF alpha biologics
- abatacept (orencia)
- rituximab (rituxan)
- tocilizumab (actemra)
- BLyS specific inhibitor: belimumab (benlysta)
- JAK inhibitor: tofacitinib (Xeljanz)
treatment goals of RA
- low dz activity or ideally remission
- aggressive tx in early RA
pretreatment evaluation prior to starting DMARDs
- 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
what two categories of drugs are used for symptomatic tx of RA?
- NSAIDs
- steroids
**used for rapid relief
what affect do NSAIDs have on disease progression for RA?
NONE!
length of tx for NSAIDs and steroids in RA
- 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
indications for use of steroids in the tx of RA
- 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 **
place in therapy for methotrexate
- DMARD of choice for initial tx of pts w/ active RA
- approved for use in RA and psoriasis
contraindications for methotrexate
- 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
dosing schedule of methotrexate
single weekly dose
what supplementation is needed when taking methotrexate
- daily folic acid 1 mg
- or
- lecovorin (folinic acid) weekly
*to prevent hematologic ADRs and other side effects
what is the preferred agent for RA if methotrexate can’t be used?
leflunomide (arava)
serious ADRs of leflunomide
- serious liver injury
- severe infections
- peripheral neuropathy
- pregnancy category X
*all of these are increased in those who are at high risk
what is the serious ADR of leflunomide that is different from methotrexate?
peripheral neuropathy
monitoring parameters of leflunomide
- CBC (look for bone marrow suppression)
- aminotransferases
- creatinine
- INR if pt is taking Warfarin
need for contraception when taking leflunomide
- reliable contraception needed!
- very teratogenic
- can stay in system for up to 2 years
what biologics are indicated for tx of RA?
- etanercept (enbrel)
- adalimumab (humira)
MoA of tocilizumab (actermra)
inhibits IL-6 signaling
MoA of tofacitinib (xeljanz)
Janus kinase (JAK) inhibitor
what is the drug of choice for SLE?
hydroxychloroquine
eye monitoring recommended for pts taking hydroxychloroquine
- 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
at what cumulative dose of hydroxychloroquine can retinal toxicity occur?
> 6 gm/kg
role of NSAIDs in the tx of SLE
- for musculoskeletal complaints
- don’t suppress dz activity
- avoid in pts w/ SLE glomerulonephritis
role of steroids in the tx of SLE
- 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
DMARDs can increase the risk of what two things?
- infection
- cancer
what lab marker would indicate the need to dc methotrexate or leflunomide?
-WBC <3,000
or
-platelet < 50,000
sulfasalazine is contraindicated at what platelet ct?
< 50,000
what is the LFT indication that would prevent someone from starting or restarting methotrexate, leflunomide or sulfasalazine?
if LFTs are > 2 times the upper limits of normal
acute hep B or C infection is a contraindication to all DMARDs except which one?
hydroxychloroquine
contraindications to all DMARDs
- serious bacterial, fungal, or herpes zoster infection
- febrile URI
- infected skin ulcer
contraindications to TNF alpha blockers
- moderate to severe heart failure (class III or IV and EF < 50%)
- demyelinating disorders (MS)
what is the recommendation for surgery when taking a biologic?
with hold biologics one week prior to surgery and one week post op
renal insufficiency contraindications
- leflunomide contraindicated in moderate to severe RI
- methotrexate contraindication when CrCl < 30
vaccines to administer before starting a DMARD
- hep B
- influenza (NOT flumist)
- prevnar 13 and pneumovax
- HPV
- herpes zoster (unless already on biologic)
- NO live vaccines
what are the most serious ADRs of TNF and non-TNF alphas?
- infections
- malignancies
