Principles of Management of Rheumatic Disease

Question 1

cardiovascular effects of NSAIS

Answer 1

• exacerbation of congestive cardiac failure (cause salt and water retention due to effect on renal function)
• can cause hypertension
• can increase the risk of myocardial infarcts and stroke

Question 2

30 year old female complains of
– Aching joints
– Tiredness
– Can’t do her usual activities
– Blood tests ordered : • RF positive/ANA positive
What would you do now? What would you be looking for on each test?

Answer 2

History: duration of joint symptoms, persistence of joint symptoms (present all day every day?), pattern of joint involvement, systemic symptoms, extra-articular manifesations, functional capability.

Physical Exam: presence of weightloss, fevers, number of swollen/tender joints, nodules, other organ system invovement (ex/ oral/eyes might indicate lupus)

CBC: Hgb, WCC, platelet count

ESR, CRP

RF and Anti-CCP (ACPA) levels for RA

ENA profile for lupus

Joint Xrays

Question 3

which scoring system can be used to evaluate the severity of disease in patients with RA?

Answer 3

DAS28. Disease activity score. takes into consideration the number of tender joints, number of swollen joints, erythrocyte sedimentation rate, and general health status.

Question 4

why is imperative that early treatment is started when someone has RA?

Answer 4

RA patients have joint erosions early. 40% wihtin 6 months, and 70% within 2 years.

-erosions represent permanent structural damage. joint damage may progress at a rapid rate. prevention of damage early in disease is likely to preserve patient function

Question 5

primary reason why mortality is higher in peopel with RA

Answer 5

because there is a higher rate of coronary artery disease in people with RA.

Question 6

outline the disease progression of RA

Answer 6

Pannus is a type of extra growth in your joints that can cause pain, swelling, and damage to your bones, cartilage, and other tissue. It most often results from rheumatoid arthritis, an inflammatory disease that affects your joints, though other inflammatory diseases are also sometimes to blame.

Question 7

lifestyle adjustment for RA

Answer 7

rest, reduced tress, exercise (helps), weight control, quit smoking.

Question 8

outline the pharmacological appraoches to treating OA, early RA, ankylosing spondylitis, and Systemic Lupus E.

Answer 8

certain NSAIDs are not very effective in active RA, but they are prescriped in mild OA and in soft tissue injuries. they are still often prescribed in RA still since it can be an anti-inflammatory via blocking prostaglandin synthesis.

Question 9

NSAIDs are used heavily in individuals with MSK issues. What can be done to reduce the risk of GI complications?

Answer 9

• use gastroprotective drugs, misoprostol and PPI
• safer NSAIDS (cox 2 selective)
• identify risk factors (age, history of GI ulcertaion or GI complication, concomitant dru use like corticosteroidS), h.pylori, combo nsaid use.
• use lowest effective NSAID dose

Question 10

renal side effects of NSAIDS

Answer 10

NSAIDS affect prostaglandin production

• prostaglandins play a key role inrenal perfusion
• in patients wiht reduced renal function, NSAIDS cause further decreased function.
• check creatinine levels routinely.

Question 11

cardiovsacular effects of NSAIDS

Answer 11

NSAIDs can cause an exacerbation of
congestive cardiac failure
– Cause salt and water retention due to effects on
renal function
• NSAIDs can cause hypertension or affect the
control of hypertension
– Need to monitor blood pressure in patients • Can increase the risk of myocardial infarcts
and stroke

Question 12

neurological effects of NSAIDS

Answer 12

• NSAIDs can cause neurological adverse
effects such as
– Dizziness – Confusion – Headaches
• Adverse effects are more frequently seen in
older patients

• Never use long acting NSAIDs in the elderly
patient

Question 14

coagulation effects of NSAIDS

Answer 14

patients taking NSAIDS bruise more easily because it affects platelets–inhibits platelet aggregation and secretion by inhibiting cyclo-oxygenase 1

• avoid NSAIDS in pts with anticoagulants, with PUD, or with esophageal varices.

Question 15

what are DMARDS

Answer 15

Disease Modifying Agents in Rheumatic
Diseases (DMARDs)

• Hydroxychloroquine
• Methotrexate
• Leflunomide
• Sulphasalazine
• Cyclophosphamide
• Azathioprine

• Mycophenolate
A is for azathioprine

Question 16

when to use which DMARD

Answer 16

Question 17

early RA principle management (for disease process)

Answer 17

DMARDS:

methotrexate (MTX) via subQ administration and HCQ

• maybe sulphasalazine
• if mtx not effective you can switch to oral leflunomide

must monitor CBC and LFTs

Question 18

this is a side effect of which drug?

Answer 18

probably methotrexate.
– Common physical adverse effects
• Nausea
• Loss of appetite
• Change in bowel habit
• Hair loss
• Skin rashes, sun hypersensitivity
• Mouth ulcers

Question 19

what lab abnormalities can you see when a patient is on mtx?

Answer 19

elevated liver enzymes

anemia because of folate inhibition

cytopenias (also because of folate)

Question 20

adverse effects of HcQ

Answer 20

Question 21

Answer 21

greyish discoloration of the skin due to HCQ therapy

Question 22

what is the goal of DMARD therapy?

Answer 22

to have a 20% improvement on a DAS28 score in a patient with a rheumatoid conition (RA)

Question 23

in addition to steroids and DMARDS and Nsaids for pain, what other agents are good for manageing RA

Answer 23

biologics – tnf-inhibitors– very effective in RA.

Question 24

two types of TNF-inhibitors

Answer 24

antibody and receptor blocker.

• there are 5– 4 are given by s.c. and 1 by IV infusion

Question 25

what are the short-term and long-term implications of blocking TNF (biologics side effects)

Answer 25

• increased risk of infection
• reactivation of latent TB
• increased risk of lymphoma

Question 26

note: there are other biologics besides tnf-inhibitors:
- Interleukin blockers
- SEBS
- small molecule therapies like Janus kinase inhibotrs to block signialling

Question 27

T/F you can use corticosteroids for long term therapy

Answer 27

false. not advisable for long-term therapy. useful in severe disease and in bridging for DMARD effect– ex/ start steroids during flare up and then taper while starting DMARD therapy.
- it is inappropriate as an ONLY therapy– needs to be used with biologics or DMARDS. It does NOT block disease progression but it helps a lot with symptoms

Question 28

when should intra-articular steroids be used?

Answer 28

• in patients who present with significant inflammation that is not responding to NSAID therapy
• in patients who are unable to tolerate NSAID therapy

Question 29

how often can intra-articular steroids be given?

Answer 29

• not more often than every 3 months and no more than 3 times per year.

-

Question 30

surgical approaches to RA

Answer 30

• debridement of joints
• synovectomy
• tendon repair
• joint replacement

Question 31

alternative therapy that works as an analgesic and gets incorporated into cartilage

Answer 31

Glucosamine Sulphate