RA Flashcards
what kind of disease is a systemic disease?
systemic disease
what does RA increase your risk of?
- Sjörgrens syndrome
- Vasculitis
- Increased cardiovascular risk
- Increased osteoporosis risk
why do we have to take into account physical dexterity?
additional support for taking medicines may be needed
* Child resistant containers may be difficult
– Patients can opt not to have these
* Supportive cutters, easy to open containers
(e.g. Salazopyrin ®)
* MDT- occupational therapists support patients to maintain independent living
what are the painkillers used in RA?
NSAIDs and COX-2 inhibitors
steroids can be used to treat flares
what are the most common DMARDs
- Methotrexate
- Sulfasalazine
- Leflunomide
- Hydroxychloroquine
what must you have trialed before starting biologics?
at least 2 DMARDs
what are the NICE guidelines surrounding RA?
ideally remission
low disease activity
regular review-monthly CRP, DAS-28 until
target reached
what is the initial pharmacological treatment?
– Monotherapy now recommended asap
– Oral methotrexate, leflunomide, sulfasalazine
(hydroxychloroquine alternative)
– Consider bridging treatment with oral, IM or IA glucocorticoids when initiating DMARD
what should you do if initial maintenance does not reach target?
- Escalate DMARD monotherapy (increase dose)
- If target not reached add second DMARD
(methotrexate, sulfasalazine, leflunomide,
hydroxychloroquine) or sequential
monotherapy
what should you do if there is an inadequate response to DMARDs?
– Biologics (or JAK inhibitors), usually in
combination with methotrexate
how long do DMARDS take to work?
weeks/ months
what is first line DMARD?
methotrexate
what monitoring should be done with DMARDs?
– Regular blood tests
– Patient counselling
– Recognition and awareness of signs/symptoms of serious
adverse effects
why are vaccinations recommended?
Immunosuppressive therapy e.g. leflunomide, methotrexate, biologics more likely to suffer clinically significant infections
what advise should be given around vaccinations?
– Flu, pneumococcal recommended
– Avoid live vaccines (give 2-4 weeks before starting immunosuppressive where possible)
– Avoid contact with chicken pox/shingles/measles. Ensure household contacts immune to measles: offer MMR
– Significant contact with chicken pox: VZ immunoglobulin can be given within 7 days of contact, measles: urgent measles IgG testing
what should be done if concomitant infection occurs which needs antibiotics?
immunosuppressive agents for RA
usually stopped until infection cleared.
– E.g. methotrexate, leflunomide
– Note that long t1/2 of leflunomide may limit benefit of
stopping, in practice tend to withhold
what should a patient do if they want to become pregnant
Risks with all DMARDS- patient should discuss
with specialist well in advance if planning to
have children
* Methotrexate, leflunomide are contraindicated
* Azathioprine, hydroxychloroquine- benefits
often outweigh risks if these drugs are needed
what should someone who is on leflunomides do if they want to become pregnant?
Due to leflunomides long half life patients
must be counselled thoroughly.
* Effective contraception should be used during
treatment and for 2 years after before
becoming pregnant, for men it should be used
for three months after treatment ends.
* If necessary, a washout protocol can be
undertaken to shorten this period
how can pregnancy affect a persons RA?
may find their condition improves during
pregnancy, experiencing fewer flares or
managing with lower doses of medication
what can happen to a persons RA in lupus?
patients can experience more severe disease
which can be dangerous if not properly
treated
how often is methotrexate taken?
once weekly NB
why and when is folic acid given?
Should be given to reduce adverse effects (but
not on methotrexate day)
how should you clinically check methotrexate?
Check and compare to the previous dose
* If the dose is altered, then check with the
patient/purple book. If the dose change is not
expected contact the prescriber
* Check bloods have been done recently in the purple book
* Medication interaction check
what could indicate methotrexate toxicity?
severe mouth ulcers, jaundice etc. as potential link to medication could be missed
what blood tests need to be done with methotrexate?
FBC- monthly for first year, then every 2 mt
U&Es- ‘’ ‘’
LFTs-‘’ ‘’
ESR/CRP- ra and GI patinets only
what happens if NSAIDs and methotrexate are used together?
IDs reduce renal excretion of Methotrexate-increased risk of toxicity
when should you stop methotrexate and tell your doctor ?
– Unexplained shortness of breath and dry cough (can occur gradually or over a few days)
– If whites of eyes become yellow or you develop severe itching
– You have fever, chills or severe sore throat/mouth
– You have severe mouth ulcers, bleeding gums, bruising or skin ulcers
– You experience severe sickness or upset stomach
– If you have never had chickenpox and come into close contact with someone who has chickenpox or shingles
– You think you/your partner have become pregnant whilst on treatment
what is given as methotrexate rescue therapy?
folinic acid (given as calcium folinate) rescue therapy counteracts anti-folate activity of methotrexate, speeds recovery of myelosuppression/ mucositis etc
* Granulocyte-colony stimulating factors (G-CSF) e.g. SC filgrastim may be considered if severe
neutropenia
how should sulfasalazine be titrated?
usually 500mg OD 7/7, 500mg
BD 7/7, 1g OM + 500mg ON 7/7, 1g BD (can go
up to 3g daily if needed)
what is common side effects of sulfasalazine?
Can turn urine orange colour, soft contact
lenses (+ tears) can be stained (yellow)
nausea, diarrhoea, stomach upset, dizziness, headache, skin rashes
what bloods should you do with sulfasalazine?
: FBC, LFTs, U&E regular monitoring in first
2 years only
what should you report with sulfasalazine?
Haematological/liver toxicity: Report
unexplained cough, breathlessness, abnormal
bruising or bleeding, severe sore throat, severe
nausea/dizziness/headache, unexplained acute
widespread rash, oral ulceration.
what dose should you give of leflunomide?
Licensed dose (adults), initially 100 mg once daily for 3 days, then 10–20 mg once daily
when is leflunomide generally used?
if liver impairment of hypoproteinaemia persist
what should be monitored with leflunomide?
- Blood pressure (Hypertension) & weight monitoring (wt loss) in addition to blood tests
what interactions should you be aware of with leflunomide?
- Increased risk toxicity with methotrexate, caution with phenytoin, warfarin, tolbutamide
what bloods monitoring is required with leflunomide?
FBC- every 2 months
u&es- 2 mths
lfts-3 months
ESR/CRP- ra only
BP- 2 mths
weight- 2 mths
how is leflunomide washed out?
: In case of serious event, or before conception.
* Colestyramine 8g TDS for 11 days (or activated charcoal 50g QDS 11 days)
* Can measure concentration of active metabolite (should be <20microg/L on 2 occasions, 2 weeks apart).
* Men and women.
how is hydroxychloroquine dosed?
200mg OD or BD depending on weight (max. 6.5mg/kg based on IBW)
what are the side effects of hydroxychloroquine?
: GI disturbances, headache, skin reactions, can
cause ocular disturbances (less common- monitor)
when are you cautious about hydroxychloroquine?
epilepsy, severe GI disorders, may exacerbate
psoriasis
what should you assess before giving hydroxychloroquine?
renal/liver function before tx but no specific routine blood monitoring, unlike other DMARDS
what are the interactions with hydroxychloroquine?
amiodarone, moxifloxacin (increased risk
ventricular arrthymias), digoxin (increased dig. Level), ciclosporin (increased ciclo. levels), some antimalarials
what are some examples of biologic medicines?
- TNF Inhibitors
- Interleukin inhibitors
- JAK inhibitors (Baracitinib, tofacitinib)
- Inhibitors of B- or T- lymphocyte activity
- PDE4 inhibition (Apremilast)
what do NICE say about biologics?
– Continue only if adequate response at 6m following initiation
* (improvement DAS-28 of 1.2 points or more)
– After initial response monitor at least 6 monthly and withdraw if adequate response not maintained
why do biologics cause increase risk of infection?
– Delay administration/withhold if signs of active infection requiring antibiotics
– May reactivate TB, HIV, Hep B or C infection therefore all patients screened before commencing therapy
– Contraindicated in active TB, severe hepatic failure (clas III/IV)
– Increased risk of lymphoma – this is disputed the more data we see
– Injection site reactions
– Infusion related reactions e.g. analphylactic shock, delayed hypersensitivity reactions, pre-treat with steroids, chlorphenamine
– Headache, flushing, GI disturbance, rash, fever, elevated LFTs
– VTE with JAK inhibitors
what advice is there surrounding biologics and surgery?
– Can delay wound healing following surgery
–Omit for at least one full dosing interval
pre-surgery – ultimate decision up to the
surgen
– Can re-start when good wound healing, all
sutures and staples are out, and no
evidence of infection
what are the current biosimilars?
infliximab (2015),
etanercept (2016), rituximab (2017), adalimumab
(2018), more in development
what are JAK inhibitors? give example
Oral immunomodulatory drugs
* Tofacitinib, Baricitinib, (Upadacitinib)
