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MO1 > RA > Flashcards

RA Flashcards

1
Q

what kind of disease is a systemic disease?

A

systemic disease

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2
Q

what does RA increase your risk of?

A
  • Sjörgrens syndrome
  • Vasculitis
  • Increased cardiovascular risk
  • Increased osteoporosis risk
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3
Q

why do we have to take into account physical dexterity?

A

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

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4
Q

what are the painkillers used in RA?

A

NSAIDs and COX-2 inhibitors
steroids can be used to treat flares

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5
Q

what are the most common DMARDs

A
  • Methotrexate
  • Sulfasalazine
  • Leflunomide
  • Hydroxychloroquine
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6
Q

what must you have trialed before starting biologics?

A

at least 2 DMARDs

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7
Q

what are the NICE guidelines surrounding RA?

A

ideally remission
low disease activity
regular review-monthly CRP, DAS-28 until
target reached

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8
Q

what is the initial pharmacological treatment?

A

– Monotherapy now recommended asap
– Oral methotrexate, leflunomide, sulfasalazine
(hydroxychloroquine alternative)
– Consider bridging treatment with oral, IM or IA glucocorticoids when initiating DMARD

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9
Q

what should you do if initial maintenance does not reach target?

A
  • Escalate DMARD monotherapy (increase dose)
  • If target not reached add second DMARD
    (methotrexate, sulfasalazine, leflunomide,
    hydroxychloroquine) or sequential
    monotherapy
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10
Q

what should you do if there is an inadequate response to DMARDs?

A

– Biologics (or JAK inhibitors), usually in
combination with methotrexate

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11
Q

how long do DMARDS take to work?

A

weeks/ months

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12
Q

what is first line DMARD?

A

methotrexate

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13
Q

what monitoring should be done with DMARDs?

A

– Regular blood tests
– Patient counselling
– Recognition and awareness of signs/symptoms of serious
adverse effects

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14
Q

why are vaccinations recommended?

A

Immunosuppressive therapy e.g. leflunomide, methotrexate, biologics more likely to suffer clinically significant infections

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15
Q

what advise should be given around vaccinations?

A

– 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

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16
Q

what should be done if concomitant infection occurs which needs antibiotics?

A

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

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17
Q

what should a patient do if they want to become pregnant

A

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

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18
Q

what should someone who is on leflunomides do if they want to become pregnant?

A

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

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19
Q

how can pregnancy affect a persons RA?

A

may find their condition improves during
pregnancy, experiencing fewer flares or
managing with lower doses of medication

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20
Q

what can happen to a persons RA in lupus?

A

patients can experience more severe disease
which can be dangerous if not properly
treated

21
Q

how often is methotrexate taken?

A

once weekly NB

22
Q

why and when is folic acid given?

A

Should be given to reduce adverse effects (but
not on methotrexate day)

23
Q

how should you clinically check methotrexate?

A

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

24
Q

what could indicate methotrexate toxicity?

A

severe mouth ulcers, jaundice etc. as potential link to medication could be missed

25
Q

what blood tests need to be done with methotrexate?

A

FBC- monthly for first year, then every 2 mt
U&Es- ‘’ ‘’
LFTs-‘’ ‘’
ESR/CRP- ra and GI patinets only

26
Q

what happens if NSAIDs and methotrexate are used together?

A

IDs reduce renal excretion of Methotrexate-increased risk of toxicity

27
Q

when should you stop methotrexate and tell your doctor ?

A

– 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

28
Q

what is given as methotrexate rescue therapy?

A

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

29
Q

how should sulfasalazine be titrated?

A

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)

30
Q

what is common side effects of sulfasalazine?

A

Can turn urine orange colour, soft contact
lenses (+ tears) can be stained (yellow)
nausea, diarrhoea, stomach upset, dizziness, headache, skin rashes

31
Q

what bloods should you do with sulfasalazine?

A

: FBC, LFTs, U&E regular monitoring in first
2 years only

32
Q

what should you report with sulfasalazine?

A

Haematological/liver toxicity: Report
unexplained cough, breathlessness, abnormal
bruising or bleeding, severe sore throat, severe
nausea/dizziness/headache, unexplained acute
widespread rash, oral ulceration.

33
Q

what dose should you give of leflunomide?

A

Licensed dose (adults), initially 100 mg once daily for 3 days, then 10–20 mg once daily

34
Q

when is leflunomide generally used?

A

if liver impairment of hypoproteinaemia persist

35
Q

what should be monitored with leflunomide?

A
  • Blood pressure (Hypertension) & weight monitoring (wt loss) in addition to blood tests
36
Q

what interactions should you be aware of with leflunomide?

A
  • Increased risk toxicity with methotrexate, caution with phenytoin, warfarin, tolbutamide
37
Q

what bloods monitoring is required with leflunomide?

A

FBC- every 2 months
u&es- 2 mths
lfts-3 months
ESR/CRP- ra only
BP- 2 mths
weight- 2 mths

38
Q

how is leflunomide washed out?

A

: 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.

39
Q

how is hydroxychloroquine dosed?

A

200mg OD or BD depending on weight (max. 6.5mg/kg based on IBW)

40
Q

what are the side effects of hydroxychloroquine?

A

: GI disturbances, headache, skin reactions, can
cause ocular disturbances (less common- monitor)

41
Q

when are you cautious about hydroxychloroquine?

A

epilepsy, severe GI disorders, may exacerbate
psoriasis

42
Q

what should you assess before giving hydroxychloroquine?

A

renal/liver function before tx but no specific routine blood monitoring, unlike other DMARDS

43
Q

what are the interactions with hydroxychloroquine?

A

amiodarone, moxifloxacin (increased risk
ventricular arrthymias), digoxin (increased dig. Level), ciclosporin (increased ciclo. levels), some antimalarials

44
Q

what are some examples of biologic medicines?

A
  • TNF Inhibitors
  • Interleukin inhibitors
  • JAK inhibitors (Baracitinib, tofacitinib)
  • Inhibitors of B- or T- lymphocyte activity
  • PDE4 inhibition (Apremilast)
45
Q

what do NICE say about biologics?

A

– 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

46
Q

why do biologics cause increase risk of infection?

A

– 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

47
Q

what advice is there surrounding biologics and surgery?

A

– 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

48
Q

what are the current biosimilars?

A

infliximab (2015),
etanercept (2016), rituximab (2017), adalimumab
(2018), more in development

49
Q

what are JAK inhibitors? give example

A

Oral immunomodulatory drugs
* Tofacitinib, Baricitinib, (Upadacitinib)

MO1 (50 decks)

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