RA Flashcards
what are the 2 types of pharmacologic therapy?
symptomatic treatment and chronic disease management
what drugs are included in symptomatic treatment for RA?
- NSAIDs
- steroids (oral and intra-articular) –> lowest effective dose
do NSAIDs slow RA disease progression?
No
*just help with pain
what are chronic treatment options for RA?
- non-biologic DMARDs
- anti-TNF (biologic) DMARDs
- non-TNF (biologic) DMARDs
what are the conventional non-biologic DMARDs?
- methotrexate
- hydroxychloroquine
- leflunomide
- sulfasalazine
what are the target-specific non-biologic DMARDs?
- tofacitinib
- upadacitinib
- baricitinib
what is the MOA & dose of methotrexate?
MOA: folate antimetabolite
Dose: 7.5mg - 25mg PO,IM SQ
what are the ADRs of methotrexate?
Thrombocytopenia, leukopenia
GI: nausea, vomiting, diarrhea,
liver damage, stomatitis, alopecia, renal damage, folic acid deficiency
what is the onset of methotrexate?
3-6 weeks
- steroids might be used as a bridge
what are CI of methotrexate?
- Pregnancy (including male patients)
- alcoholism
- liver disease
- preexisting blood dyscrasias
what labs to get to monitor methotrexate?
CBC with diff, LFTs, sCr, Hep B & C, TB serology
Labs baseline, 2-4 wks for 3 mo, and continue to increase interval
what supplement do patients on methotrexate need?
folic acid
- 1 mg daily
- also folic acid 5 mg Q week
what are the ADRs of Leflunomide?
- Headache
- alopecia
- rash
- diarrhea
- nausea
- increased LFTs
- URTI
what are CIs of leflunomide?
pregnancy
- contraceptives for both males and females
if females become pregnant, what can be used to pull leflunomide out of the body?
cholestyramine
what are the labs for monitoring for leflunomide?
- pregnancy tests prior to initiation
- CBC
- LFTs
- hepatitis
- TB
what are the ADRs of sulfasalazine?
- GI side effects
- Headache
- rash
- nausea
- dyspepsia
- anorexia
what are CI are sulfasalazine?
- Hypersensitivity to sulfa or salicylate preparations, GI or GU obstruction
what are monitoring for sulfasalazine?
- CBC
- LFTs
- renal function
what is the onset of sulfasalazine?
more than 1 month
what is the onset of Hydroxychloroquine?
3-4 weeks
what are the ADRs of Hydroxychloroquine?
- retinopathy
- nausea
- vomiting
- diarrhea
- rash
- pigmentation changes
- increased LFTs
what are the warnings of Hydroxychloroquine?
1.cardiomyopathy
2. bone marrow suppression
what to monitor when taking Hydroxychloroquine?
- CBC
- LFTs
- sCr
- eye exams
Can a patient be on more than one csDMARD?
yes, could be on all 4
what is the onset of Tofacitinib? (Target specific non-biologic DMARDs)
2 weeks
what are the ADRs of Tofacitinib?
- infection
- diarrhea
- nausea
- headache
what are the warnings of Tofacitinib?
- bone marrow suppression
- decreased HR
- GI perforation
- hepatotoxic
what to monitor when taking Tofacitinib?
- CBC
- LFTs
- sCr
- lipids
- hepatitis
- TB
what is the BBW of Tofacitinib? (Oral drug)
- serious infection
- lymphoma and other malignancies
- thrombosis
- increased all cause mortality
- TB
what are the ADRs of Upadacitinib?
- URTI
- neutropenia
- nausea
- thrombosis
- increased lipids
what is the dose of Upadacitinib?
Daily
What to monitor for Upadacitinib?
- CBC
- LFT
- Lipids
What are the BBW of Upadacitinib?
- Serious infection
- Malignancies
- Thrombosis
What are the ADRS of Baricitinib
- URTI
- Nausea
- Thrombosis
- Increased LFTs
- Lipids
What to monitor for Baricitinib
- CBC
- LFTs
- Lipids
What are the BBW of Baricitinib
- Serious infections
- Malignancies
- Thrombosis
can a patient take both Methotrexate and tofacitinib?
Yes
can a patient take both Tofacitinib and baracitinib?
No
can a patient take Methotrexate, leflunomide, sulfasalazine, hydroxychloroquine and tofacitinib?
Yes
what is the MOA of anti-TNF DMARDs?
monoclonal antibody that binds and inhibits tumor necrosis factor alpha (TNFα)
what is the dose of Infliximab
(Remicade)?
3mg/IV
what are the ADRs of Infliximab (Remicade)?
- Headache
- abdominal pain
- anemia
- increased LFTs
- flushing skin rash
- infection
what is the dose of Adalimumab (Humira)?
40mg sub q
what are the ADRs of Adalimumab (Humira)?
- Headache
- rash
- infection
- abdominal pain
- nausea vomiting
- increased CPK
what are the CI/warnings of Inflixima (Remicade)?
less than 5 mg/kg in heart failure
what labs to monitor for Infliximab (Remicade)?
- vitals every 2-10 minutes during infusion
- TB and HBV
- CBC
- LFT
What is the place in therapy for Infliximab (Remicade) (indication)?
combination with methotrexate
what is the CI/warnings of Adalimumab (Humira)?
Precaution in HF patients
what labs to monitor for Adalimumab (Humira)?
1, CBC
2. TB
3. HBV
when is Adalimumab (Humira) indicated?
Combination with monotherapy
what are common warnings of anti-TNF DMARDs?
- Don’t use with HF
- Cardiovascular/cerebrovascular reactions
- Hematologic disorders
- Hepatic reactions
- Hepatitis B reactivation
all anti-TNF DMARDs BBW is?
- *Severe infections
- Lymphomas or other malignancies*
- Tuberculosis
what are the other TNF DMARDs?
- Etanercept (Enbrel)
- Golimumab (Simponi)
- Certolizumab Pegol (Cimzia)
- all subQ, have same side effects
what are the non-TNF DMARDs?
- Rituximab (Rituxan)
- Tocilizumab (Acetemra)
- Abatecept (Orencia)
- Anakinra (Kineret)
- Sarilumab (Kevzara)
when are non-TNF DMARDs used?
when there are other CIs
What are the ADRS for Rituximab (Rituxan), Tocilizumab (Acetemra), Abatecept (Orencia)
R: increased LFT
T: Increased cholesterol and LFT
A: headache, nausea, infections, URTI
What are the ADRS for Anakinra (Kineret), Sarilumab (Kevzara)
A: headache, vomiting, infection, arthralgia, nausea
S: increased LFTs
what are the csDMARDs? (Non-biologic DMARD)
- Methotrexate
- sulfasalazine
- hydroxychloroquine
- leflunomide
What are the tsDMARD (non biologic DMARD)
- Tofacitinib
- Upadacitinib
- Baricitinib
*All JAK inhibitors
What are the BDMARDS? (Anti-TNF)
- Infliximab (remicade )
- Adalimumab (Humira)
*etanercept (enbrel)
*Golimumab
*certolizumab
What are the bDMARDS (non TNF)
- Rituximab
- Tocilizimab
- Abatecept
- Anakinra
- Sarilumab
what are the treatment guidelines for RA?
- methotrexate
- combo of synthetic DMARDs or add biologic
- change to alternative bDMARD or tsDMARD
if there is a CI to methotrexate, what to use?
another csDMARD - sulfasalazine, hydroxychloroquine, leflunomide
all patients with RA (low and high-disease activity) should be started on?
methotrexate (unless CI)
what drugs are recommended to be combined for RA?
csDMARDs are recommended in combination with bDMARDs or tsDMARDs
T/F. biologic DMARDs should not be used in combination with other bDMARDs or tsDMARDs.
T
can 2 bDMARDs be used together?
No
can a JAK inhibitor and bDMARD be used together?
No
