RA Flashcards
Patient with RA now with elevated Cr. Thoughts?
Secondary amyloidosis
Is renal amyloid protein dissolvable with Rx of RA?
It is!!! If we are able to control the inflammation. No one DMARD is above than the other—> GOAL is to normalize CRP.
What are the 6 drug classes for RA
- CsDMARD (4)
- BDMARD- TNF inhibitor
- BDMARD - CTLA-4 inhibitor
- BDMARD - IL-6 inhibitors
- BDMARD - anti-CD20
- TsDMARD- JAK inhibitors
What are the 16 drugs used for RA treatments at this time
- MTX
- Leflunomide
- SSZ
- HCQ
- Adalimumab
- Infliximab
- Certolizumab
- Golimumab
- Etanercept
- Abatacept
- Rituximab
- Tocilizumab
- Sarilumab
- Tofacinib
- Baricitinib
- Ubatacitinib
What is a serious infection for guidelines and trials
Anything that puts the patient in the hospital or requires IV antibiotics
Can you use combination MTX and TNF from the get go based on RA ACR guidelines?
You ABSOLUTELY can if they have poor prognostic factors. It is a conditional recommendation to use MTX monotherapy.
ACR 2021 guidelines: DMARD naive patient with low disease activity, order of drug choice
HCQ>SSZ>MTX>leflunomide
Patient not tolerating oral MTX well, what can you do? Should we just jump to a TNF (follow ACR)
Nope!!
1. Split the dose
2. Increase folic acid
3. Can switch to folinic acid
Patient on MTX developed nodules, next steps? ACR based
Switch to a different drug
A patient has preexisting lung disease, do you use MTX?
Yes if it is mild, stable, or incidentally detected on imaging
Do you really have to stick to MTX if the patient has lung disease?
Absolutely not!! It is a conditional recommendation and not necessarily needs to be done if you or patient are not comfortable
Which degree of heart failure can you not use TNF agents?
NYHA class 3 or 4
Patient with a lymphoproliferative disease, preferred agent?
Rituximab
Hepatitis B core Ab positive, should they receive prophylactic antiviral for rituximab?
Oh YES
Hep B core Ab positive, should they receive prophylactic antiviral for biologics and tsDMARD?
- ACR conditionally recommends monitoring for patients with core Ab positive but surface Ab negative; strongly recommends Rx if both core Ab and surface Ag are positive.
- I think both should get prophylactic antiviral
Someone has NAFLD, what should we do for MTX imitation or continuation?
- If LFT and synthetic function normal, no fibrosis —-> continue MTX
On rituximab and has hupoaggamaglobulinemia but no infections, what to do?
Continue rituximab
Patient has serious infection within 12 months of being considered for RA Rx, what should be the treatment options.
- Conventional DMARDS
- Abatacept
Do NOT use biologics or increased doses of GCs
Patient with non-TB mycobacterial infection in RA, what to do with GCs, csDMARD vs biologics, and role of Abatacept
- GC: either d/c or use at lowest possible dose
- CsDMARD over biological (OBVIOULSY!!)
- Abatacept of high disease activity in csDMARD
What are the 4 criteria included in ACR-EULAR RA criteria
- Joints
- Duration
- Inflammatory markers
- Serologies
What are the 4 joint criteria and how do you score them
- 1 large joint (0)
- 2-10 large joints (1)
- 1-3 small joints (3)
- 10 joints (at least 1 small joint) (5)
What are the 2 criteria for duration of symptoms
<6 weeks - 0
>6 weeks - 1
What are the two inflammatory markers
Normal ESR and CRP - 0
Elevated ESR and CRP - 1
What are the three serological criteria for RA EULAR-ACR
- Negative - 0
- Low titre RF/CCP - 2
- High titre RF/CCP - 3
