RA Flashcards by Carter Berg

What are the consequences of RA?

Loss of cartilage= permanent
Scar tissue
ligament lossening
tendon contracts

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Who is more at risk of RA?

Women and younger

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What are the symptoms of RA?

symmetrical joint pain
worse in morning
appetite decrease
swelling
nodules

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What 2 things separate OA from RA?

RA is longer morning stiff and symmetrical

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What other body signs of RA not on joints?

effects vessels
fribrosis of lung
eye loss
inflam of heart
bone softening
anemia

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What labs can indicate RA?

R factor and high ER and CRP

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Do we want to take it slow or treat aggressive with RA?

Aggressove

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Non pharm for RA

rest, educate, diet

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What are our go to DMARD

Methotrexate and leflunomide

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How do MXT and leflonumide work?

M=antifolate= less DNA synth
Stop DNA synth of inflammatory

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Onset for DMARD

1-2 months

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What is dosing for MXT?

at least 15 mg -25 mg WEEKLYI

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If renal what is dose of MXT

50%

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Which is better MXT oral or SQ

SQ= more potent and no gi effects
BUT oral has better adherence

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S/E of DMARDs

Fatigue, stomatitis, nausea hair loss, photosensitive

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Most tolerated DMARD

Hydrozychloroquine

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How can we stop s/e of MXT?

folate 1-5 mg
split dosing but take it same day
SQ
PPI

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Serious side effects of hydroxychloroquine

ocular toxicity

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How long can MXT male sterility last for?

up to a year

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Serious s/e of MXT

hepatotx
pulmonary tox

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Can you give MXT in pregnant?

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DI of MXT?

NSAIDs= not really
trimethoprim= BAD
PPI=no
Loop=no

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Which one is more potent MXT or Leflonumide?

Both

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Place of therapy for hydroxychloroquine and sulfasalazine?

Combo

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What are the classes of Biologic DMARDS

TNF inhibitors IL 1/6 inhibitors T cell co stim inhibitors B cell depletors

S/e of biologic DMARDs

Nausea, headache, diarrhea, injection site irritation, hypersensitivity, infection, neutropenia, cancer

What do you give prior to Biologic admin?

acet, anti histamine and steroid

Who is at risk of getting infections from biologic DMARDs and what infections?

>65 or on high dose pneumonia, TB, hepatitis

If infection occurs while on biologic DMARD what happens?

d/c for a bit

What biologic is best if high risk of infection?

adacept

Which cancers do biologic DMARDs give you?

skin and lymphoma

Which biologic does not have antibodies against them?

IL1-6

Which TNF drug is the best?

all good

What is general dosing of TNF?

weekly or every 2 weeks

Which TNF is IV?

infliximab

Which TNF in renal impairment?

NONE

Which TNF in pregnancy?

cetrolizumab

Who cant get TNF?

severe infection or Heart failure

Unique issue with TNF?

seizure risk and cause autoimmune diseases

WHat IL-1or 6 inhibitor is the weakest/most tolerable?

Anakinra

Any contraindications for IL?

No except severe infection in tocilizumab

Which is is more potent TNF or IL?

equal

What adjustment is needed for renal for IL?

NONE

General dosing of IL?

every 2 weeks anakinra= daily!

Unique S/e of IL?

increase lipids, gi perforation

What is the t cell co stimulation inhibitor?

abatacept

Unique s/e of abatacept?

COPD NO LIVER issues BLOOD GLUCOSE

What is the B cell depletor? General dosin?

rituximab 1 g IV 2 weeks apart may need second course

Unique s/e of Rituximab?

Gi perforation, HTN, BG increase, SJS, TEN

I am a patient with severe liver issues. WHat drug for RA?

abatacept

I am a patient with severe heart failure issues. What drug for RA?

NOT TNF

I am a patient with seizures. What drug for RA?

NOT TNF

I am a patient with BG issues. What drug for RA?

NOT ABATACEPT

I am a patient with COPD. What drug for RA?

NOT ABATACEPT

I am a patient with GI perforation risk. What drug for RA?

NOT IL or abatacept

I am a patient with HTN/lipids. What drug for RA?

NOT IL/abatacept

What is absolute last line for RA

C. Janus kinase inhibitors- tofacitinib

What is good about janus kinase inhibitors?

ORAL MEDS

IN regards to tolerability, how do janus kinase inhibitors stack up?

NOT tolerated= CV, Cancer, perforations interactions with 3A4

Which is better CS or NSAIDs?

What are the three ways that CS are used?

short course-10-15 mg Chronic= 5-10 Pulse= high for a few days= NOT GOOD

Issues with CS?

Cataracts, weight, osteoporosis

Issues with CS intraarticular injection?

tendon rupture=rest joint

What is strategy of NSAID use?

High dose, maybe add PPI

What is general therapy for RA?

CS, NSAID, MXT and biologic

If you enter remission can you taper of biologic?

Yes but cannot quit them

What is first line for low risk RA per guidlines?

HCQ

When should you stop MXT if planning to become pregnant? Male and female

3 months before contraception

What are okay options if pregnant?

all biologics except B cell one Certolizumab best HCQ and SSZ okay

During lactation what drugs should you avoid?

MXT and LEF