RA Flashcards
Reumatoid arthritis characterized by what
systemic double join involvement
age of onset RA and gender
30-50 years
more common in females
shortens life span
race considerations in RA
no discrimination
what to consider to see if genetic?
MHC typing to get HLA level
etiology of RA
unknown
RA has synovial space in joints infiltrated with what
inflammatory cells
(macrophage, t cells, plasma cells)
what is pannus
inflamed proliferation synovium
what do the inflammatory cells do once they invade synovial
release cytokines that lead to cellular proliferatiion and death
what does a pannus do?
invades healthy cartilage and bone and produces erosions that destroy joint
clinical presentation of RA
stiffness and muscle ache - joint swelling
- fatigue
- weak
- loss appetite
- fever
clinical criteria for diagnosis of RA
score of 6 or more points
based on type of joint and number of joints involved
most common joints in RA
hands
wrists
feet
common joints in OA
hands
knee
hip
not as common places for joint inflammation in RA
elbows
shoulder
hip
ankle
knee
reumatoid nodules location
hands
elbow
forearm
reumatoid nodules when to treat
only if symptomatic
usually no intervention required
vasculitis symptoms
inflammation of small supervicial blood vessels
stasis ulcers
infarction leading to necrosis
pulmonary symptoms RA
pleural effusion
pulmonary fibrosis
inflam of arteries and lungs (pnemonitis)
ocular symptoms of RA
inflam of eye, nodules on sclera
keratconjunctivitis sicca - Sjorens syndrome
itchy dry eyes
cardiac effects RA
increase risk CV mortality
pericarditis
conduction abnormalities
myocarditis
Feltys sx RA
splenomegaly - inflamed spleen
neutropenia
additonall disease states that could happen from RA
lympadenopathy
renal disease
thrombocytosis
anemia
(could be from drugs taken)
erythrocyte sedimentation rate and C reactive protein used for what
to see if meds working, disease progression
both non-specific to RA
rheumatoid factor used for what
most patients are RF +
specfic antibody for IgM
higher titer = poorer prognosis
Anti-CCP or ACPA used how
high specificity
marker of poor prognosis
antinuclear antibodies (ANA)
suggest autoimmune disease
more suggestive of SLE
what is joint aspiration
take out fluid from joint to measure
turbid
WBC increased
glucose decreased
radiographic images used how
evaluate disease progression
what increases risk of poor prognosis
elevated CRP and ESR
RF high titers
elevated Anti-CCP / ACPA
erosions on Xray
duration of disease
swelling > 20 joints
goals of therapy
relieve symptoms
preserve function
prevent damage
control extra-articular manifestations
non-pharm treatment RA
rest
weight reduction
surgery
PT/OT
splints/prosthetics
support groups
education
adjunct therapies for RA
NSAIDs
corticosteroids
NSAIDs help with what
pain, swelling, stiffness
DO not alter disease progression
NSAIDs and coritcosteroids as monotherapy?
NO, use with DMARDs
NSAIDs dosed at what
anti-inflammatory doses
if sulfa allergy, what NSAID can we not use?
celecoxib
corticosteroids used for what
anti-inflammatory and immunosuppressive
when could we use corticosteroids?
acute flares
extra-articular manifestations
dose goal for steroids
physiological dose to reduce adverse effects
do not use intraarticular injections how freuntly
more than every 2-3 months
short term side effects corticosteroids
hyperglycemia
gastritis
mood changes
increased BP
long term side effects corticosteroids
aseptic necrosis
cataracts
obesity
growth failure
osteoporosis
HPA suppression
baseline monitoring for corticosteroids
BP
BG
maintenance monitoring for corticosteroids
BP
BG
every 3-6 months
what is a DMARD
disease modifying anti-reumatic drug
what can DMARDs do
decrease/prevent joint damage
preserve joint integrity
onset of action DMARDs
6 months, takes awhile
conventional synthetic DMARDs still used
methotrexate
sulfasalazine
hydroxychloroquine
leflunomide
DMARD of choice
methotrexate, best long term outcome
methotrexate dosing and onset
7.5 mg PO or IM weekly
(max 15-20 mg in 1 day)
onset 1-2 months
how is methotrexate metabolized
hepatic w some renal
methotrexate adverse effects
bone marrow supression
N/V/D, stomatitis, mucositis
cirrhosis, hepatitis, fibrosis
teratogenic
rash
how long to wait after methotrexate to consider getting pregnant
3 months
what can be given with methotrexate to decrease symptoms of BMS and stomatitis/mucosisit
folic acid 1 mg / day
contraindications to methotrexate
pregnancy
pleural effusions
chronic liver disease/ alcohol abuse
immunodeficiency
blood dyscrasias
leukopenia
CrCl < 40 ml/min
baseline monitoring for methotrexate
CXR
CBC
SCr
LFTs
Albumin
hep B and C studies
maintenance monitorign for methotrexate
CBC, SCr, LFTs
< 3 month: 2-4 weeks
3-6 month: 8-12 weeks
6 month: 12 weeks
leflunomide is a _____
prodrug
leflunomide dosage form
oral
leflunomide onset
1 month
leflunomide caution
if taken with methotrexate may cause liver tox
halflife of leflunomide and excretion
14-16 days
hepatobilliary
leflunomide adverse effects
diarrhea
rash
alopecia
increased LFTs
teratogen
what can we use if trying to get pregnant and need leflunomide out of the system
cholestrymine
baseline monitoring leflunomide
CBC
SCr
LFTs
maintenance monitoring leflunomide
CBC
SCr
LFTs
< 3 month: 2-4 weeks
3-6 month: 8-12 weeks
6 month: 12 weeks
sulfasalazine is a ____ and inhibits what
prodrug, IL-1 inhibitor
onset of sulfasalazine
1-2 months
sulfasalazine side effects (8)
N/V/D
headache
anorexia
rash
thrombocytopenia
hepatotoxicity
anemia
hypersensitivity to sulfa - photosensitivity
baseline monitoring sulfasalazine
CBC
LFTs
SCr
maintenance monitoring sulfasalazine
CBC
SCr
LFTs
<3 months: 2-4 weeks
3-6 months: 8-12 weeks
6 months: 12 weeks
hydroxychloroquine effectivenss
not as good as methotrexate or leflunomide
hydroxychloroquine onset
2-4 months, d/c if no effect at 6 month
HCQ advantage
no myelosupression, hepatic, or renal toxicities
HCQ adverse effects
retinal toxicity
N/V/D
rash, alopecia
HCQ monitoring
vision exam at baseline and every 6-12 months
biologic DMARD drugs
etanercept
infliximab
adalimumab
golimumab
certolizumab
TNF inhibitors class side effects (7)
infections
risk malignancy
HSTCL
demyelinating disease
CHF exacerbation
hepatotoxicity
Hep B reactivation
no live vaccine admin
headache/rash
etanercept dosage form
SQ
etanercept can be used with what
methotrexate
or monotherapy
monitoring for etanercept, infliximab, adalidumab, certolizumab
TB skin test befoer therapy
no other lab monitoring
infliximab must be used with what
methotrexate, if inadequate response to methotrexate alone
can infliximab be monotherapy
no, use with MTX
indication for adalidumab
monotherapy or combination with MTX or other DMARDs
use after failure of one or more DMARDs
dosing regimen for adalidumab
40 mg SQ every other week or every week if not taking MTX with it
golimumab indication
combo with MTX
mod to severe RA
monitoring for golimumab
CBC w PLT
LFTs
certolizumab indication
mod to severe RA
with or without DMARD
anakinra MOA
IL-1 antagonist
anakinra indication
mod to severe RA
failure on DMARD
mono or + DMARD
anakinra side effects
injection site reactions
headache
N/V/ flu sx
hypersensitivity to e. coli proteins
risk infections
decreased neutrophils
anakinra monitoring
neutrophil count
baseline
monthly x 3 months
quarterly for 1 year
abatacept MOA
selective T cell co-stimulation modulator
abatacept indication
mod to severe RA
mono or + DMARD
must fail a DMARD
abatacept caution in which pts
COPD
abatacept adverse effects
headache
nausea
upper resp infection
nasopharyngitis
infusion rxns
serious infection
malignancy
abatacept monitoring
no hematologic monitoring
IL-6 inhibitors
tocilizumab
sarilumab
tocilizumab and sarilumab indication
mod to severe RA
mono or with DMARD
after failure of DMARD
IL-6 inhibs warning
black box for serious infections
IL-6 inhibs contraindications
liver toxicity
thrombocytopenia
neutropenia
IL-6 inhibitors side effects
serious infection
liver toxicity
thrombocytopenia
neutropenia
lipid abnormalities
intestinal perforations (toc)
infusion reactions (toc)
tocilizumab and sarilumab monitoring
neutrophil count
platelet count
LFTs
lipid profile
at 4-8 weeks then every 3 months
rituximab indication
with methotrexate
mod to severe RA after fail of TNF
rituximab MOA
Anti CD20
rituximab dosage form
IV infusion
tocilizumab dosage form
IV infusion
sarilumab dosage form
SQ
what can be given before retuximab to reduce chance of infusion reaction
methylprednisolone IOV
black box warning retuximab
fatal infusion reaction
tumor lysis syndrome
side effects retuximab
tumor lysis syndrome
mucocutaneous reaction
viral infection
hypersensitivity
renal tox
bowek obstruction
hep B reactiv
cardiac arrythmia
retuximab monitoring
CBC w plt
SCr
vital signs during infusion
targeted synthetic DMARDs
tofacitinib
baricitinib
updacitinib
tofacitinib
baricitinib
updacitinib MOAs
JAK inhibitors
indication for JAK inhibs
mod to severe RA after fail TNF
mono or with MTX / DMARD
JAK inhibs cant be used with what
cyclosporine
azathioprine
biologics
warnings of JAK inhibs
CYP 450
hepatic impairment - do not use
risk infection
risk malignancies
risk CV events
risk thrombosis
no live vaccines
do not use JAK inhibitors if what
Hg < 9
ANC < 1000
ALC < 500
adverse effects JAK inhibs
upper respiratory
headache
nausea
JAK inhibitors monitoring
lymphocyte
neutrophil
hemoglobin
LFTs
lipid profile
what is early RA considered
< 6 months
late > 6 months
jfode
