RA Flashcards

1
Q

PHARMACOLOGIC TREATMENT

(5)

A
  • NSAIDs
  • corticosteroids
  • DMARDs
  • Biologic: anti-TNF
  • Biologic: non-TNF
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2
Q

NSAIDs

  • Effective in reducing pain, swelling, and stiffness
  • Do NOT alter disease ___
  • Dose at anti-inflammatory doses
  • Use in combination with ___
A
  • progression
  • DMARDs
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3
Q

CORTICOSTEROIDS

  • Used for anti-inflammatory & ___ properties
  • Not used as ___
  • Use in combination with DMARD
  • Use in ___ flares
  • Use in patients with extra-articular manifestations
A
  • immunosuppressive
  • monotherapy
  • cute
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4
Q

CORTICOSTEROIDS: DOSING

  • ___ and ___ have steroid sparing effects
    ■ Low dose: < 10mg/day of prednisone
    ■ High dose: > 10mg/day up to 60mg daily
    ■ Short-term: < ___ months of therapy

Intraarticular injections
o Do NOT use > every __ - __ months
o Use 10 – 25 mg/injection of HC per joint

A
  • NSAIDs, DMARDs
  • 3
  • 2-3
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5
Q

CORTICOSTEROID ADVERSE EFFECTS

Short Term
- ___ glycemia
- gastritis
- ___ changes
- elevated ___

Long Term
- ___ necrosis
- cataracts
- ___
- growth failure
- ___

A
  • hyperglycemia
  • mood
  • BP
  • aseptic
  • obesity
  • osteoporosis
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6
Q

DMARDs

Disease Modifying Anti-Rheumatic Drugs
- Potential to decrease/ ___ joint damage & ___ joint integrity
- ___ of initiation is critical
- Onset of action is ___

A
  • prevent, preserve
  • timing
  • delayed
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7
Q

Conventional Synthetic DMARDs

(4)

A
  • Methotrexate (MTX)
  • Sulfasalazine (SSZ)
  • Hydroxychloroquine (HCQ)
  • Leflunomide
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8
Q

METHOTREXATE

  • Most predictable benefit
  • DMARD of ___
  • DMARD with best ___ outcome
  • MOA: inhibit ___ acid reductase (inhibits neutrophil adhesion and chemotaxis)
A
  • choice
  • long-term
  • dihydrofolic
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9
Q

METHOTREXATE

Dosing Regimen
■ 2.5 mg tablets
■ Dose: ___ mg per ___ by mouth or intramuscularly (up to 15-20 mg – weekly dose can be taken in one day)
■ Onset: __ - __ months

Pharmacokinetics
■ 35- 50% bound to ___
■ Hepatic metabolism with some renal excretion

A
  • 7.5, week
  • 1-2
  • albumin
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10
Q

MTX: ADVERSE EFFECTS

Hematologic
- Bone ___ suppression

Gastrointestinal
- N/V/D*
- Stomatitis/mucositis

Hepatic
- Cirrhosis
- Hepatitis
- Fibrosis
* = prescribe 1mg/day of ___ acid to reduce symptoms

Pulmonary
- Pneumonitis
- Fibrosis

Dermatologic
- Rash
- Urticaria
- Alopecia

Teratogenic
– Wait one cycle on BCP
– Wait __ months before considering conception

A
  • marrow
  • folic
  • 3
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11
Q

MTX: CONTRAINDICATIONS

  • pregnancy
  • chronic ___ disease ( ___ abuse)
  • immunodeficienncy
  • Pre-existing blood dyscrasias
  • Pleural/peritoneal effusions
  • Leukopenia/ ___
  • CrCL < ___ ml/min
A
  • liver, EtOH
  • thrombocytopenia
  • 40
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12
Q

MTX: MONITORING

baseline:
- ___
- CBC
- ___
- ___
- albumin

maintenance: CBC, SCr, LFT
- < 3 months: 2-4 weeks
- 3-6 months: 8-12 weeks
- > 6 months: 12 weeks

A
  • CXR
  • SCr
  • LFTs
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13
Q

LEFLUNOMIDE (Arava®)

Prodrug
■ MOA:
– inhibit de novo biosynthesis of ___
– Interferes with ___ kinase activity
– Inhibit cell cycle progression

A
  • pyrimidines
  • tyrosine
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14
Q

LEFLUNOMIDE (Arava®)

Dosage Regimen
■ 10 mg and 20 mg tablets
■ Dose: ___ mg by mouth x 3 days; then 20 mg daily
■ Onset: 1 month
■ Caution: if also taking MTX b/c ___ toxicity

Pharmacokinetics
■ t ½ = 14 – 16 ___
■ ___ clearance

A
  • 100
  • liver
  • daysLEFLUNOMIDE (LEF):
    ADVERSE EFFECTS
  • Hepatobiliary
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15
Q

LEFLUNOMIDE (LEF): ADVERSE EFFECTS

  • Diarrhea
  • Rash
  • Alopecia
  • Increased ___
  • ___
A
  • LFTs
  • Teratogenicity
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16
Q

LEF: MONITORING

___ , ___ , and ___

Baseline

Maintenance
- < 3 months: 2-4 weeks
- 3-6 months: 8-12 weeks
- >6 months: 12 weeks

A

CBC, SCr, LFT

17
Q

SULFASALAZINE

Prodrug: cleaved in colon to ___ and ___
■ MOA: inhibits ___

Dosing Regimen:
– 500 mg tablets
– Dose: 500mg by mouth twice daily
– 1g 2-3 times daily
– Onset: 1-2 months

A
  • sulfpyradine, 5-ASA
  • IL-1
18
Q

SSZ: ADVERSE EFFECTS

Gastrointestinal
- N/V/D, anorexia

Dermatologic
- ___ / Urticaria/ Photosensitivity

Hematologic
- Leukopenia, ___
- Rare: Hemolytic and aplastic anemia

Caution for ___

A
  • Rash
  • thrombocytopenia
  • allergy
19
Q

SSZ: MONITORING

___ , ___ , and ___

Baseline
Maintenance
- < 3 months: 2-4 weeks
- 3-6 months: 8-12 weeks
- >6 months: 12 weeks

A

CBC, SCr, LFT

20
Q

HYDROXYCHLOROQUINE

MOA: modification of ___ infiltration in joint

Dosing Regimen
– 200 mg tablets
– Dose: 200 mg by mouth twice daily
– Onset: 2-4 months (D/C if not efficacious in ___ months)

Pharmacokinetics
– ___ metabolism
– ___ excretion

A
  • cytokine
  • 6
  • hepatic
  • renal
21
Q

HCQ: ADVERSE EFFECTS

Advantage
- No ___, hepatic, renal toxicities

Ocular
- ___ toxicity
- > 70 yo, cumulative dose > 800 g, night/peripheral
changes

Gastrointestinal
– N/V/D (take with ___ )

Dermatologic
– Increase skin ___ , rash, alopecia

monitoring: ___ exam every 6-12 months

A
  • myelosuppression
  • retinal
  • food
  • pigment
  • vision
22
Q

TNF NEUTRALIZERS (5)

A
  • Etanercept
  • Infliximab
  • Adalimumab
  • Golimumab
  • Certolizumab
23
Q

TNF NEUTRALIZERS: WARNINGS/PRECAUTIONS

Risk of ___

Do not use in combination with ___ inhibitors or ___ co-stimulation modulators

Black Box warnings
■ Neurologic / ___ disorders
■ Malignancies
■ Congestive heart failure
■ ___ reactivation
■ No concurrent ___ vaccination administration

A
  • infection
  • IL-1, t-cell
  • demyelinating
  • Hepatitis B
  • live
24
Q

TNF NEUTRALIZERS: ADVERSE EFFECTS

  • ___ and rash
  • Risk of ___ (upper respiratory most common)
  • ___ site reaction
  • Exacerbations of ___
  • Risk of ___
  • Risk of evidence of ___ disease
A
  • HA
  • infection
  • injection
  • CHF
  • malignancy
  • demyelinating
25
# ETANERCEPT (Enbrel®) Mechanism of Action – ___ protein with two soluble TNF receptors fused to the IgG1 molecule – Binds to and inhibits ___ – Binding occurs before the ___ can interact with cell-surface TNF receptors that would produce an inflammatory response Dosage Regimen – 50mg ___ once weekly
- dimeric - TNF - cytokine - SC
26
# INFLIXIMAB (Remicade®) Mechanism of Action - ___ antibody - Immunoglobulin - Mouse & human portions to reduce ___ potential Dosage regimen - 3 mg/kg IV at 0,2,& 6 weeks then every 8 weeks - Can increase dose to 10mg/kg or as often as every 4 weeks - Indicated in combination with ___
- chimaric - antigenic - MTX
27
# ADALIMUMAB (Humira®) Mechanism of Action - Recombinant ___ IgG1 monoclonal antibody specific for human ___ - Binds to ___ and blocks interaction with the p55 and p75 cell surface TNF receptors Indications - Patients who have inadequate response to one or more ___ - Can be used ___ OR in ___ Dosage Regimen ■ 40mg SC every ___ week ■ If not taking ___ can increase to 40mg SC every week for improved response
- human, TNF - TNF-a - DMARDs - alone, combination - other - MTX
28
# GOLIMUMAB (Simponi®) Indications - Moderate to severe RA - Used in combination with ___ Mechanism of Action - ___ monoclonal antibody specific for ___ - Prevents binding of TNF-alpha to receptors Dosage Regimen - 50mg SC once ___ Monitoring Parameters: - CBC with PLT - ____
- MTX - human, TNF-a - monthly - LFTs
29
# CERTOLIZUMAB (Cimzia®) Mechanism of Action - Binds to membrane associate and soluble ___ and neutralizes Indications - RA patients with moderate to severe disease - Can be used ___ or in ___ with non-BRM DMARDs Dosage Regimen - 400mg (2 injections of 200mg) SC at 0,2,4 weeks then 200mg every 2 weeks or 400mg every 4 weeks
- TNF-a - alone, combo
30
# ANAKINRA (Kineret®) Indication: - Moderate to severe RA in patients who have failed one or more ___ - Can use ___ or in ___ Mechanism of Action: - ___ , non- ___ version of the human ___ receptor antagonist - Selectivity blocks IL-1 by binding to the IL-1 receptor
- DMARDs - alone, combo - recombinant, non-glycosylated, IL-1
31
# ANAKINRA (Kineret®) Dosage Regimen ■ 100mg SC daily ■ If CrCl < ___ mL/min, use 100mg SC every ___ day ■ Do not use in ___ with TNF agents or ___ (due to increased risk of ___ ) Adverse Effects ■ ___ site reactions ■ Headache, N/V, flu-like symptoms ■ ___ to e.coli-derived proteins ■ Increased risk of serious ___ ■ Decreased ___
- 30, other - combo, abatacept, infection - injection - hypersensitivity - infectons - neutrophils
32
# ANAKINRA: MONITORING ___ count - Prior to start - Monthly for 3 months - ___ for up to one year
- neutrophil - Quarterly
33
# SELECTIVE T-CELL CO-STIMULATION MODULATOR ___ (Orencia®) Indication: - Moderate to severe RA - If had inadequate response to one or more __ - Monotherapy or in combination with ___ (not with TNF –inhibitors or IL-1 antagonists) Mechanism of Action: - Selective ___ modulator - Inhibits ___ activation
- Abatacept - DMARDs - DMARDs - co-stimulation - T-cell
34
# ABATACEPT: DOSING Available in ___ mg vials - < 60kg: 500mg IV over 30 minutes - 60-100 kg: 750mg IV over 30 minutes - >100 kg: 1g IV over 30 minutes - Dose at 0, 2, and 4 weeks then every ___ weeks thereafter
- 250 mg - 4
35
# ABATACEPT: WARNINGS - Do not use with ___ antagonists or ___ antagonists - Increased risk of ___ - No ___ vaccination administration - Caution in patients with ___
- TNF-a, IL-1 - infection - live - COPD
36
# ABATACEPT: ADVERSE EFFECTS - Headache - Nausea - Upper respiratory ___ - Nasopharingitis - ___ reactions - Serious ___ - ___
- infection - infusion - infection - Malignancy