RA 2 Flashcards

Question

bDMARD/tsDMARD: Tips

Answer 1

● Infection: ○ Hold until 48h after antibiotics complete &/or symptoms resolved ■ Including topical infections - eye/ear/skin/thrush ■ Do not need to hold for minor illness (cold) – consider delay if bad ○ May not respond the same to infection ■ Including fever, congestion (nose, throat), etc ■ Potential infections need to be assessed and antibiotics started promptly ○ Prevention: ■ Ideally vaccinate 4 weeks prior to initiation; AVOID LIVE vaccines ● Peri-operative ○ Hold pre-op and post-op to decrease risk of infection and ensure appropriate healing ■ Timing dependent on the bDMARD and the operation

Answer 2

ABC Special Authorization / NIHB Requirements * In severely active rheumatoid arthritis refractory to: * MTX (3 month trial, ≥20mg dose (≥15mg if >65yo)) * MTX IM or subcut (3 month trial, ≥20mg dose) (if no response; if GI intolerance) * MTX plus another DMARD (eg. HCQ, SSZ) (4 month trial) (+2 other DMARDs) * If MTX contraindicated, a combination of 2 csDMARDs (3mo trial) * leflunomide 20mg/day (10 week trial) (n/a) * if prescribing rituximab, then antiTNF (n/a) * For continued coverage must have a good response * Must be initially prescribed by an authorized prescriber * Only one biologic covered at a time, cannot switch back to a previously tried biologic All bDMARD and tsDMARD companies have a ‘support program’ that help patients manage their therapy & supports acquisition trying methotrexate ensuring that it's been done by injection. So either subcutaneous or IM must be used in combination with another conventional synthetic DMARD. For Alberta Blue Cross and specifically for rheumatoid arthritis. Leflunomide needs to have been trialed. And then if rituximab, a TNF inhibitor for Alberto Blue Cross, for continued coverage, we need to continue to demonstrate that the drug was effective. Disease measures have been reduced so that Das 28 score and that that response is, is continuing and safety is followed as well.

Answer 3

Effectiveness ● Signs/Symptoms ○ pain (VAS) ○ duration of morning stiffness ○ fatigue ○ tender & swollen joints ○ activities of daily living (function) ○ (deformities, instability) ○ (EA manifestations) ● Lab/Diagnostic Imaging ○ CRP (preferred to ESR) ○ (X-rays - not generally done) Safety ● Signs/Symptoms ○ per individual drug (e.g. rash, injection site reaction) ● Lab ○ per individual drug (e.g. CBC/diff, lip

Answer 4

● Steroids can be added to DMARD therapy as part of the initial treatment strategy ○ oral or intramuscular (or intraarticular) ● Steroids and NSAIDs may be used as an option for: ○ Managing flares ○ As bridging therapy while awaiting DMARD onset ○ Symptom control, if no other options exist ● Should be used in the lowest possible dose and tapered as rapidly as possible

Answer 5

● Beneficial for managing symptoms affecting many joints ○ decrease pain, inflammation, and stiffness to improve function ○ do NOT alter disease outcomes ● Common regimens: ○ Prednisone 20mg daily x 2wks, taper by 5mg q2wk (8wks total) ○ Methylprednisolone acetate 40-80mg IM ■ self tapering so may help prevent ‘steroid cycling’ ○ Naproxen 550mg po BID ● Frequently used in practice ○ use lowest effective dose for shortest duration & as infrequently as possible naproxen as maybe the more preferred. And said from a cardiovascular risk point of vie

Answer 6

● Useful in controlling residual synovitis in a (single) joint, tendon, or bursa, with less systemic toxicity ● Dose: ○ Methylprednisolone acetate 10-80 mg IA ○ Triamcinolone acetate 20-80 mg IA ● Efficacy ○ relief onset in few days, lasts weeks to months ● Frequently used in practice ○ most useful when only one or two inflamed joints ○ may help avoid ‘steroid cycling maybe be the thing that puts them into remission or at least as something that's effective for four months. I got here may help avoid steroids cycling. So remember people feel good on steroids and they feel not so good when they come off. not only because they can function with inflammation but because of their mood. So using them through intra-articular injections and or intramuscular injections can help avoid that cycle.

Answer 7

● May be needed on occasion or for patients with residual pain but no synovitis (query OA?) ○ help manage symptoms, but do not affect course of disease or prevent damage to joints ● May include: ○ Analgesics: acetaminophen, opioids, cannabis ○ Anti-inflammatories: NSAIDs (po or topical) ○ NHPs ● Some relief within hours, but may take days or weeks to work fully ○ if it hasn’t worked within a month, it is unlikely to ● Some evidence to support: ○ Omega-3 fatty acids…in a dose of ~3.5g EPA+DHA! ■ anti-inflammatory effect supports DMARD efficacy/regimen longevity ○ Calcium/Vitamin D ■ to modify osteoporosis risk ● Some things to avoid: ○ immune system ‘boosters’ such as ginseng (including ColdFX), echinacea Patient / healthcare professional arthritis specific monographs available at: www.albertarheumatology.com

Answer 8

we wouldn't want to do multiple in-charge peculiar injections. We would see that type of steroid use for someone who has one or two joints that are that are being impacted. Prednisone 20mg daily x 2wks then taper 5mg 12 wks for 8wks total

Answer 9

● Empower patients to take an active role in making therapy decisions ● Patient Assessment and Medication Management ○ efficacy measures: components of DAS-28, lab work ■ “How are you managing at home?” (self-care, household chores) ■ “When you wake up in the morning, are you more stiff than later in the day? How long does it last?” ■ “Considering all of the ways your arthritis has affected you over the past week, how would you rate yourself on a scale of 0 to 10?” ■ “Is there anything you’re not doing because of your arthritis that you’d like to be?” ○ safety measures: s/s, lab work(!!) ● Management of Complications / Co-Morbidities ○ tobacco cessation ○ screening for cardiovascular risk, modifiable RF ■ 2021 Dyslipidemia guidelines – screen regardless of age ○ osteoporosis ■ 2010 Osteoporosis guidelines ● measure BMD once age ≥50 ● prescribe therapy if prednisone ≥7.5mg/day x3mo cumulative dose ○ screening for depression ○ screening for indicated vaccines

Answer 10

nfluenza Ideally HD (if have coverage) Annually Pneumococcus Prevnar-13 (conjugated) * Once Pneumovax (PPV-23) (polysaccharide) * Given 8 weeks later (+booster ³5 years later (@age ³65)) Tetanus Tdap Pertussis once as adult Td Every 10 years Zoster Shingrix Age >50 ±hx of shingles ³1 year prior COVID-19 mRNA vaccine: 3 dose primary Boosters as recommended/available Vaccines for At Risk Groups Hepatitis A / Hepatitis B Twinrix (HAV+HBV) Recombivax, Engerix-B (HBV only) 0, 6-36 months later 0, 1, 6 months HPV Gardasil: 3 dose regimen Age >26 and <45 we do want all of our patients to be annually vaccinated for influenza at any age, to be vaccinated with the pneumococcal vaccine. So both Prevnar and Pneumovax 23, ideally, in that order. Tetanus boosters Shingrix: rheumatoid arthritis, longstanding, uncontrolled, are at higher risk of shingles and shingles recurrences - we vaccinate at age 50 rather than at age 60. - also vaccinate anyone who's starting on a JAK inhibitor regardless of age COVID - 3 dose, 5th dose avail and recommendede hepatitis a and B and HPV - if folks haven't been vaccinated yet in, in schools and are 26-45 years of age, both men and women.

Answer 11

some response is always better than no response. Caution with respect to the biologics and targeted synthetic. So live vaccines contra indicated for sure. Inactivated vaccines considered safe for all groups. ooster like MMR would be more likely to be considered safe, buy more health care providers. Something like yellow fever vaccine, which is likely a novel antigen, would be something that we would want to avoid in people who are on any type of disease modifying therapy. ● Immune response when vaccines are administered: ○ May not be as strong; may not last as long ○ Efficacy most reduced by MTX, prednisone, RTX ○ But still 100% WORTH IT!!!! ● csDMARDs ○ inactivated vaccines considered safe ○ some live vaccines considered safe ■ MMR booster ● bDMARDs and tsDMARDs ○ inactivated vaccines considered safe ○ LIVE vaccines CONTRAINDICATED there is guidance now to hold methotrexate for two weeks after influenza vaccine with the caveat, if disease activity allows