RA Flashcards
Risk factors of RA
- Viral infection
- Birthweight greater than 10 lbs
- HLA DR4 allele
- Decaf coffee consumption
Factors that decrease risk of RA
- High Vit D intake
- OCPs
- Tea consumption
Systemic inflammation that occurs with RA
- Blood vessels
- Eyes
- Nerves
- Heart
- Skin
Misc effects of RA
- Decreased QOL
- Increased med costs
- Decreased employability
RA vs. OA
- Symmetrical (bilateral)
- Younger pts
Early vs. established RA classifications
Less than 6 months (early)
Over 6 months (established)
Low vs. moderate vs. high rheumatoid activity
Less than 6 joints (low)
6-20 joints (moderate)
Over 20 joints (high)
Poor prognosis factors of RA
- Persistent synovitis
- Early erosive disease
- Rheumatoid nodules
- HLA-DR4 alleles
- Fam hx
- High ESR and CRP
When should DMARDs be given in RA?
Within first 3 months of onset
Types of DMARDs
- Non biologic
- Biologic
When are nonbiologic DMARDs used in RA?
- Early disease w/low activity w/o poor prognosis (monotherapy)
- Early diseae w/HIGH activity w/o poor prognosis
- Established disease, low activity, w/o poor prognosis
MC used nonbiologic DMARD in RA?
MTX
MTX MOA in RA
- 1st line
- Inhibits DNA synth, repair, cellular replication
- May affect immune function
- Unclear how exactly it works in RA
Key features of RA (dosing, onset, ADEs)
- Weekly dosing
- Onset in 3-6 wks
- Avoid ETOH and PPIs
- Can cause stomatitis, nausea, diarrhea, alopecia
- Preg Cat X
What can be taken to decrease the side effects of MTX?
Folic acid
What is Leflunomide (Arava)? MOA?
- Immunomodulatory pro-drug
- Usually 2nd line to MTX
- Inhibits pyrimidine synthesis (anti-proliferative and anti-inflammatory effects)
Leflunomide ADEs
- Diarrhea, alopecia, rash, HA
- Hepatotoxicity, PN, wt gain
- Maintain hydration
- Monitor BP
- Preg Cat X
When is Hydroxycholoroquine (Plaquenil) used in RA and MOA?
- Mild to mod w/o poor prognosis and for women of CBP
- Inhibits locomotion of neutrophils and chemotaxis of eosinophils
- Impairs complement-dependent antigen-antibody reactions
Features of hydroxycholoroquine (Plaquenil)
- Longer onset of action (8-12 wks)
- Eye exam every 3 months
- Rash, diarrhea, abdominal
- Blue/black skin discoloration
- Deafness, tinnitus
Sulfasalazine use in RA
- Can be monotherapy (MTX usually better choice)
- Inhibits PG synthesis
ADEs of sulfasalazine
- HA, nausea, dyspepsia
- Blue skin, sun sensitivity, jaundice
- Preg Cat B
How is minocycline used in RA?
- Unlabeled use
- Antimicrobial, immunomodulatory
- Potent inhibitor of metalloproteinates (which are active in RA joint destruction)
ADEs of minocycline
- Rash, HA, diarrhea
- Anorexia, tooth discoloration
- Avoid in pregnancy
Use of tofacitinib in RA
- 2nd line to MTX
- JAK inhibitor (reduces inflammation)
- Should NOT be combined with a biologic
ADEs of tofacitinb
- TB
- Lowers blood counts
- Increases cholesterol and liver enzymes
- HA, diarrhea, infection, hepatic injury
Types of biologics used in RA
- Anti TNF biologics
- Non TNF biologics
When are biologics used in RA?
High disease activity w/poor prognosis
General warnings of biologics
Serious infections (including TB) Malignancy
What is etanercept and its MOA?
- Self injection biologic for RA
- Binds w/circulating TNF inhibiting it
- No development of neutralizing antibodies
ADEs and other features of etanercept
- Self injected
- Keep refrigerated
- Local reactions, HA, rash, respiratory infections, etc.
- Preg Cat B
If latent TB test is positive, what should be done before starting biologic for RA?
Start treatment for TB prior to starting biologic
What is infliximab and its MOA?
- IV biologic for RA
- Chimeric monoclonal ab (human and mouse proteins)
- Binds w/circulating TNF inhibiting it
Which biologic is better to combine w/MTX to reduce risk of antibody development?
Infliximab
ADEs and other features of infliximab
- IV infusion
- Rash, fever, HA, chills, hepatic impairment
What is infliximab pretreated with?
Corticosteroid and oral antihistamine
What is adalimumab and its MOA?
- Self injected biologic for RA
- Fully human monoclonal ab
- Inhibits TNF (p55 and p75)
ADEs of adalimumab
- Latex allergy
- HA, rash, injection site reaction, URI, back pain
- HTN, hypercholesterol
- Stop at 30 weeks gestation (crosses placenta)
What is abatacept and its MOA?
- Non TNF biologic for RA
- Inhibits activation of T cells
- IV loading dose and then SC maintenance
ADEs of abatacept
- HA, rash, nausea, URI, back pain, HTN, injection site irritation
- Preg Cat C
What is tocilizumab and its MOA?
- Non TNF biologic for RA
- MAB that inhibits IL6 reducing cytokines and inflammation
- IV every 4 weeks
ADEs of tocilizumab
- Increased LFTs
- HA, HTN, injection site irritation, jaundice
- Preg Cat C
What is rituximab and its MOA?
- Non TNF biologic for mod-severe RA
- Chimeric murine/human MAB
- Removes circulating B cells
- IV infusion w/MTX
ADEs of rituximab
Edema, fever, fatigue, HA, insomnia, flu like symptoms, HTN or hypotension
Pretreatment of rituximab
Corticosteroids, APAP, antihistamine
What are the less common biologics for RA?
- Golimumab (greater risk of infection)
- Certolizumab pegol
- Anakinra (requires daily injection and not as efficacious)
How can different agents be combined in RA?
Nonbiologic and nonbiologic
Biologic and nonbiologic
NOT NOT biologic and biologic
Which RA drugs require TB screening?
Biologics
MTX
Leflunomide
How many anti-TNF biologics do we try before moving to a non TNF biologic in RA?
2
