RA Flashcards
what is ra
chornic systemic autoimmune inflammatory disease
symmetric ad erosive polyarthritis
causes pain stiffness and fatigue
if not treated appropriatelu can result in joitn destruction and severe disability
some of the things happening in the joint
inflamed tendon
bone erosion
lots of inflammatory cells
thinning of cartilage
bref pathophys
form antibodies called rheumatoid factors
anticitrullinated protein antibody is produced
complex interaction of intra and extraellular molecules
onset
25-50yrs
cevelops rapidly
joints affected
hand
are there systemic symptoms present
yes
and notable lab changes or radiograph
ESR/CRP
RF/antiCCO
joint space narrowing
erosions (OA you see osteophytes)
differences in pain/stiffness between OA and RA
OA: worsened by activity, stiffness lasts <1hr in the morning
RA: pain decreased with activity, tenderness is common, stiffness in the morning lasts >1hr
difference in the radiograph between OA and RA
OA: there are osteophytes, the bones rubs together because of the thinned cartilage
RA: bone erosion, swollen inflammed synovial membane
risk factors
genetic predisposition exposure to unknown environmental factors age gender obesity smoking
what is early RA
symptoms of less than 3 months duration
what is established RA
have symptoms due to inflammation or joint dmaage
why is the time of diagnosis crucial
joint damage begins within 2 years of symptoms
early diagnosis is within 6months of the onset of joint symptoms
diagnosing criteria - joint involvement
one medium to large joint = 0 2-10 medium to large joints =1 1-3 small joints = 2 four to ten small joints = 3 more than 10 joints (at least one small) = 5
diagnosing criteria - serology
negative RF and negative anti CCP = 0
low + RF and low + antiCCP = 2
high + RF or high + anti CCP = 3
diagnosing criteria - acute phase reactants
normal CRP and normal ESR = 0
abnormal CRP or ESR = 1
diagnosing criteria - duration of symptoms
<6week = 0
6 weeks or more = 1
what are the criteria for diagnosing RA
must have 6 or more points
symptoms of RA
joint pain and stiffness >6weeks stiffness lasts >1hr fatigue, weaknes,, fever muscle pain and afternoon fatigue joint deformity later symmetrical joitn involvement tenderness warmth and swelling over joints nodules
challenges to lab tests
normal >30% of the time
RF and anti CCP not detectable in everyone
compare RF + anti CCP to CRP + ESR
RF and anti CCP + patients have a worse prognosis
CRP and ESR are not specific to rheumatoid arthritis
other potential diagnostic tests
joitn aspiration fluid - increased WBC without infection, crystals
joint radiographs - periarticular osteo, joint space narrowing, erosions
goals of therapy*
control symptoms and halt progression
50% improvement in 3 months and clinical remission
alleviate pain, stiffness, fatigue
maintain physical function and work capacity
what does DMARD stand for
non biologic diseas emodifying antirheumatic drugs
role of methotrexate
most effective
first line for all levels of disease activity
mtx onset
4-6 weeks
mtx safety
best side effect to efficacy ratio
stomatitis, nausea, diarrhea, alopecia - give folic acid
avoid sig alcohol
teratogenic
when would sq mtx be recommended
GI intolerant
lose benefit over time
mtx lab monitoring
CBC, platelets, LFT, albumin, scr, alkaline phosphatse (same as lefluonomide) check every 4 weeks for 3 months then every 8 weeks for 3 months then every 12 weeks
baseling screen for HCV,HBV,HIV in high risk
baseline chest xray in case pulmonary infiltrates develop
leflunomide use
allternative to mtx
equally effective
leflunomide safety
diarrhea, alopecia, rash, headache, hepatotoxicity
teratogenic
long half life
hydroxychloroquine us
monotherpay only in mild disease usualy used in combo
least effective onset 2-6months
safety of hydroxychloroquine
best tolerated rash, craamps, diarrhea, headache blurred vision or difficulty seeing at night reversible upon discontinuation ocular toxicity hemolysis in G6PD deficiency
hydroxychloroquine lab monitoring
baseline CBC, platelets, ALT, alkaline phosphate, albumin, scr
complete ophthalmologic exam baselin and annually for high risk (>60, retinal disease, liver disease), every 5 years for low risk
mtx dose
titrated to max dose 25mg per week
lefluonomide dosing
10-20mg daily
hydroxychloroquine dosing
200 bid after 1-2 months may decrease to 200 od
sulfasalazine use
2nd line is contraindicated to mtx
1st line option when used in combo
less active antiRA drug than mtx so avoid as mono treatment in poor prognosis
sulfasalazine onset
2-3 months
safety of sulfasalazine
dose limiting GI effects - nausea, anorexia, diarrhea so titrate slowly
rare hepatitis, leukopenia, agranulocytosis
hemolysis in G6PD deficiency
sulfasalazine monitoring
CBC, paltelet, alk phos, albumin, scr
sulfasalazine CI
sulfa allergy
sulfasalazine dosing
500 BID then 1 g BID
tofacitinib MOA
JAK inhibitor - decreases signalling by a number of cytokine and growth factor receptors
use of tofacitinib
monotherapy or with mtx
role yet to be determined may help in patients with inadequate responses
safety of tofacitinib
black box for serious infections
not approved for use with biologics or other stronger immunosuppresants
abnormalities in liver enzymes and lipids
monitoring of RA
disease activity every 1-3 months , every 6-12 once goals met
add or change dmards every 3-6months
titrating doses can occur rapidly every 1-3months
radiograph of hands and feet every year or longer
remission or low disease activity
CDAI assessment tool
role of oral glucocorticoids
short term use at initial diagnosis for symptom control or during flares
more effective than nsaids
dosing or oral glucocorticoids
lowest effect dose <10mg daily
safety of glucocorticoids
hyperglycemia and CNS
insomnia, GI, impaired wound healing, irritability
long term use: osteoporosis, glaucoma, weight gain, fluid retenion, increased infection risk
steroid injections
intraarticular steroid can be used when 1 or a few joints are excessively swollen compared to other affected joints - every 3mont no more than 3x a year
IM of long acting depot available for ppl with poor adherance
glucocorticoid monitoring
hyperglycemia - diabetes patients daily, every 3 months in others
CNS effects
BP and lipids every 3 months
3 possible mechanisms of biologics
interfere with cytokine function and growth factors
inhibit the second signal required for t cell activation
deplete B cell s
anti-tnf agents
infliximab
etanercept
adalimumab
certolizumab pegol
biologics that inhibit t cell activation
abatacept
tocilizumab
anakinra and canakinumab
biologics that deplete b cells
rituximab
role of biologics
50% of patients have an inadequate response to dmards so can try these
consider after 3-6months of 2 dmards
biologics onset
1-4 weeks
biologics have improved efficacy when used with
mtx
never use infliximab as monotherapy
efficacy of TNF agents
quickest onset
largest best symptoms and joint outcomes
use with mtx
coverage of biologics
part 3 eds
when should/can biologics be used in mtx naive patients
high disease activity
+ lab tests
bone erosions
large number of affected joints
safety of TNF agents
serious infetions
must be withheld during systemic infection - monitor for
TB screening mandatory
neoplasm??
avoid in recent history of malignancy
worsening new onset HF
patients with demyelinating disorder should not use it
how to discontinue therapy
risk for disease flares upon discontinuation
remission must be stable for several months
1. remove nsaids/BC
2. remove least active drugs
3. want mtx indefinitely
discontinuing therapy when on a biologic
- remove nsaid/GC
- watch for maintenance of remission
- try expanding interval bt doses ro reducing the dose and eventually discontinuing
non pharms
rest exercise PT, OT nutrition and dietary therapy bone protection CV risk reduction -quit smoking, exercise vaccinations
mtx dosing
max dose of 25mg per week
NOT DAILY
how to reduce side effects of mtx
give folic acid 5mg weekly on the day following mtx
addressing vaccinations before starting biologics
cant give live vaccines so make sure their vaccinations are up to date before starting
anti TNF agents SE and CI
SE:injection site reactions, TB, opportunistic infections, malignancy, exacerbate CHF
CI:bacterial or viral infections (stop in illness), latent TB
