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Clinical 2.0 winter > RA > Flashcards

RA Flashcards

1
Q

what is ra

A

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

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2
Q

some of the things happening in the joint

A

inflamed tendon
bone erosion
lots of inflammatory cells
thinning of cartilage

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3
Q

bref pathophys

A

form antibodies called rheumatoid factors
anticitrullinated protein antibody is produced
complex interaction of intra and extraellular molecules

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4
Q

onset

A

25-50yrs

cevelops rapidly

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5
Q

joints affected

A

hand

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6
Q

are there systemic symptoms present

A

yes

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7
Q

and notable lab changes or radiograph

A

ESR/CRP
RF/antiCCO
joint space narrowing
erosions (OA you see osteophytes)

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8
Q

differences in pain/stiffness between OA and RA

A

OA: worsened by activity, stiffness lasts <1hr in the morning
RA: pain decreased with activity, tenderness is common, stiffness in the morning lasts >1hr

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9
Q

difference in the radiograph between OA and RA

A

OA: there are osteophytes, the bones rubs together because of the thinned cartilage
RA: bone erosion, swollen inflammed synovial membane

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10
Q

risk factors

A 
genetic predisposition 
exposure to unknown environmental factors
age
gender
obesity
smoking
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11
Q

what is early RA

A

symptoms of less than 3 months duration

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12
Q

what is established RA

A

have symptoms due to inflammation or joint dmaage

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13
Q

why is the time of diagnosis crucial

A

joint damage begins within 2 years of symptoms

early diagnosis is within 6months of the onset of joint symptoms

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14
Q

diagnosing criteria - joint involvement

A 
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
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15
Q

diagnosing criteria - serology

A

negative RF and negative anti CCP = 0
low + RF and low + antiCCP = 2
high + RF or high + anti CCP = 3

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16
Q

diagnosing criteria - acute phase reactants

A

normal CRP and normal ESR = 0

abnormal CRP or ESR = 1

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17
Q

diagnosing criteria - duration of symptoms

A

<6week = 0

6 weeks or more = 1

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18
Q

what are the criteria for diagnosing RA

A

must have 6 or more points

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19
Q

symptoms of RA

A 
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
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20
Q

challenges to lab tests

A

normal >30% of the time

RF and anti CCP not detectable in everyone

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21
Q

compare RF + anti CCP to CRP + ESR

A

RF and anti CCP + patients have a worse prognosis

CRP and ESR are not specific to rheumatoid arthritis

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22
Q

other potential diagnostic tests

A

joitn aspiration fluid - increased WBC without infection, crystals
joint radiographs - periarticular osteo, joint space narrowing, erosions

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23
Q

goals of therapy*

A

control symptoms and halt progression
50% improvement in 3 months and clinical remission

alleviate pain, stiffness, fatigue
maintain physical function and work capacity

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24
Q

what does DMARD stand for

A

non biologic diseas emodifying antirheumatic drugs

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25
role of methotrexate
most effective | first line for all levels of disease activity
26
mtx onset
4-6 weeks
27
mtx safety
best side effect to efficacy ratio stomatitis, nausea, diarrhea, alopecia - give folic acid avoid sig alcohol teratogenic
28
when would sq mtx be recommended
GI intolerant | lose benefit over time
29
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
30
leflunomide use
allternative to mtx | equally effective
31
leflunomide safety
diarrhea, alopecia, rash, headache, hepatotoxicity teratogenic long half life
32
hydroxychloroquine us
monotherpay only in mild disease usualy used in combo | least effective onset 2-6months
33
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 ```
34
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
35
mtx dose
titrated to max dose 25mg per week
36
lefluonomide dosing
10-20mg daily
37
hydroxychloroquine dosing
200 bid after 1-2 months may decrease to 200 od
38
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
39
sulfasalazine onset
2-3 months
40
safety of sulfasalazine
dose limiting GI effects - nausea, anorexia, diarrhea so titrate slowly rare hepatitis, leukopenia, agranulocytosis hemolysis in G6PD deficiency
41
sulfasalazine monitoring
CBC, paltelet, alk phos, albumin, scr
42
sulfasalazine CI
sulfa allergy
43
sulfasalazine dosing
500 BID then 1 g BID
44
tofacitinib MOA
JAK inhibitor - decreases signalling by a number of cytokine and growth factor receptors
45
use of tofacitinib
monotherapy or with mtx | role yet to be determined may help in patients with inadequate responses
46
safety of tofacitinib
black box for serious infections not approved for use with biologics or other stronger immunosuppresants abnormalities in liver enzymes and lipids
47
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
48
role of oral glucocorticoids
short term use at initial diagnosis for symptom control or during flares more effective than nsaids
49
dosing or oral glucocorticoids
lowest effect dose <10mg daily
50
safety of glucocorticoids
hyperglycemia and CNS insomnia, GI, impaired wound healing, irritability long term use: osteoporosis, glaucoma, weight gain, fluid retenion, increased infection risk
51
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
52
glucocorticoid monitoring
hyperglycemia - diabetes patients daily, every 3 months in others CNS effects BP and lipids every 3 months
53
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
54
anti-tnf agents
infliximab etanercept adalimumab certolizumab pegol
55
biologics that inhibit t cell activation
abatacept tocilizumab anakinra and canakinumab
56
biologics that deplete b cells
rituximab
57
role of biologics
50% of patients have an inadequate response to dmards so can try these consider after 3-6months of 2 dmards
58
biologics onset
1-4 weeks
59
biologics have improved efficacy when used with
mtx | never use infliximab as monotherapy
60
efficacy of TNF agents
quickest onset largest best symptoms and joint outcomes use with mtx
61
coverage of biologics
part 3 eds
62
when should/can biologics be used in mtx naive patients
high disease activity + lab tests bone erosions large number of affected joints
63
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
64
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
65
discontinuing therapy when on a biologic
1. remove nsaid/GC 2. watch for maintenance of remission 3. try expanding interval bt doses ro reducing the dose and eventually discontinuing
66
non pharms
``` rest exercise PT, OT nutrition and dietary therapy bone protection CV risk reduction -quit smoking, exercise vaccinations ```
67
mtx dosing
max dose of 25mg per week | NOT DAILY
68
how to reduce side effects of mtx
give folic acid 5mg weekly on the day following mtx
69
addressing vaccinations before starting biologics
cant give live vaccines so make sure their vaccinations are up to date before starting
70
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

Clinical 2.0 winter (28 decks)

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