RA and Gout Flashcards
What two NSAIDs are used to relieve symptoms in long-term treatment of RA?
indomethacine and naproxen; don’t halt disease progression!!
How are glucocorticoids useful in the Tx of RA?
initially before a DMARD has taken effect; intro-articularly to help alleviate symptoms
What are the actions of glucocorticoids?
inhibit PLA2 (inhibiting release of arachidonic acid and prostaglandin formation) inhibition of cytokine production (preventing induction of COX-2)
What was the mechanism of gold salts in the Tx of RA? Are these still used?
antipruritic; repress immune responsiveness, especially by inhibiting proper macrophage function
no longer used - produced serious side effects in 30% of patients
The prolonged use of what drugs can cause serious effects such as hyperglycemia, osteoporosis, and poor wound healing?
glucocorticoids
What antimalarial drugs have been used in the treatment of RA and SLE? Which was better tolerated?
chloroquine and hydroxychloroquine;
hydroxychloroquine better tolerated and fewer adverse effects (long term chloroquine can cause irreversible retinal damage)
Sulfasalazine use for treating RA is increasing. It acts more quickly than antimalarials. What is the proposed mechanism? And what side effects cause a third of patients to discontinue use?
possibly inhibits IL-1 and TNF-alpha release;
side effects: N/V, HA, skin rashes, neutropenia
What immunosuppressive drug is the most commonly used DMARD in RA treatment and is still considered the ‘gold standard’?
methotrexate (MTX)
What’s the MOA of MTX as learned in cancer? What is likely it’s principal MOA in the low doses used in RA Tx?
typically, inhibits DHFR (folate analog!)
in low dose - inhibition of AICAR transformylase and thymidylate synthetase with secondary effects on PMN chemotaxis
AMP accumulates, converted to adenosine, a potent inhibitor of inflammation
What side effects of MTX are seen with the low doses used in RA Tx?
nausea, stomatitis
hepatotoxicity can occur and pts should be monitored for it
What’s the new immunosuppressive drug being used in RA? How does it work?
leflunomide; prodrug
inhibits DHODH, required for de novo pyrimidine synthesis
T-cell response to stimuli inhibited
Significant side effects of leflunomide?
diarrhea, hepatotoxicity
Name the five TNF-alpha antagonists (biologics).
etanercept, infliximab, adalimumab, golimumab, certolizumab
Etanercept is the only TNF-alpha antagonist that isn’t a mAb. What is it?
fusion protein of two TNF receptors fused with Fc portion of IgG; binds TNF and prevents it from binding to receptors
What’s the problem with infliximab?
it’s a chimeric Ab, so it’s antigenic and can cause production of anti-mouse Abs
Adalimumab has more convenient dosing than etanercept. What’s the difference?
etanercept - twice weekly subcu injection
adalimumab - twice monthly subcu
Golimumab is only dose once per month which is great! But what are those pesky side effects?
increased risk of serious infections - TB, fungal, other opportunistic
The metabolism and elimination of certolizumab is delayed by conjugating it to what molecule?
polyethylene glycol
What’s the IL-1 antagonist used for RA treatment? What’s the downside to its use?
anakinra; short half-life necessitates daily high dose treatments
Another RA med that can cause serious infections but works by antagonizing IL-6 receptor is..
tocilizumab
What two drugs that can be used in RA refractory to TNF inhibitors act by inhibiting lymphocytes?
abatacept and rituximab
How does abatacept work? Side effects?
inhibits T-cell activation and induces apoptosis;
HA, infections
We know rituximab is anti-CD20 and reduces B-cells. What side effects do you have to watch out for in RA though?
infections; hypersensitivity reactions (decrease with repeat dosing)
What are the two general causes of hyperuricemia?
high rate of production and low rate of excretion
