RA and SLE Flashcards
The classic symptoms of RA include:
Joint swelling, Stiffness, Pain, Weakness and eventually Bone deformity
What time of day do RA symptoms seem to be the worst in patients:
Morning
Diagnostic criteria for RA include: 1) Morning stiffness of joints lasting >1hr; 2) Arthritis in 3 or more joints; 3) Swelling (arthritis) of hand, foot or wrist joints; 4) Symmetric involvement; 5) Subcutaneous nodules; 6) Positive serum rheumatoid factor (~70% of patients); 7) Radiographic erosions or periarticular osteopenia in hand or wrist joints. How long much symptoms be present for diagnosis?
> =6 weeks. Must have criteria 1-4. Minimum of 4 criteria for diagnosis.
How long after diagnosis of RA should patients be started on DMARDs?
within 3 months of diagnosis.
What class of drugs may be used as bridge therapy for patients with RA?
NSAIDs or steroids.
What class of drugs help to slow down RA and help prevent further joint damage?
DMARDs (Disease-Modifying Antirheumatic Drugs).
Name some short term side effects of Prednisone therapy.
Fluid retention, Stomach upset, Emotional instability, Increased appetitie, Weight gain. (With high doses: increased blood glucose and/or BP)
Name some long-term side effects of Prednisone therapy.
Adrenal suppression/Cushing’s syndrome; Impaired wound healing; HTN; Hyperglycemia, Cataracts; Osteoporosis; Hypokalemia; Grouth suppression in children; Muscle wasting; Dermal thinning; Bruising; Can; Menstrual irregularities; and others
Methotrexate (Rheumatrex), Hydrochloroquine (Plaquenil), Sulfasalazine; Minocycline; Leflunomide (Arava) are all examples of (biologic/non-biologic) DMARDs
Non-biologic. Methotrexate and Hydroxychloroquine are most commonly used.
Most common side effects of Methotrexate include:
N/V/D, GI upset, Anorexia, Reddening of skin, can cause LIVER, LUNGS (dammage) , nausea, darreha and STOMATITIS (MOUTH SORES). Hence dry cough, sob, weakness, yellow skin
What is the dosing interval of Methotrexate for RA?
WEEKLY. Dose may be spread over 12-36 hours. It is NEVER dosed daily for RA.
Methotrexate is a Pregnancy category _
X. Under no circumstances should it be used during pregnancy or suspected pregnancy.
Hydroxychlorquine common side effects inlude:
Decreased visual acuity, Photophobia, Blurred vision, Corneal deposits, N/V, Others: SJS, pruritus, alopecia, ataxia, pigmentation of skin and hair, neuromyopathy with long-term use
Etanercept (Enbrel), Adalimumab (Humira), Infliximab (Remicade), Crtolizumab (Cimzia), Golimumab (Simponi), Rituximab (Rituxan), Anakinra (Kineret) Abatacept (Orencia) and Tocilzumab (Actermra) are all examples of (biologic/non-biologic) DMARDs
Biologic. (Note the mab suffixes of more of these drugs)Most commonly used: Etanercept, Adalimumab, Infliximab, Rituximab
Infliximab (Remicade) and Rituximab (Rituxan) may be given with ___ for the treatment of RA.
Methotrexate
The DMARDs Etanercept (Enbrel), Adalimumab (Humira), Infliximab (Remicade), Certolizumab pegol (Cimzia) and Golimumab (Simponi) are all part of the class __ __ __ __ inhibitors
Tumor necrosis factor alpha inhibitors (TNF-alpha inhibitors)
BBW for most biologic DMARDs includes risk of ____ or ___
Serious infections or malignancies
The most common side effects of biologic DMARDs are:
Infections and injection site reactions
Biologic DMARDs should not be used if the patient has an active ____.
Infection. (ie severe infection or sepsis)
What medication is considered first line for RA?
Methotrexate. Biologic DMARDs may be added on as second-line therapy (most commonly Etanercept (Enbrel) or Adalimumab (Humira))
Can you use more than one biologic DMARD for RA at once?
No. Do not use biologics in combination. TNF inhibitors may cause neurological reactions, demyelinating disease, malignancies, HepB reactivation, TB activation, HF, SLE, or immunosuppression
(True/False) Live vaccines should not be given to patients using biologic DMARDs
True. Avoid live vaccines.
All TNF-alpha blockers requires a test for this infectious disease prior to administration, then annually thereafter:
TB. TNF-alpha blockers may activate latent TB.
Name the 7 drugs commonly associated with Drug induced lupus:
Procainamide, Hydralazine, Isoniazid, Quinidine, Chlorpromazine, Methyldopa, and Minocycline.
The most common symptoms of SLE include:
Fatigue, Fever, Anorexia, Weight loss, Muscle aches, Arthritis, Rash (Butterfly rash), Photosensitivity, Joint pain, Stiffness
(True/False) SLE can cause severe damage to several organs
True. It is important to treat SLE to prevent disease flares.
What two antimalarial agents may be used to treat SLE?
Hydroxychloroquine or Chloroquine. May take up to 6 months to see maximal effects.
What medication may be prescribed at higher doses to help control a current flare or at lower doses as chronic, suppressive therapy for SLE?
Prednisone
What biologic agent may be used for SLE?
Belimumab (Benlysta) - inhibits B cells* know brand name
The cytotoxic agents Cyclophosphamide, Azathioprine or Mycophenolate mofetil (Cellcept) may be used in (mild/moderate/severe) SLE.
Severe.
MESNA therapy and hydration may help with this side effect of Cyclophosphamide:
Hemorrhagic cystitis
Can methotrexate be used while breastfeeding?
No
Methotrexate may cause failure of this organ:
Liver (Toxicity)
Etanercept may cause damage to of this organ:
Liver
Etanercept is injected where and how often?
SC into thigh, abdomen, or upper are. One time or weekly
How should Etanercept (Enbrel) be stored?
Refrigerator. Allow to cool to room temperature before injecting. Do not shake. If particles or discoloration are present then do not use.
Brand name of Etanercept:
Enbrel
Brand name of Adalimumab
Humira
Brand name of Infliximab
Remicade
Brand name of Rituximab
Rituxan
prior to starting enbrel get tested for
TB, WBC and liver enzymes
TB positive and found to be latent now what w/ tnf?
Start tb therapy BEFORE starting on TNFF
leflunamide and pregnancy
wait 2 years after stopping to start this agent. teratogenic.
All TNF blockers BBW
BBW: infection and malignancies
All TNF blockers ADR
ADR: injection site reactions (fever rash etc)
All TNF blockers CI
CI: sepsis
All TNF blockers monitoring
Montior: WBC, HF, LFTs
what are the first line in biologics?
Enbrel and Humira - Self inject and first line w/ biologics
All TNF blockers special injection instructions
Do not shake, refrigiergate and bring to room temp before injecting
All TNF blockers, what disease should they be evaluated for and what is the treatment?
Evauluate for TB- if latent give ISONIAZID!!!! nothing else.
adalimumab humira dosing
EVERY OTHER WEEK!!!
ENBREL- dosing
ENBREL- once a week enbrel is the only weekly one
INFLIXIMAb dosing
INFLIXIMAN also 0,2, 6,8 (every other)
abatacept
Orencia
Rituxan
Anti Cd 20 monoclonal antibody** note NOT TNF but still a biologics
BBW of rituxan:
- progressive multifocal leukoencephlopathy, Tumor lysis, Fata mucocutaneous reactions (SJS, TEN)
monitoring of rituxan
monitoring: cardiac, vital signs, CBC, CD20, REnal
tofacitinib, MPOA, Pregancy category?
Tofacitinib (Xeljanz) is an inhibitor of Janus kinase (JAKs). It is a new ORAL medication that is taken BID. Tofacitinib is pregnancy category C and should not be used with biologic DMARDS or other potent immunosuppressants like cyclosporine or azathioprine.
cytotoxic agents
cyclophosphamide, azathioprine, mycophenalate mofetil all cause hepatotoxicity, malignancy, and bone marrow supression
anakinra
kineret
abacept
orenecia
tocilizumab
actemra
name two NSAIDs commonly used for RA treatment?
Ibuprofen and celecoxib
the celecoxibe dose for RA ?
100-200 po BID whihci s a higer dose than the max dose for OA 200 QD
what are some contraindationts to prednisone?
live vaccines, systemic fungal infections, and varicell (see immunizations chapter)
trexall
methotrexate
rheumatrex
methotrexate
plaquenil
hydroxycholorquin
contraindications for methotrexate?
pregnacy
alcoholoism
chronic liver disease
bloodyscrasias
mechanism of action of methotrexate?
folate antimetabolite that inhibits DNA synthesis ( decreasing the activity of immune system)
hydroxycholorqine dose for RA
400-600mg per day initially then 200-400 mg/day maintenance. Take with food.
which agents can you used for mild RA?
minocycline, sulfasalazine, hydroxycholroquine
dyancin
minocycline
minocycline dose
100mg po bid
enbrel
etanecept
etanercept MOA
TNF inhibitor
adalimumab moa
tnf inhibitor
infliximab MOA
TNF inhibitor
remicade
infliximab
humira
adalimumab
