RA- csDMARDs DI

Question 1

csDMARDs in RA

Answer 1

MTX, HCQ, SSZ, LEF

Question 2

MTX MoA

Answer 2

Folate antagonist

Question 3

MTX dosing

Answer 3

7.5mg PO QW, titrate to ≥15mg QW within 4-6 weeks

Can split PO dose over 24 hours or switch to SQ formulation if QW PO dose not tolerated

Question 4

MTX onset of effect

Answer 4

1-2 months

Question 5

MTX ADEs

Answer 5

N/V/D
Stomatitis
Dizziness/fatigue/HA
Pneumonitis/pulmonary fibrosis
Myelosuppression
Immunosuppression/increased infection risk
Hepatotoxicity/increased LFTs
Alopecia
Rash

Question 6

MTX CIs

Answer 6

Pregnancy and breastfeeding
Liver or renal disease
Immunodeficiency
Myelosuppression

Question 7

MTX dose adjustments

Answer 7

Dose adjustments are made based on degree of hepatic or renal impairment

Question 8

MTX: reason we use folate supplementation with it

Answer 8

It decreases ADEs, administer the day after MTX is given

Question 9

When to use MTX in RA guidelines

Answer 9

DMARD-naïve patients with moderate-high disease activity; considered first-line monotherapy treatment!

Question 10

What to rule out at baseline prior to MTX therapy

Answer 10

Pregnancy, also need a chest x-ray

Question 11

HCQ MoA

Answer 11

Thought to inhibit cytokine production (unknown)

Question 12

HCQ dosing

Answer 12

Initial: 400-600mg PO QD

Maintenance: 200-400mg PO QD or divided doses

Question 13

HCQ onset of action

Answer 13

2-4 months

Question 14

HCQ ADEs

Answer 14

N/V/D
QTc prolongation
Irreversible retinal damage
Photosensitivity and hyperpigmentation of the skin (blue/black)

Question 15

Avoid HCQ in what?

Answer 15

ocular disease

Question 16

Use HCQ with caution in what?

Answer 16

Liver disease

Question 17

Ocular disease and HCQ

Answer 17

The disease is dose-dependent

Question 18

Can you use HCQ in pregnancy?

Answer 18

Yes!

Question 19

HCQ monitoring

Answer 19

Baseline labs, eye exam at baseline and q3months

Question 20

SSZ MoA

Answer 20

Unknown

Question 21

What is responsible for SSZ’s effects?

Answer 21

The metabolites (5-ASA and sulfapyridine)

Question 22

SSZ dosing

Answer 22

500-1000mg PO QD, but up to 3g has been used

Question 23

SSZ onset of action

Answer 23

1-3 months

Question 24

SSZ ADEs

Answer 24

N/V
Abdominal pain
Anorexia
Reversible oligospermia
Rash, pruritus, urticaria
Blood dyscrasias (agranulocytosis, aplastic anemia, hemolytic anemia, leukopenia, thrombocytopenia)

Question 25

Avoid SSZ in these disease states

Answer 25

Sulfa allergy, intestinal or urinary obstruction, porphyria, renal impairment

Question 26

Use SSZ with caution in this disease state

Answer 26

Hepatic impairment

Question 27

SSZ and pregnancy

Answer 27

Preferred in pregnancy!

Question 28

Can you use SSZ as monotherapy?

Answer 28

Yes! It can be used as monotherapy or in combo with other DMARDs

Question 29

SSZ monitoring: if treatment lasts <3 months

Answer 29

monitor CBC, LFTs, SCr q2-4w

Question 30

SSZ monitoring: if treatment lasts 3-6 months

Answer 30

monitor CBC, LFTs, SCr q8-12w

Question 31

SSZ monitoring: if treatment lasts >6 months

Answer 31

monitor CBC, LFTs, SCr q12w

Question 32

What to rule out at baseline before starting SSZ

Answer 32

G6PD deficiency

Question 33

LEF MoA

Answer 33

Inhibits pyrimidine synthesis, decreases lymphocyte production

Question 34

LEF dosing

Answer 34

Loading: 100mg PO QD x3 days

Maintenance: 10-20mg PO QD

Question 35

LEF onset of action

Answer 35

1-3 months

Question 36

LEF ADEs

Answer 36

N/V/D
Reversible alopecia
Rash
Peripheral neuropathy
HTN

Question 37

Avoid LEF in…

Answer 37

Pregnancy and breastfeeding, liver disease

Question 38

What removes LEF and the active metabolites?

Answer 38

Cholestyramine

Question 39

LEF’s half-life

Answer 39

Super long, can be detectable up to 2 years

Question 40

Can LEF be used as monotherapy?

Answer 40

Yes! It can also be used in combination with other DMARDs