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PHA 332 > RA in practice > Flashcards

RA in practice Flashcards

1
Q

what is the pharmacists role in RA?

A

signposting to further support or iitial diagnosis
high risk drugs- ensuring drugs are used safely
support for systemic conditions
general lifestyle advice
support on taking medications
management of analgesia
be aware of assoicated risk factors and support
specalist pharmacist

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2
Q

what kind of disease is RA?

A

RA is a systemic disease

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3
Q

what are some associated conditions with RA?

A 
• Sjörgrens syndrome
- lubricating eye drops/ointments
- Artificial saliva replacement
• Vasculitis
- steroids, cyclophosphamide..
• Increased cardiovascular risk
- assessment e.g. QRISK and appropriate medication initiation
• Increased osteoporosis risk
- assessment e.g. FRAX (+/- DXA) and appropriate medication 
initiation
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4
Q

when may physical decterity come into play in RA? what support can be offered?

A

compromised due
to RA affecting hands, additional support for
taking medicines may be needed
• Child resistant containers may be difficult
– Patients can opt not to have these
• Supportive cutters, easy to open containers
(e.g. Salazopyrin ®)
• MDT- occupational therapists support patients
to maintain independent living

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5
Q

are DMARDs and biologics analgesics?

A

no

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6
Q

what kind of condition is RA? what can be used for symptomatic relief ?

A

As RA is an inflammatory condition, an anti-
inflammatory (NSAID or COX-2 inhibitor) may
be required for symptomatic relief

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7
Q

what are the most common DMARDs?

A
  • Methotrexate
  • Sulfasalazine
  • Leflunomide
  • Hydroxychloroquine
  • Biologics
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8
Q

what is the initial recommended pharmacological treatment for RA?

A

Monotherapy now recommended asap
– Oral methotrexate, leflunomide, sulfasalazine
(hydroxychloroquine alternative)
– Consider bridging treatment with oral, IM or IA
glucocorticoids when initiating DMARD [st

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9
Q

if target is not reached after monotherapy what should be done?

A 
If target not reached add second DMARD 
(methotrexate, sulfasalazine, leflunomide, 
hydroxychloroquine) or sequential 
monotherapy
• Inadequate response to conventional 
DMARDS
– Biologics (or JAK inhibitors), usually in 
combination with methotrexate
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10
Q

how long do DMARDs take to work?

A

weeks/months

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11
Q

what is the usual first line DMARDs unless C/I

A

Methotrexate is considered anchor drug- usual first line

unless c/I

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12
Q

because DMARDs have a signifigant side effect profile what monitoring should be done?

A

Regular blood tests
– Patient counselling
– Recognition and awareness of signs/symptoms of serious
adverse effects

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13
Q

what advice is given to RA patients about vaccinations?

A

– Flu, pneumococcal recommended
– Avoid live vaccines (give 2-4 weeks before starting
immunosuppressive where possible)
– Avoid contact with chicken pox/shingles/measles. Ensure
household contacts immune to measles: offer MMR
– Significant contact with chicken pox: VZ immunoglobulin
can be given within 7 days of contact, measles: urgent
measles IgG testing

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14
Q

who are the people who are on immunocompromised therapy that are more likely to suffer clinical infections?

A

leflunomide, methotrexate,

biologics more likely to suffer clinically significant infections

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15
Q

what happens if someone with RA needs antibiotics for an infection?

A

mmunosuppressive agents for RA

usually stopped until infection cleared.

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16
Q

when should methotrexate be taken?

A

once weekly- on the same day

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17
Q

who should be prescribed methotrexate?

A

nly be prescribed by
HCP who are fully aware of benefits/risks and
have all necessary prescribing competence

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18
Q

why should folic acid be given with methotrexate? what day should it be given on?

A

Should be given to reduce adverse effects (but
not on methotrexate day)
• E.g.
– Once a week on a different day to methotrexate
– Three times a week
– Every day apart from methotrexate day

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19
Q

what clinical checks of methotrexate should be done?

A

Check patients previous dose (PMR, patient)
– If not the same, is dose increase/decrease reasonable?
– Is patient expecting dose change?
– Check purple book- bloods/dose
– Discuss any concerns regarding bloods with prescriber &
document this

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20
Q

what drugs interact with methotrexate?

A

e.g. antifolate effects (phenytoin, trimethoprim), various herbal
preparations, increased monitoring vigilance and caution with
leflunomide.
• Alcohol + Methotrexate can both increase risk of liver damage-
uncertainty about safe levels

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21
Q

why should NSAIDS and methotrexate be avoided?

A

NSAIDs reduce renal excretion of Methotrexate-

increased risk of toxicity

22
Q

when can methotrexate and NSAIDs be used together?

A

Avoid inappropriate clinical use of NSAIDs e.g. post
surgical pain relief, OTC/self-medication
• Benefit may outweigh risk for RA pain control- some
patients find it difficult to manage without therefore
commonly used for THIS indication in practice;
rheumatologist should be aware

23
Q

what methotrexate counselling should be given?

A

• Medication is for…not a painkiller…
• How to take (once weekly, ? X 2.5mg tablets)
• Folic acid on a different day (Note various regimens e.g. once
weekly, three times a week, every day except methotrexate
day)
• How to differentiate between folic acid and methotrexate
(both yellow tablets)
• Purple book (inc. bring to appointments/pharmacist etc)
regular monitoring
• Possible side-effects e.g. feeling sick, upset stomach or
diarrhoea
• Stop and tell your doctor (same day) if…

24
Q

when should you stop and tell your doctor .. with mtx?

A

– Unexplained shortness of breath and dry cough (can occur
gradually or over a few days)
– If whites of eyes become yellow or you develop severe
itching
– You have fever, chills or severe sore throat/mouth
– You have severe mouth ulcers, bleeding gums, bruising or
skin ulcers
– You experience severe sickness or upset stomach
– If you have never had chickenpox and come into close
contact with someone who has chickenpox or shingles
– You think you/your partner have become pregnant whilst
on treatment

25
Q

what is the possible mtx rescue therapy?

A

• Acute toxicity with methotrexate may require folinic
acid (given as calcium folinate) rescue therapy
• Folinic acid counteracts anti-folate activity of
methotrexate, speeds recovery of myelosuppression/
mucositis etc
• Granulocyte-colony stimulating factors (G-CSF) e.g.
SC filgrastim may be considered if severe
neutropenia (specialist)
• Fluid & electrolyte balance, blood products etc

26
Q

how should you take sulfasalazine?

A

take with a glass of water swallow whole

27
Q

what are the side effects of sulfasalzine to be aware of?

A

Can turn urine orange colour, soft contact
lenses (+ tears) can be stained (yellow)
nausea, diarrhoea,
stomach upset, dizziness, headache, skin rashes.

28
Q

what are the common blood tests with sulfaslazine?

A

FBC, LFTs, U&E regular monitoring in first

2 years only

29
Q

what should you be aware of for haematological/liver toxicity?

A

Report
unexplained cough, breathlessness, abnormal
bruising or bleeding, severe sore throat, severe
nausea/dizziness/headache, unexplained acute
widespread rash, oral ulceration.

30
Q

what is the dose for leflunomide?

A 
Licensed dose (adults), initially 100 mg once daily for 3 days, then 
10–20 mg once daily
31
Q

why do most patients not get a loading dose of leflunomide?

A

poorly tolerated

32
Q

when is leflunomide c/i?

A

Not used if liver impairment or hypoproteinaemia present

33
Q

what needs to be monitored with leflunomide?

A 
Blood pressure (Hypertension) & weight monitoring (wt loss)  in 
addition to blood tests
34
Q

what interactions are present with leflunomide?

A

Increased risk toxicity with methotrexate, caution with

phenytoin, warfarin, tolbutamide.

35
Q

what are the counselling points for leflunomide?

A

Leflunomide is used to treat…it works to dampen down the disease process and
reduce the inflammation that can lead to pain, swelling, stiffness and joint damage
• It is taken as a (10 or 20mg) tablet once a day
• It may take 6 weeks or longer before you feel the full effect so persist with tx
• The most common side-effects are;
– Some people can feel sick, have diarrhoea, mouth ulcers, weight loss, stomach upset,
rash or headache, though this will not happen to everyone
• More serious side-effects are much less common and you will be monitored regularly
while on treatment with regular blood tests, blood pressure and weight checks
Because the drug dampens down the immune system, if you have never had
chickenpox you should avoid anyone who has
• You should ideally avoid alcohol. If you do decide to drink, very small amounts e.g..

36
Q

why would you wash out leflunomide?

A

in case of serious event or before conception

37
Q

how do you wash out leflunomide?

A

Colestyramine 8g TDS for 11 days (or activated

charcoal 50g QDS 11 days)

38
Q

what should the conentration of the active metabolite be for the leflunomide wash out?

A

<20microg/L on 2 occasions, 2 weeks

apart).

39
Q

what is the dose of hydroxychloroquine?

A

200mg OD or BD depending on weight (max. 6.5mg/kg

based on IBW)

40
Q

what are the side effects of hydroxychloroquine?

A

GI disturbances, headache, skin reactions, can

cause ocular disturbances (less common- monitor)

41
Q

what disorders should you be cautious about in hydroxychloroquine?

A

Caution in epilepsy, severe GI disorders, may exacerbate

psoriasis

42
Q

what should you address/ monitor in hydroxychloroquine?

A

Assess renal/liver function before tx but no specific routine
blood monitoring, unlike other DMARDS

43
Q

what do you do if someone who is on hydroxychloroquine has visual problems?

A

referal to opthamologist

44
Q

what does hydroxychloroquine interact with?

A

amiodarone, moxifloxacin (increased risk
ventricular arrthymias), digoxin (increased dig. Level),
ciclosporin (increased ciclo. levels), some antimalarials

45
Q

what are some biologic medicines?

A
  • TNF Inhibitors
  • Interleukin inhibitors
  • JAK inhibitors (Baracitinib, tofacitinib)
  • Inhibitors of B- or T- lymphocyte activity
  • PDE4 inhibition (Apremilast)
46
Q

what do biologics do?

A

Not painkillers
• Reduce pain stiffness, inflammation, joint damage
• Cytokine expression differs greatly between patients

47
Q

when are biologics prescribed?

A

failure to respond to/tolerate DMARD therapy

48
Q

when should you only continue biologics?

A

only if adequate response at 6m following

initiation

49
Q

how often should biologics be monitored?

A

After initial response monitor at least 6 monthly and

withdraw if adequate response not maintained

50
Q

what increased risk of infection do biologics put you at?

A

– Delay administration/withhold if signs of active infection requiring
antibiotics
– May reactivate TB, Hep B or C infection therefore all patients screened
before commencing therapy
– Contraindicated in active TB, severe hepatic failure (clas III/IV)
– Increased risk of lymphoma
– Injection site reactions
– Infusion related reactions e.g. analphylactic shock, delayed
hypersensitivity reactions, pre-treat with steroids, chlorphenamine
– Headache, flushing, GI disturbance, rash, fever, elevated LFTs
– VTE with JAK inhibitors

51
Q

should you continue biologic treatment after surgery?

A

Can delay wound healing following surgery
– Omit for at least one full dosing interval
pre-surgery
– Can re-start when good wound healing, all
sutures and staples are out, and no
evidence of infection

52
Q

what are JAK inhibitors?

A

• Oral immunomodulatory drugs
• Tofacitinib, Baricitinib, (Upadacitinib)
• Can be used according to NICE guidance if
severe disease activity if criteria met
• Patient access schemes
• Withdraw after 6 months if insufficient benefit
• VTE Risk (MHRA Alert March 2020)
• Drug interactions

PHA 332 (42 decks)

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