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PHA223 > RA in practice (Louise) > Flashcards

RA in practice (Louise) Flashcards

1
Q

associated conditions with RA

A

sjorgrens syndrome
vasculitis
increased CV risk
increased osteoporosis risk

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2
Q

treatments for Sjorgens syndrome

A

lubricating eye drops/ointments

aftificial saliva replacement

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3
Q

What is sjorgrens syndrome?

A

dry mucus membranes

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4
Q

What is vasculitis?

A

inflammation of blood vessels

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5
Q

treatments for vasculitis

A

steroids

cyclophosphamine (chemotherapy)

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6
Q

Are DMARDs/biologics analgesics?

A

no

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7
Q

What anti-inflammatories can be given for pain relief in RA?

A

NSAIDs

COX-2 inhibitors

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8
Q

examples of DMARDs

A 
methotrexate
sulfasalazine
leflunomide
hydroxychloroquine
biologics
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9
Q

initial pharmacological treatment for RA

A

monotherapy (usually methotrexate)

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10
Q

What drugs are given with DMARDs?

A

oral/IM/IA steroid while waiting for the DMARD to have its effect

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11
Q

What to do if target is not reached?

A
  • increase the DMARD dose (monotherapy)
  • add 2nd DMARD (methotrexate, sulfasalazine, leflunomide, hydroxychloroquine)
  • or try different monotherapy
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12
Q

What to give if no response to DMARDs?

A

biologics (or JAK inhibitors) in combination with methotrexate

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13
Q

How long do DMARDs take to work?

A

weeks/months

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14
Q

What needs to be regularly tested when taking DMARDs?

A

regular blood tests

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15
Q

vaccines for patients taking immunosuppressives

A
  • flu, pneumococcal vaccines recommended

- avoid live vaccines (or give 2-4 weeks before starting immunopressive therapy)

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16
Q

immunosuppressive treatment and chicken pox/measels/shingles

A
  • avoid contact with chicken pox/measels/shingles
  • ensure household contacts are immune to measels (MMR)
  • if significant contact with chicken pox - VZ immunoglobulin can be given within 7 days of contact
  • measels contact - urgent measels IgG testing
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17
Q

What can reactivate when taking biologics?

A

reactivation of latent TB

-> screen before therapy

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18
Q

patient needs antibiotics for an infection

A

immunosuppressants stopped until infection is cleared

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19
Q

pregnancy and immunosuppressants

A

patient should discuss with specialist in advance if planning to conceive

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20
Q

immunosuppressants contraindicated during pregnancy

A

methotrexate

leflunomide

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21
Q

What immunosuppressants an be given in pregnancy if they are needed?

A

azathioprine

hydroxychloroquine

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22
Q

How often is methotrexate taken?

A

once weekly

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23
Q

What is taken with methotrexate, its frequency and why?

A

folic acid

  • > not taken on the methotrexate day
  • > reduced adverse effects of methotrexate
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24
Q

What to check on an Rx for methotrexate?

A
  • dose, if increased/decrease reasonable (check last dose)
  • is patient expecting a dose change?
  • check purple book -> bloods/dose
  • discuss concerns with bloods with prescriber and document this
  • drug interactions
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25
Q

drug interactions with methotrexate

A
  • antifolates - phenytoin, trimetoprim
  • herbal
  • lefunomide - caution
  • alcohol - inc risk of liver damage (small amount)
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26
Q

What to do if bloods are out of range with methotrexate?

A

contact the prescriber (rheumatologist)

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27
Q

signs of methotrextae toxicity

A

severe mouth ulcers

jaundice

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28
Q

What happens if renal function worsens on methotrexate?

A

if kidney function worsens then methotrexate levels will increase - overdose/toxicity

-> renally excreted

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29
Q

FBC with methotrexate

A

monthly for 1st year

then every 2 months

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30
Q

results of FBC when to stop methotrexate

A

leucopenia <3.5 x 10^9 /L
neutropenia <2 x 10^9 /L
thrombocytopenia <150 x 10^9 /L
fall in platelets (easy bruising/bleeding)

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31
Q

What blood tests need to be done with methotrexate

A

FBC
U&Es and serum creatinine
LFTs
ESR/CRP

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32
Q

What can reduce renal function when taking methotrexate?

A

dehydration

diuretics/ACEIs

33
Q

NSAIDs and methotrexate

A

NSAIDs reduce renal excretion of methotrexate - increased risk of toxicity

34
Q

When can NSAIDs be taken with methotrexate?

A

for pain control in RA where patient can’t manage without the NSAID

-> only on Rx

35
Q

When should NSAIDs not be taken with methotrexate for RA?

A

post surgical pain relief

OTC/self medication

36
Q

counselling for methotrexate

A
  • it’s not a pain killer, reduce progression of joint damage
  • taken once weekly
  • take folic acid on different day
  • how to differentiate between MTX and folic acid (both yellow tabs)
  • purple book to appointments/pharmacy
  • regular monitoring
  • side effects (feeling sick, upset stomach, diarrhoea)
  • stop and tell doctor on same day if serious s/e
37
Q

serious s/e of methotrexate - tell doctor on same day

A
  • unexplained SOB and dry cough - pulmonary toxicity
  • whites of eyes become yellow or severe itching - liver toxicity
  • fever, chills, severe sore throat/mouth - infection
  • severe mouth ulcers, bleeding gums, bruising, skin ulcers
  • severe sickness/upset stomach
  • never had chicken pox and in contact with someone who has cp/shingles
  • you/partner becomes pregnant
38
Q

rescue therapy for acute methotrexate toxicity

A

folinic acid (calcium folinate)

39
Q

How does folinic acid work as rescue therapy?

A

folinic acid counteracts anti-folate activity of methotrexate
speeds recovery of myelosuppression (bone marrow suppression)/mucositis

40
Q

What additional therapy for methotrexate rescue therapy is given for severe neutropenia?

A

G-CSF - granulocyte colony stimulating factors

-> SC filgrastim

41
Q

other things to treat for acute toxicity with methotreate

A 
fluid and electrolyte balance (hydrated)
blood products (may need)
42
Q

How is sulfasalazine taken?

A 
take with glass of water
swallow whole (enteric coated)
43
Q

dose titration for sulfasalazine

A

500mg OD for 1 week
500mg BD for 1 week
1g OM and 500mg ON for 1 week
1g BD

44
Q

max dose of sulfasalazine

A

3g daily

45
Q

s/e of sulfasalazine

A 
can turn urine orange
contact lenses/tears stained yellow
nausea
diarrhoea
stomach upset
dizziness
headache
skin rashes
46
Q

blood tests for sulfasalazine

A

FBC
LFTs
U&E

47
Q

How often are blood tests done for sulfasalazine?

A

regular in first 2 years only

48
Q

signs of liver toxicity taking sulfasalazine

A 
unexplained cough
breathlessness
abdominal bruising/bleeding
severe sore throat
severe nausea/dizziness/headache
unexplained acute widespread rash
oral ulceration
49
Q

licenced dose of leflunomide

A
  • initially 100mg OD for 3 days (loadig dose)

- then 10-20mg OD

50
Q

When is leflunomide not given?

A

liver impairment

hypoproteinaemia

51
Q

tests while taking leflunomide

A

BP (hypertension)
weight monitoring (weight loss)
blood tests

52
Q

interactions with leflunomide

A

methotrexate - increased risk of toxicity

phenytoin, warfarin, tolbutamide - caution

53
Q

counselling for leflunomide

A
  • used to dampen down the disease process and reduce inflammation that can lead to pain/swelling/stiffness
  • taken OD
  • may take 6 weeks before you feel the full effect
  • s/e: feel sick, diarrhoea, mouth ulcers, weight loss, stomach upset, rash, headache
  • serious s/e, less common
  • regular blood tests/BP/weight monitored
  • avoid contact with chicken pox if you’ve never had it
  • avoid alcohol, or very small amounts
54
Q

serious side effects of leflunomide (when to stop and contact doctor)

A 
sore throat
fever
infection
unexplained bruising/bleeding
rash
breathlessness
unusual tiredness
stomach pain
yellowing of whites of eyes/skin
(anything that's severe)
55
Q

What is leflunomide wash out?

A

if a serious event/adverse effect or before conception

-> because it has a long half life

56
Q

How to do a leflunomide wash out?

A

colestyramine 8g TDS for 11 days
OR
activated charcoal 50g QDS for 11 days

  • measure concentration of the active metabolite - should be <20mcg/L on 2 occasions 2 weeks apart
  • for men and women
57
Q

dose of hydroxychloroquine

A

200mg OD or BD depending on weight

max 6.5mg/kg based on IBW

58
Q

max dose of hydroxychloroquine

A

6.5mg/kg based on IBW

59
Q

side effects of hydroxychloroquine

A

GI disturbances
headache
skin reactions
ocular disturbances (less common, monitor)

60
Q

cautions for hydroxychloroquine

A

epilepsy
severe GI disorders
can exacerbate psoriasis

61
Q

tests before starting hydroxychloroquine treatment

A

assess renal/liver function before prescribing

-> NO blood tests

62
Q

annual tests with hydroxychloroquine

A

eye tests

-> refer to opthamologist if any occular problems (reduced vision)

63
Q

interactions with hydroxychloroquine

A 
amiodarone
moxifloxacin (inc risk of ventricular arrhythmais)
digoxin (inc digoxin levels)
ciclosporin (inc ciclosporin levels)
some antimalarials
64
Q

What are biological medicines?

A

pharmaceutical products manufactured in, extracted from or semi-synthesised from biological sources

65
Q

examples of biologicals

A 
TNF inhibitors
interleukin inhibitors
JAK inhibitors
inhibitors of B or T lymphocyte activity
PDE4 inhibitors
66
Q

How do biologicals work?

A

reduce pain stiffness, inflammation, joint damage

67
Q

How long until full effect of biologics?

A

up to 3 months

can notice effects in first week

68
Q

What can biologics be combined with?

A

methotrexate (MTX)

69
Q

Why do some patients respond better than others to biologics?

A

cytokine expression differs greatly between patients

70
Q

When are biologics given?

A

no response/intolerant to DMARDS

- DAS-28 > 5.1 on 2 occassions at least 1 month apart and had trial of 2 DMARDs including methotrexate

71
Q

When are biologics continued?

A

if adequate response after 6 months

- improvement in DAS-28 of 1.2 or more

72
Q

How often monitoring after initial response of biologics?

A

at least every 6 months

- withdraw if adequate response not maintained

73
Q

adverse effects of biologics

A
  • increased risk of infection
  • withhold if infection that needs antibiotics
  • can reactivate TB/hep B or C infection (screened before starting therapy)
  • c/i in active TB, severe hepatic failure
  • inc risk of lymphoma (blood cancer)
  • injection site reactions
  • infucion related reactions (alaphylactic shock, hypersen rxns, pre treat with steroids/antihistamines)
    headache, flushing, GI disturbance, rash, fever, elevated LFTs
  • VTE with JAK inhibitors
74
Q

biologics and surgery

A
  • can delay wound heal after surgery
  • omit for at least 1 full dosing interval pre-surgery
  • can restart when good wound healing, all sutures/staples out and no evidence of infection
75
Q

Why are biosimilars increasingly being used?

A

saves the cost of biologics

76
Q

What are JAK inhibitors?

A

oral immunomodulatory drugs

77
Q

examples of JAK inhibitors

A

tofacitinib

baricitinib

78
Q

When should JAK inhibitors be withdrawan if no benefit?

A

after 6 months

79
Q

risks with JAK inhibitors

A

VTE risk - don’t Rx if Hx of MI/stroke/previous blood clot

PHA223 (43 decks)

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