RA in practice (Louise) Flashcards
1
Q
associated conditions with RA
A
sjorgrens syndrome
vasculitis
increased CV risk
increased osteoporosis risk
2
Q
treatments for Sjorgens syndrome
A
lubricating eye drops/ointments
aftificial saliva replacement
3
Q
What is sjorgrens syndrome?
A
dry mucus membranes
4
Q
What is vasculitis?
A
inflammation of blood vessels
5
Q
treatments for vasculitis
A
steroids
cyclophosphamine (chemotherapy)
6
Q
Are DMARDs/biologics analgesics?
A
no
7
Q
What anti-inflammatories can be given for pain relief in RA?
A
NSAIDs
COX-2 inhibitors
8
Q
examples of DMARDs
A
methotrexate sulfasalazine leflunomide hydroxychloroquine biologics
9
Q
initial pharmacological treatment for RA
A
monotherapy (usually methotrexate)
10
Q
What drugs are given with DMARDs?
A
oral/IM/IA steroid while waiting for the DMARD to have its effect
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
12
Q
What to give if no response to DMARDs?
A
biologics (or JAK inhibitors) in combination with methotrexate
13
Q
How long do DMARDs take to work?
A
weeks/months
14
Q
What needs to be regularly tested when taking DMARDs?
A
regular blood tests
15
Q
vaccines for patients taking immunosuppressives
A
- flu, pneumococcal vaccines recommended
- avoid live vaccines (or give 2-4 weeks before starting immunopressive therapy)
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
17
Q
What can reactivate when taking biologics?
A
reactivation of latent TB
-> screen before therapy
18
Q
patient needs antibiotics for an infection
A
immunosuppressants stopped until infection is cleared
19
Q
pregnancy and immunosuppressants
A
patient should discuss with specialist in advance if planning to conceive
20
Q
immunosuppressants contraindicated during pregnancy
A
methotrexate
leflunomide
21
Q
What immunosuppressants an be given in pregnancy if they are needed?
A
azathioprine
hydroxychloroquine
22
Q
How often is methotrexate taken?
A
once weekly
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
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
25
drug interactions with methotrexate
- antifolates - phenytoin, trimetoprim
- herbal
- lefunomide - caution
- alcohol - inc risk of liver damage (small amount)
26
What to do if bloods are out of range with methotrexate?
contact the prescriber (rheumatologist)
27
signs of methotrextae toxicity
severe mouth ulcers
| jaundice
28
What happens if renal function worsens on methotrexate?
if kidney function worsens then methotrexate levels will increase - overdose/toxicity
-> renally excreted
29
FBC with methotrexate
monthly for 1st year
| then every 2 months
30
results of FBC when to stop methotrexate
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)
31
What blood tests need to be done with methotrexate
FBC
U&Es and serum creatinine
LFTs
ESR/CRP
32
What can reduce renal function when taking methotrexate?
dehydration
| diuretics/ACEIs
33
NSAIDs and methotrexate
NSAIDs reduce renal excretion of methotrexate - increased risk of toxicity
34
When can NSAIDs be taken with methotrexate?
for pain control in RA where patient can't manage without the NSAID
-> only on Rx
35
When should NSAIDs not be taken with methotrexate for RA?
post surgical pain relief
| OTC/self medication
36
counselling for methotrexate
- 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
serious s/e of methotrexate - tell doctor on same day
- 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
rescue therapy for acute methotrexate toxicity
folinic acid (calcium folinate)
39
How does folinic acid work as rescue therapy?
folinic acid counteracts anti-folate activity of methotrexate
speeds recovery of myelosuppression (bone marrow suppression)/mucositis
40
What additional therapy for methotrexate rescue therapy is given for severe neutropenia?
G-CSF - granulocyte colony stimulating factors
| -> SC filgrastim
41
other things to treat for acute toxicity with methotreate
```
fluid and electrolyte balance (hydrated)
blood products (may need)
```
42
How is sulfasalazine taken?
```
take with glass of water
swallow whole (enteric coated)
```
43
dose titration for sulfasalazine
500mg OD for 1 week
500mg BD for 1 week
1g OM and 500mg ON for 1 week
1g BD
44
max dose of sulfasalazine
3g daily
45
s/e of sulfasalazine
```
can turn urine orange
contact lenses/tears stained yellow
nausea
diarrhoea
stomach upset
dizziness
headache
skin rashes
```
46
blood tests for sulfasalazine
FBC
LFTs
U&E
47
How often are blood tests done for sulfasalazine?
regular in first 2 years only
48
signs of liver toxicity taking sulfasalazine
```
unexplained cough
breathlessness
abdominal bruising/bleeding
severe sore throat
severe nausea/dizziness/headache
unexplained acute widespread rash
oral ulceration
```
49
licenced dose of leflunomide
- initially 100mg OD for 3 days (loadig dose)
| - then 10-20mg OD
50
When is leflunomide not given?
liver impairment
| hypoproteinaemia
51
tests while taking leflunomide
BP (hypertension)
weight monitoring (weight loss)
blood tests
52
interactions with leflunomide
methotrexate - increased risk of toxicity
phenytoin, warfarin, tolbutamide - caution
53
counselling for leflunomide
- 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
serious side effects of leflunomide (when to stop and contact doctor)
```
sore throat
fever
infection
unexplained bruising/bleeding
rash
breathlessness
unusual tiredness
stomach pain
yellowing of whites of eyes/skin
(anything that's severe)
```
55
What is leflunomide wash out?
if a serious event/adverse effect or before conception
-> because it has a long half life
56
How to do a leflunomide wash out?
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
dose of hydroxychloroquine
200mg OD or BD depending on weight
| max 6.5mg/kg based on IBW
58
max dose of hydroxychloroquine
6.5mg/kg based on IBW
59
side effects of hydroxychloroquine
GI disturbances
headache
skin reactions
ocular disturbances (less common, monitor)
60
cautions for hydroxychloroquine
epilepsy
severe GI disorders
can exacerbate psoriasis
61
tests before starting hydroxychloroquine treatment
assess renal/liver function before prescribing
-> NO blood tests
62
annual tests with hydroxychloroquine
eye tests
| -> refer to opthamologist if any occular problems (reduced vision)
63
interactions with hydroxychloroquine
```
amiodarone
moxifloxacin (inc risk of ventricular arrhythmais)
digoxin (inc digoxin levels)
ciclosporin (inc ciclosporin levels)
some antimalarials
```
64
What are biological medicines?
pharmaceutical products manufactured in, extracted from or semi-synthesised from biological sources
65
examples of biologicals
```
TNF inhibitors
interleukin inhibitors
JAK inhibitors
inhibitors of B or T lymphocyte activity
PDE4 inhibitors
```
66
How do biologicals work?
reduce pain stiffness, inflammation, joint damage
67
How long until full effect of biologics?
up to 3 months
| can notice effects in first week
68
What can biologics be combined with?
methotrexate (MTX)
69
Why do some patients respond better than others to biologics?
cytokine expression differs greatly between patients
70
When are biologics given?
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
When are biologics continued?
if adequate response after 6 months
| - improvement in DAS-28 of 1.2 or more
72
How often monitoring after initial response of biologics?
at least every 6 months
| - withdraw if adequate response not maintained
73
adverse effects of biologics
- 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
biologics and surgery
- 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
Why are biosimilars increasingly being used?
saves the cost of biologics
76
What are JAK inhibitors?
oral immunomodulatory drugs
77
examples of JAK inhibitors
tofacitinib
| baricitinib
78
When should JAK inhibitors be withdrawan if no benefit?
after 6 months
79
risks with JAK inhibitors
VTE risk - don't Rx if Hx of MI/stroke/previous blood clot
