RA treatment Flashcards
Methotrexate
GOLD STANDARD
Dosing: 7.5 mg/week can go up to 15-20 mg/week
Route: PO or IM
Methotrexate side effects
N/V/D
Fever, rash, alopecia
Bone marrow suppression (anemia)–>add folic acid 1mg/day
Mucositis, stomatitis, hepatitis, pneumonitis
Teratogenic
Contraindications to methotrexate
Pregnancy
Pleural effusions
Immunodeficiency
Chronic liver disease, alcohol abuse
Preexisting blood dyscrasias
CrCl < 40
Leukopenia/cytopenia
Methotrexate monitoring
CBC
CXR
LFT
SCR
Albumin
Leflunomide
Prodrug that inhibits biosynthesis of pyrimidines
LOADING DOSE
Route: PO
Onset: 1 month
T1/2 life: 14-16 days
Leflunomide Side effects
Diarrhea
Rash
Alopecia
Teratogenic
Increase LFTs
Leflunomide monitoring
CBC
SCr
LFT
Sulfasalazine
Route: PO
Onset: 1-2 months
Hydroxychloroquine
modification of cytokine infiltration in joint
Route: PO
Onset: 2-4 months
Hydroxychloroquine side effects
N/V/D–>take with food
Increase skin pigmentation, rash, alopecia
Retinal toxicity: > 70 yo, cumulative dose > 800 g, night/peripheral changes
VISION EXAM EVERY 6-12 MONTHS
Etanercept
TNF inhibitor
SQ weekly
Infliximab
TNF inhibitor
IV infusion
Combination required? Yes, with MTX
Adalimumab
TNF inhibitor
SQ every other week
Inadequate response to 1 or more DMARDS
Golimumab
TNF inhibitor
SQ monthly
Moderate to severe RA
Combination required? Yes, with MTX
Certolizumab
TNF inhibitor
SQ
Moderate to severe RA
TNF inhibitor monitoring
CXR, PPD skin test
Hep B,C
S/sx of infection
SCr, electrolytes
UA
LFT
CBC
Anakinra
IL-1 antagonist
SQ daily: if CrCl < 30 mL/min, every other day
Moderate to severe RA with inadequate response to 1 or more DMARD
Anakrina Side effects
N/V, flu-like symptoms
HA, hypersensitivity
Injection site reactions
Decreased neutrophils
Anakrina monitoring
Neutrophil count
Prior, monthly x 3 months, every 3 months for 1 year
Abatacept
Selective T-cell co-stimulation modulator
IV infusion
Moderate to severe RA with inadequate response to 1 or more DMARDs
CANNOT BE USED IN COMBINATION WITH TNF-inhibitors or IL-1 antagonists
Abatacept Side effects
Nausea
HA
Nasopharnygitis
Infusion site reactions
Infection
Malignancy
AVOID IN CPOD
Tocilizumab/Sarilumab
IL-6 antagonist
Tocilizumab: IV infusion every 4 weeks
Sarilumab: SQ every 2 weeks
Moderate to severe RA with inadequate response to 1 or more DMARD
Tocilizumab/Sarilumab side effects
Lipid abnormalities
Intestinal perforations–>tocilizumab
Infusion reaction–>tocilizumab
BLACK BOX: serious infection
CONTRAINDICATED IN LIVER TOXICITY, THROMBOCYTOPENIA, AND NEUTROPENIA
Tocilizumab/Sarilumab monitoring
LFT–>after 4-8 weeks
Lipids–>after 4-8 weeks
Neutrophil–>after 4-8 weeks
Platelets–>after 4-8 weeks
Rituximab
anti-CD20
IV infusion
Administer methylprednisolone 100 mg 30 minutes before infusion
Moderate to severe RA with inadequate response to 1 or more DMARD
Combination required? Yes, with MTX
Rituximab monitoring
CBC
SCr
Vital signs (each dose)
Tofactinib, Upadacitinib, Baricitinib
JAK inhibitor
Route: PO
Moderate to severe RA with inadequate response to 1 or more DMARD
CANNOT BE USED IN COMBINATION WITH BRM, AZA, CYCLOSPORINE
Tofactinib, Upadacitinib, Baricitinib side effects
Nausea
Headache
Upper respiratory
Tofactinib, Upadacitinib, Baricitinib monitoring
LFT
Lipids
Neutrophil
Lymphocytes
Hemoglobin
