RA Tx

Question 1

often the inital tx

Answer 1

NSAIDs

Question 2

do NSAIDs alter the natural course of RA

Answer 2

no

Question 3

what drug should you use in conjunction with NSAIDs to decrease gastric ulcers

Answer 3

PPI (e.g omeprazole)

Question 4

when are glucocorticoids used are what are some toxicities/ adverse effects

Answer 4

Hyperglycemia (DM) – short term 
Osteopenia/Osteoporosis
Cataracts
Osteonecrosis of the bone 
Skin ecchymosis
Increase incidence of infections
Increased cardiovascular disease

Question 5

when would you use DMARDs

Answer 5

when cortico and NSAIDs dont work

considered for ongoing active disease

Question 6

methotrexate MOA and AR

Answer 6

interferes with purine synthesis (stuns T cells so cant spit
out cytokines)

possible liver fibrosis/cirrhosis
teratogenic
Hematologic toxicity: cytopenias

Question 7

is methotrexate slow or fast acting

Answer 7

slow

Question 8

what should be supplemented with methotrexate and what does it prevent

Answer 8

Folic acid 1 mg daily-prevents stomatitis, alopecia, marrow suppression

Question 9

Hydroxychloroquine (Plaquenil®) AR

Answer 9

Skin rash, anorexia, and nausea occur in 8%
Retinal pigmentation “bulls-eye” around the macula
(where the finest vision is)
Takes years to develop, irreversible
Corneal deposits also occur
Monitor retinal pigmentation - yearly
Reversible “neuromuscular” syndrome

Question 10

Sulfasalazine (Azulfidine®) AR

Answer 10

Leukopenia and neutropenia in 1-5%

Question 11

Leflunomide (Arava®) MOA

Answer 11

Pyrimidine synthesis inhibitor (stuns T cells to put out less cytokines)

Question 12

Leflunomide (Arava®) AR

Answer 12

can stay in system for YEARS and cause fetal
abnormalities
Hepatotoxicity: Monitor liver enzymes every 2-3 months
Diarrhea, hair loss, and rash may occur in 10-15% of patients
Syndrome of extreme weight loss seen

Question 13

DMARDs vs biologics

Answer 13

biologics-Laser gun, hit a certain cytokine and block it unlike methotrexate that just stuns the T cell

Question 14

anti-TNF agents examples

Answer 14

Etanercept (Enbrel®) 
Infliximab (Remicade®) 
Adalimumab (Humira®) 
Certolizumab (Cimzia®) 
Golimumab (Simponi®)

Question 15

cept

Answer 15

fusion of a receptor to the Fc part of human immunoglobulin G1 (IgG1)

Question 16

mab

Answer 16

indicates a monoclonal antibody

Question 17

ximab

Answer 17

indicates a chimeric mAb

Question 18

zumab

Answer 18

indicates a humanized mAb

Question 19

umab

Answer 19

indicates a fully human mAb

Question 20

biological DMARDs and infection

Answer 20

Temporarily discontinue biologic agents around the time of infection or major surgery and then start back up when recovered

Question 21

biological DMARDs and TB

Answer 21

may reactivate TB (Form granuloma around the TB in our lungs when we inhale it. Skin test may be +. The granuloma needs TNF to stay intact, if give TNF inhibitor, leads to reactivation of TB)

Question 22

Biological DMARDs:Fungal and Opportunistic Infections

Answer 22

Histoplasmosis, Coccidioidomycosis, Candidiasis,

Cryptococcus, Aspergillosis, and Pneumocystis

Found in endemic areas

Apparently more common with infliximab compared to etanercept

Question 23

what do you want to avoid biologics in

Answer 23

MS and CHF

Question 24

Biologic Agents: IL-6 inhibition Tocilizumab (Actemra®) Sarilumab (Kevzara ®) AR

Answer 24

Serious infections
GI perforations (due to diverticulitis)
          A little more than other agents 
Neutropenia
Thrombocytopenia
Elevated LFTs
Demyelinating disorders
Malignancies

Question 25

Rituximab (Rituxan®) MOA

Answer 25

blocks B cells

Question 26

Tofacitinib (Xeljanz®)
Baricitinib (Olumiant ®)
Upadacitinib (Rinvoq®)

increases your risk for…and whats the MOA

Answer 26

shingles

blocks janus kinases