Rheum Flashcards
Methotrexate
7.5 mg, once a week. can combine with DMARDS, antiinflammatory, slows RA progress, dihydrofolate reductase inhibitor, can give IV via PO (cheaper), reassess at 6-12 weeks, titrate up q 2-4 weeks, follow renal and liver (esp CKD) if Cr>1.5, NEVER use. always use folic acid (1 mg), red liver and pulm toxicity (5%), dec. n/v, check CBC (bone marrow) watch LFT (NO etoh, inc risk). cbc, lft, cr and CXR prior to starting. hep a,b,c, hiv, ppd after starting. cbc lft q 4-8 wks, cr every time you check albumin. no sulfamethazole. male or female, 3 month rule for pregnancy. glucocorticoid start bridge temporarily, helps with pain and inflammation, as low as possible.
mild RA
no TNF inhibitors, use other agents
hydrochloroquine
DMARD, watch for retinal toxicity, see opthamologist at 6 mo, effective on mild form
sulfasalazine
DMARD, good for mild disease, exp IBD good option, watch bone marrow suppression (CBC), are they tolerating GI issues, effective mostly on mild form
azathioprine
good for IBD, if over 65 and renal insufficiency, good option, can’t use MTX or sulfasalazine, not most effective but effective enough, watch for drug-drug interaction, ALLOPURINOL,
cyclophosphamide
used in severe vasculitis, extra-articular involvement, not first line, adjust dose for renal insufficiency, infertility with high doses, greater r/f malignancy, can cause hemorrhagic cystitis, take in am with lots of water
D-penicilimide
for long-term, poorly controlled, bone marrow suppression, rash, nothing tastes good/metallicky, good for persistent symptoms, weight loss, associated with lupus. 125-250 once a day up to 1g/day
leflunomide
like azothioprine but better, immunosupportive, antiinflammatory, liver function toxicity (rare), low SE profile, long half-life, if wanan get pregnant must wait months and months, take chorostylamine for 2 weeks, decreases hepatic absorption and pregnancy can happen sooner (must be undetectable first)
TNF alpha antagonists
Adalimumab (Humira), Etanercept (Enbrel), Infliximab (Remicade), Certolizumab (Cimzia), Golimumab (Simponi), good drug, good efficacy
Interleukin-1 antagonist
Anakintra (Kineret), not very effective, not used often
Suppress T-Cell activation
Abatacept (Orencia), very effective, try if TNF inh doesn’t work
Anti-B-cell monoclonal antibody
Rituximab (Rituxan), very effective, try if TNF inh doesn’t work
Infliximab
chimeric, 25% mice, the less mice the better outcome, can develop antibodies, essentially a very expensive placebo, must be infused every 4-8 weeks, avoid this. bind and neutralize membranes and circulating tnf
if tnf-a inh is all human
better, no antibodies. can give SQ, easier to give but weekly
rituximab
b-cell mediated, 3rd or 4th line treatment, causes destruction of b-cells, causes compliment cascade, lots of SE, non-selective
