Rheum pharma

Question 7

How do you manage RA?

Answer 7

MDT - esp Physio and OT; ROM exercises

NSAIDs

Low dose corticosteroids possible while waiting for DMARDs to work

Early DMARDs in primary care

Question 8

What does DMARD stand for?

Examples of DMARDs

Start early and treat aggressively!

Answer 8

Disease modifying anti-rheumatic drugs

Methotrexate

Sulphasalazine

Gold compounds

Penicillamine

Chloroquine

Leflunomide

Anti-TNf e.g. infliximab

Other biological agents e.g. rituximab

Question 9

What is mechanism of action of MTX?

Other than RA, what else used in?

Contraindications to treatment?

Answer 9

Dihydrofolate reductase inhibitor that prevents folate reduction –> reduces amount of important cofactor in DNA synthesis. i.e. interferes with DNA synthesis

Psoriasis, Crohn’s, Cancer (different dose)

Severe blood disorders, immunodeficiency, pregancy/trying to get pregnant M+F, breastfeeding

Question 10

Common side-effects

Serious side-effects

What drugs increase levels and therefore toxicitiy?

Dose?

Answer 10

Mucositis, GI upset, skin reactions

Bone marrow suppression, Hepatotoxicity, neurotoxicity, pulmonary fibrosis/pneumonitis

NSAIDs, trimethoprim, Co-trimoxazole

~10mg once weekly, always give with folic acid 5mg

Question 11

What blood tests need to be done pre-Rx?

How should someone on MTX be monitored?

Answer 11

• FBC, U+E, creatinine, LFT, CXR
• FBC fortnightly for 6/52 after each dose change, then monthly
• LFT fortnightly
• U+E 6-12 monthly, unless suspect bigger problem

Question 12

With patient on MTX, what are red flags that should lead to discussion with doctor?

Answer 12

• Any sign of infection, rash or oral ulceration
• Signs of blood dyscrasia - e.g. abnormal bruising, infection
• WBC < 150, MCV > 105
• > 2 fold rise in AST/ALP
• Rise within normal rage should suggest further investigation

Question 13

When use sulphasalazine

How long does it take to become effective?

What is DRESS?

Monitoring?

Answer 13

1. 1st/2nd choice in mild/mdoerate disease
2. 3 months
3. Drug rash, eosinophilia, systemic symptoms –> hypersensitivity reaction that can be induced by sulfa
4. 3 monthly, blood profile, LFTs etc. because can cause GI upset, BMS, deranged LFTs

Question 14

Indications for steroids in RA?

>10 side effects?!!

Answer 14

• Control of acute flare; adjunct; tide over while DMARD takes effect

1. Increased appetitie –> weight gain
2. Hyperglycaemia/DM
3. Cushings –> addisonian crisis on withdrawal
4. Osteoporosis
5. Psychosis
6. Bruising
7. Skin thinning
8. Infection
9. Ulcers
10. Delayed wound healing
11. Glaucoma/cataracts

Question 15

Gold - main risk?

Hydroxychloroquine - best for?

What used in 2-5% of patients?

What is MOA of leflunomide and when use?

Answer 15

BMS and Nephrotic syndrome

SLE - not really used in RA

Azathiprine or cyclosporin A

Pyrimidine antagonist - used after MTX but before CyA

Question 16

what is TNF alpha?

Give examples of anti-TNF agents - when are they used?

What are absolute CI, and what must be checked beforehand?

Other targets? When use?

Answer 16

Acute phase Immune Cytokine produced predominantly by macrophages; intrinsically involved in RA mediated inflammation

Infliximab, Adalimumab (self adminster), Etanercept, Certolizumab; Used if ≥2 2nd line agents fail; Also used in Psoriatis ± Arthritis, ank spond, Crohn’s, Behcets

Previous TB - can be reactivated; and any current severe infection. Check beforehand full haem/bio profile, autoantibodies and also Demyelination (can be effect of treatment)

CD-20 Bcell receptor - Rituximab. In those on MTX who fail with TNF biological