RHEUM TREATMENT Flashcards
OSTEOARTHRITIS
TX no known cure, goals = relieve ___, minimize disability & disease progression, maintain QOL
- Conservative = ____ affected joint, brace or cane, stretching & strengthening exercise (low impact)
- Meds =
o Tylenol (for mild – moderate pain, not really 1st line bc high doses hepatotoxicity)
o ______ (topical or oral) = more effective than Tylenol, but ↑ adverse effects (GI bleeding and renal toxicity) ***use when Tylenol doesn’t work and no CI
o _____ creams (Capsaicin or methylsalycylate/Bengay) or topical lidocaine patches
- _______r injection for temp relief corticosteroids, hyaluronic acid (gel), PRP, placental tissue matrix (PTM)
o Costly!!! Small risk of infection or injection site reactions
- Consider ____ (total hip and knee replacement) if persistent pain, limited ADL’s, end-stage radiograph changes, med therapy fails excellent functional & symptomatic improvement
PAIN rest NSAIDs topical intra-articular surgery
GOUT
TREATMENT
ACUTE MANAGEMENT (ATTACKS)
- ______ (classically), ____, corticosteroids (oral taper, intra-articular where it is injected into joint, or IM)
o MOA of colchicine: disrupts innate inflammatory cascade, stabilizes tubulin
o SE of colchicine: VERY NARROW THERAPETIC WINDOW (pts can OD on this), diarrhea, GI distress, interacts with many meds
- Supportive: off-loading, ___
CHRONIC MANAGEMENT
1. Urate lowering therapy (ULT): __________ inhibitors (allopurinol or febuxostat), probenecid, or biologic uricase enzyme
Xanthine oxidase inhibitors (_____ or febuxostat)
o MOA of XOIs: inhibits xanthine oxidase enzyme thereby decreasing the production of uric acid; shifts serum urate balance towards elimination from the body
o SE of XOIs: generally well tolerated, some GI upset at higher doses, rare hypersensitivity reaction (DRESS), mobilization flare
o Allopurinol IS SAFE in CKD just start at lower dose and go up slower
_______
o Used to augment allopurinol or if pt cannot tolerate allopurinol
2. Flare prophylaxis for at least 3-6 months after starting ULT: ______, ______ low-dose prednisone (like 5 mg)
***When you start someone on allopurinol (urate lowering therapy), you need to give them something every day for 3-6 months for flare prophylaxis (colchicine or low dose naproxen typically if pt has CKD, VERY low dose prednisone)
COLCHICINE, NSAIDS ice xanthine oxidase allopurinol probenecid colchicine, nsaids
PSEUDOGOUT
TREATMENT
ACUTE FLARES: _____ (by mouth or joint injection), colchicine, ____
PROPHYLAXIS: colchicine or _____
**No CPP lowering therapy in existence
STEROIDS, NSAIDS
NSAIDs
RA
TREATMENT
1) Early referral to rheumatology clinic
2) Start conventional _____ therapy ASAP +/- ____ bridge therapy (to slow disease progression)
o NON-BIO DMARDs: _____, ______ (Plaquenil), Sulfasalazine, Leflunomide
o BIO DMARDs: _____, IL6 inhib, anti-B cell antibody, T-cell co-stimulation inhibitor, IL1 inhib
Used after inadequate response to methotrexate alone
o Start corticosteroids at low/moderate doses
3) Treat-to-Target: monitor response, visits every 1-3 months, if no response escalate therapy
4) Low-threshold to add additional DMARDs including biologics
5) Augmentative measures include:
o PO _____(for immediate symptom control – DO NOT MODIFY DISEASE, only improve pain/fxn)
o Local intra-articular steroids
o PT/OT, exercise
o Surgery: joint replacement surgery, joint fusion, tendon reconstruction
DMARD, PREDNISONE METHOTREXATE HYDROXYCHLOROQUINE TNF INHIBITOR NSAIDs
RA
METHOTREXATE: 1st line non-biological ______ (immunomodulator) – subq or oral (1x/week dose)
- MOA: 1) Alters enzymatic adenosine signaling between immune cells which disrupts cytokine production AND 2) inhibits dihydrofolate reductase thereby interfering with the formation of DNA, RNA and proteins (folate antagonist)
- INDICATIONS: ____ DMARD in most pts (good for ____ disease or high disease activity)
- CONTRAINDICATIONS: ______ (teratogenic)
- ADVERSE EFFECTS: nausea, _____ distress, diarrhea, fatigue, ____ loss, ____ ulcers/stomatitis, slightly ↑ risk of infections
o LIVER: ↑ liver ____/worsening of chronic liver disease, fulminant hepatic fibrosis/cirrhosis (rare)
o LUNG: Hypersensitivity ______
o MARROW: bone marrow suppression _____ , macrocytosis, aplastic anemia (rare)
- MONITORING: Obtain baseline ____, CBC, ____ function, and ____ panel then monitor CBC, AST/ALT, _____ throughout therapy
***OTHER = take daily folic acid supplement to prevent side effects
DMARD initial, severe pregnancy abdominal, hair, oral enzymes pneumonitis cytopenia LFTs, renal, hepatitis BUN/Cr
RA
HYDROXYCHLOROQUINE (Plaquenil) = mild non-biologic DMARD (used more in ___) – oral
- MOA: poorly understood; anti-malarial
- INDICATIONS: ___ disease or id dx is uncertain
o Can be used in combo with ___ and sulfasalazine = TRIPLE THERAPY
- CONTRAINDICATIONS: none
- ADVERSE EFFECTS: nausea & )_____ rash
o VERY RARE = ↑ risk of _____ retinopathy: abnormal deposition of Plaquenil in photoreceptor layer resulting in _____ visual loss (risk is dose & duration dependent, hardly get before 0-5 yrs on drug)
- MONITORING: baseline exam and ____ screening annually
***OTHER = safe in pregnancy
LUPUS MILD MTX photosensitive bulls eye permanent opthalmic
RA
TNF INHIBITORS = biologic DMARD – subq every 1-2 wks or IV infusion every 4-8 wks
Etanercept (Enbrel), Infliximab (Remicade), Adalimumab (Humira), Golimumab (Simponi), Certolizumab pegol (Cimzia) ***all work, choice dpeedns on pt and insurance
- MOA: Monoclonal antibodies which inhibit TNF resulting in downstream reduction in cytokine signaling
- INDICATIONS: used when _____ doesn’t work (biologics are not first line therapy)
- CONTRAINDICATIONS: ___, Class III-IV ____ failure, untreated ___ infection
o Prior to starting therapy MUST r/o TB with PPD or QuantiFERON +/- CXR
o Also do HEP B/C panel
- SIDE EFFECTS: injection site reactions, _____ reactions
- ADVERSE EFFECTS: ↑ risk of _____, ↑ risk of skin ____ & hematologic malignancy, new onset __, hepatitis or ___ reactivation
METHOTREXATE
MS, HEART FAILURE, TB
INFUSION
infections, cancer, MS, tb
FIBROMYALGIA
TX _______ = PCP, pain management, psychiatrists, psych
- Adjunctive= exercise (low impact aerobics = swimming, walking, biking), optimize sleep, tx underlying psych/mood disorders
- FDA approved: Amitriptyline (___), Cymbalta or Savella (___), or Lyrica (acts on voltage dep. Ca channels; esp helpful for sleep sxs)
care team
TCA, SNRI
SLE
TREATMENT
PHARMACOLOGIC MANAGEMENT
- ______ (Plaquenil) anchor drug for all, reduces disease flares
o Decreases mortality and flares
o Get yearly eye exam
- _______ used to control flares of systemic disease
- _________ (Mycophenolate Mofetil/CellCept or Cyclophosphamide/Cytoxan or Azathioprine) used when resistant to corticosteroids or with CNS or renal involvement
***Cyclophosphamide is good for lupus nephritis (major complication of SLE)
- _____ (Belimumab) acts on B-cells; designed for SLE; usually reserved for dz unresponsive to corticosteroids or other immunosuppressive agents
NON-PHARMACOLOGIC
- Minor joint pain = rest/NSAIDs
- Sun protection
- STOP _____!!!
- Family planning (better to conceive in low activity state)
HYDROXYCHLOROQUINE CORTICOSTEROIDS IMMUNOSUPPRESSANTS BENLYSTA smoking
SCLERODERMA
TREATMENT
- No disease modifying agents
- Eat ___, frequent meals
- Symptomatic treatment:
o GERD: ___
o Raynaud’s symptoms: _____(nifedipine, amlodipine), PDE-5 inhibitors (sildenafil), topical nitroglycerine for active skin ulcers
o Severe systemic disease: ________ (conventional and biologic)
o Scleroderma-renal crisis: EMERGENCY tx with ____ inhibitors
Avoid ____ thought to contribute to renal crisis
Avoid ___ can induce/worsen vasospasm
o Prognosis:
lcSSc usually follows more indolent course
dcSSc associated with higher morbidity and mortality
SMALL PPIs CCBs immunomodulators ACE steroids, beta blockers
POLYMYOSITIS
TREATMENT
- 1ST LINE: high-dose ____
- ________ (Methotrexate, CellCept, Azathioprine), Rituximab, IVIG can be used if resistant
STEROIDS
IMMUNOMODULATORS
DERMATOMYOSITIS
TREATMENT
- 1ST LINE: high-dose ____
- _______ (Methotrexate, CellCept, Azathioprine), Rituximab, IVIG can be used if resistant
- Limit ___ exposure in dermatomyositis
o Skin involvement may respond to __________
STEROIDS
IMMUNOMODULATORS
SUN
HYDROXYCHLOROQUINE
PSORIATIC ARTHRITIS
TREATMENT
- Mild: ____ = 1st line initial therapy
- Severe (ex. > 5 joints, severe damage on radiographs, no response to NSAIDs): _________ (or other DMARDs like sulfasalazine or anti-malarials)
- ________ (etanercept, infliximab, golumumab, and certolizumab) if methotrexate is unsuccessful
NSAIDs
methotrexate
TNF INHBIITORS
ANKLOSING SPONDYLITIS
TREATMENT
- 1st line: _____(Naproxen, Celebrex, Indomethacin, Mobic)
- 2nd line: _____ (if no response to NSAIDs)
o TNF inhibitors = Enbrel, Humira, Remicade
o ____ inhibitors = Cosentyx, Taltz
- Adjunctive treatments: encourage exercise, PT/OT if needed, long-term injury prevention
NSAIDS
BIOLOGICS
IL-17
REACTIVE ARTHRITIS
TREATMENT
- 1st line/TOC: _____
- Refractory cases: steroids, cs_____(methotrexate, sulfasalazine), biologics
- Only treat with ___ if infection is active (otherwise no indication)
NSAIDS
DMARDS
ABX
