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Therapeutics IV > Rheumatoid Arthritis > Flashcards

Rheumatoid Arthritis Flashcards

1
Q

Erythrocyte Sedimentation Rate (ESR)

A

non specific

normal = 0 - 20 mm/hr

elevated in RA (> 20) = also elevated in general inflammatory disease

done routinely to see if meds are helpful or not or if there is a flare in the disease

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2
Q

C-reactive protein

A

non-specific

normal = 0 - 0.5 mg/dL

positive = > 0.5 mg/dL

> 10 mg/dL can indicate bacterial infection

done routinely to see if meds are helpful or not or if there is a flare in the disease

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3
Q

Rheumatoid factor (RF)

A

*hallmark diagnostic criteria (but false positives are possible)

antibody specific for IgM

not all patients with RA diagnosis are RF+ (pts can have a score of 6 or more w/out a positive RF test)

this is a dilution test that is reported as a titer (higher the titer can indicate more disease progression)

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4
Q

Anti-CCP/ACPA

A

relatively new (< 20 years its been around)

HIGH specificity

auto-antibody diagnostic test

present earlier in disease

predictive value for erosive disease

marker of poor prognosis

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5
Q

antinuclear antibodies (ANA)

A

less specific for RA –> still indicative for an autoimmune disease

elevated titer suggests autoimmune disease

more indicative of SLE (systemic lupus erythematosus)

reported as a titer (measurement of an amount or [ ] of a substance in a solution)

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6
Q

Joint aspiration

A

removing fluid from a space surrounding a joint to determine fluid contents

turbid = cloudy or muddy in appearance, less viscous than a normal joint space liquid (most likely due to elevated WBCs)

WBC: 5,000 - 50,000/mm^3

Glucose: normal to low compared to serum

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7
Q

Radiographic changes

A

class/hallmark way to diagnose RA

joint space narrowing

erosions of bone

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8
Q

Poor SOCIAL factors

A

low socioeconomic status

lack of formal education

psychological stress

poor Health Assessment Questionnaire (HAQ) scores
—is a quality of life score

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9
Q

Poor PHYSICAL factors

A

extra-articular factors (outside the joint space)

elevated ESR and CRP

high titers of RF

Elevated anti-CCP/ACPA

Erosions on X-Ray

Duration of disease

Swelling of > 20 joints

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10
Q

RA age of onset

A

any age

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11
Q

RA disease distribution

A

systemic involvement

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12
Q

RA ESR

A

elevated

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13
Q

RA inflammation

A

PRESENT

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14
Q

RA joint involvement

A

bilateral

SYMMETRIC

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15
Q

RA morning stiffness

A

> 1 hour

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16
Q

RA osteophyte

A

osteophyte = bony lumps that grow on the bones of the spine or around the joints

in RA, ABSENT

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17
Q

RA pannus

A

often PRESENT

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18
Q

RA Rheumatoid factor

A

frequently positive

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19
Q

RA subcutaneous nodules

A

frequently present

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20
Q

RA swelling

A

diffuse symmetric

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21
Q

RA typical presentation

A

malaise

fatigue

musculoskeletal pain

fever

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22
Q

RA has _________ w/ OA

A

VERY LITTLE

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23
Q

RA Tx Goals

A

improve/increase quality of life

reduce morbidity and mortality

alleviate S/Sx of disease

preserve fxn

prevent structural damage and deformity

control/avoid extra-articular manifestations

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24
Q

For RA, _____ _______ the damage that has already been done

A

CANNOT REVERSE

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25
What is key w/ RA?
early tx to decrease disease severity
26
RA non-pharmacologic tx
education emotional support rest weight reduction physical therapy heat splints/prosthetics surgery
27
RA pharmacologic tx
NSAIDs corticosteroids DMARDs (more specific to RA) biologic agents anti-TNF biologic agents non-TNF
28
NSAIDs & COX-2 Inhibitors Facts
``` Effective in reducing pain, swelling, and stiffness • Do NOT alter disease progression • Dose at anti inflammatory doses • Use in combination with DMARDs ```
29
NSAIDs & COX-2 Inhibitors cannot be used for...
...MONOTHERAPY
30
NSAIDs & COX-2 Inhibitors MOA
Inhibits COX and thus inhibits formation of prostaglandins and inflammatory mediators (involved in pain and inflammation)
31
Celecoxib (Celebrex) Dose + Caution
Dose: 100 200 mg by mouth twice daily – CAUTION with sulfa allergy (know anti-inflammatory doses)
32
Don't use Celecoxib (Celebrex) in patients with a...
SULFA ALLERGY
33
Corticosteroids
``` Used for anti inflammatory and immunosuppressive properties • Not used as monotherapy • Use in combination with DMARD • Use in acute flares • Use in patients with extra articular manifestations ``` want to use AS LITTLE as possible
34
Corticosteroids not used for...
...MONOTHERAPY
35
Use corticosteroids in patients with an...
ACUTE FLARE
36
Corticosteroids MOA
inhibit IL-1 production
37
NSAIDs and DMARDs have...
steroid sparing effects
38
Corticosteroid SHORT term effects
hyperglycemia gastritis mood changes elevated BP
39
Corticosteroid LONG term effects
aseptic necrosis cataracts obesity growth failure HPA suppression osteoporosis
40
DMARDs Facts
``` D isease M odifying A nti R heumatic D rugs • Potential to decrease/prevent joint damage & preserve joint integrity • Timing of initiation is critical • Onset of action is delayed ```
41
Methotrexate is the DMARD...
OF CHOICE GOLD STANDARD
42
Methotrexate (MTX) Facts
``` Most predictable benefit • DMARD of choice • DMARD with best long term outcome • MOA: inhibit dihydrofolic acid reductase (inhibits neutrophil adhesion and chemotaxis) ```
43
Methotrexate Preferred administration
PO
44
Methotrexate Unique Dosing
7.5 mg PO PER WEEK
45
Methotrexate AE
``` Hematologic – Bone marrow suppression* • Gastrointestinal – N/V/D* – Stomatitis*/mucositis* • Hepatic – Cirrhosis – Hepatitis – Fibrosis ``` *= prescribe 1mg/day of folic acid to reduce symptoms ``` Pulmonary – Pneumonitis – Fibrosis • Dermatologic – Rash – Urticaria – Alopecia • Teratogenic (Wait one cycle on BCP // Wait 3 months before considering conception) ```
46
What are the worst methotrexate AE?
Gastrointestinal impacts = N/V/D Decreases Pt Compliance
47
What should patients always have with methotrexate?
FOLIC ACID ( 1 mg/day) to reduce symptoms
48
What should women be taking while taking methotrexate?
Birth control if during child bearing age
49
MTX Contraindications
``` Pregnancy • Chronic liver disease (EtOH) • Immunodeficiency • Pre existing blood dyscrasias • Pleural/peritoneal effusions • Leukopenia/Thrombocytopenia • CrCL < 40 mL/min ```
50
Leflunomide (Arava) is a _________
pro-drug
51
Leflunomide (Arava) Patients need what?
Loading dose
52
Leflunomide T1/2
14 - 16 days hepatobiliary clearance
53
Leflunomide AE
diarrhea rash alopecia increased LFTs teratogenicity
54
Sulfasalazine is a _______
pro-drug
55
Sulfasalazine MOA
inhibits IL-1
56
Which drugs should you be cautious using in sulfa allergy patients?
sulfasalazine and celecoxib
57
Sulfasalazine AE
``` Gastrointestinal – N/V/D, anorexia • Dermatologic – Rash/ Urticaria/ Photosensitivity • Hematologic – Leukopenia, thrombocytopenia – Rare: Hemolytic and aplastic anemia • Caution for allergy ```
58
Role of hydroxychloroquine?
Use in early or less aggressive disease
59
Advantage of hydroxychloroquine
its less efficacious but it DOES NOT have bone marrow suppression (myelosuppression)
60
Hydroxychloroquine unique AE
retinal toxicity (night/peripheral vision changes) caution in elderly pts need routine patients inform patients take with food
61
Traditional DMARDs are...
conventional and ORAL agents
62
TNF Neutralizers (Biologic DMARDs)
``` Etanercept • Infliximab • Adalimumab • Golimumab • Certolizumab ```
63
Anti-TNFs should not be used in combination with other....
IL-1 inhibitors or T-cell co stimulation modulators
64
Anti-TNFs Warnings/Precautions
``` Risk of infection • Do not use in combination with IL 1 inhibitors or t cell co stimulation modulators • Black box warnings • Demyelinating disorders • Malignancies • Congestive heart failure • No concurrent live vaccination administration • TB skin test before start test ```
65
If using an anti-TNF, make sure the patient is not getting...
...a live vaccine
66
Anti-TNF AEs
``` Headaches and rash • Risk of infection (upper respiratory most common) • Injection site reaction • Exacerbations of CHF • Risk of malignancy • Risk of evidence of demyelinating disease ```
67
Etanercept (Enbrel) is used...
...monotherapy OR in combination with MTX
68
Infliximab (Remicade) has...
mouse and human portions to reduce antigenic potential
69
Infliximab (Remicade) Dosage Form
IV
70
Infliximab (Remicade) indicated to be used with...
MTX~!
71
Adalimumab (Humira) indicated
if pts had inadequate response to previous therapy
72
Adalimumab (Humira) can be used...
alone OR in combination
73
Golimumab (Simponi) used...
used in combination w/ MTX
74
Golimumab (Simponi) indicated
moderate to severe RA
75
Golimumab (Simponi) is a...
...human monoclonal antibody specific for TNF-alpha
76
Golimumab (Simponi) requires...
Laboratory monitoring: CBC with PLT LFTS
77
Certolizumab (Cimzia) can be used
alone OR in combination with non-BRM DMARDs for moderate to severe disease
78
Anakinra (Kineret) can be used...
alone or with other agents (not anti-TNFs)
79
For Anakinra (Kineret)...[dosing]
can decrease the dose if CrCl < 30 ml/min
80
For Anakinra (Kineret) AE
``` Injection site reactions • Headache, N/V, flu like symptoms • Hypersensitivity to e.coli derived proteins • Increased risk of serious infections • Decreased neutrophils ```
81
For Anakinra, suggested to monitor
``` Neutrophil count: – Prior to start – Monthly for 3 months – Quarterly for up to one year ```
82
For Anakinra, its the only
IL-1 inhibitor
83
Abatacept (Orencia) indication
moderate to severe RA
84
Abatacept (Orencia) can be used
monotherapy or in combination
85
Abatacept (Orencia) warnings
``` Do not use with TNF antagonists or IL 1 antagonists • Increased risk of infection • No live vaccination administration • Caution in patients with COPD ```
86
Abatacept (Orencia) warnings
``` Headache • Nausea • Upper respiratory infection • Nasopharingitis • Infusion reactions • Serious infection • Malignancy ```
87
IL-6 inhibitors
tocilizumab (Actrema ®) and sarilumab (Kevzara ®)
88
IL-6 inhibitors indication
Moderate to severe RA after inadequate response to one or more DMARDs – Alone or in combination with MTX or another DMARD
89
IL-6 inhibitors warnings
Black box warning : serious infections • Contraindicated in patients with liver toxicity, thrombocytopenia, and neutropenia
90
tocilizumab AE
``` Serious infection • Liver toxicity • Thrombocytopenia • Neutropenia • Lipid abnormalities • Intestinal perforations (tocilizumab) • Infusion reactions (tocilizumab) ```
91
Unique Tocilizumab AE
Lipid abnormalities
92
IL-6 inhibitors Monitoring Parameters
Neutrophil count at 4 8 weeks then every 3 months • Platelet count at 4 8 weeks then every 3 months • LFTS at 4 8 weeks then every 3 months • Lipid profile after 4 8 weeks then every 6 months
93
Rituximab (Rituxan) Indication
``` For moderate to severe RA – In those with inadequate response to TNF antagonists – In combination with MTX ```
94
Rituximab used...
in combination with MTX
95
Rituximab reserved...
...for those who failed or did not have adequate response to Anti-TNF reserved for later in therapy
96
Rituximab AE
``` Tumor lysis syndrome • Mucocutaneous reactions • Viral infection • Hypersensitivity • Renal toxicity • Bowel obstruction • Hepatitis B reactivation • Cardiac arrhythmia ```
97
Tafacitinib (Xeljanz, XR) Indication
Moderate to severe RA after inadequate response to MTX
98
Tafacitinib (Xeljanz, XR) used...
Alone or in combination with MTX or another DMARD
99
Tafacitinib (Xeljanz, XR) NOT used...
Not in combination with BRM, azathioprine, or cyclosporine
100
Tafacitinib Warnings
``` Cytochrome P 450 interactions • Do not use in hepatic impairment • Risk of infection (Black box warning) • Risk of malignancy (Black box warning) • Do not use if: – Hemoglobin < 9 mg/dL – ANC < 1000 cells/mm 3 – ALC < 500 cells/mm 3 ```
101
Tafacitinib AE
``` Upper respiratory – Headache – Diarrhea – Nasopharyngitis ```
102
Tafacitinib Monitoring Parameters
``` Lymphocyte count – Neutrophil count – Hemoglobin – Liver enzymes – Lipid profile ```
103
BARICITINIB (Olumiant ® ) indication
Moderate to severe RA after inadequate response to TNF – Alone or in combination with MTX or other DMARDs – Not in combination with BRM, azathioprine, or cyclosporine
104
In order to use BARICITINIB (Olumiant ® )...
must have failed a anti-TNF therapy
105
BARICITINIB WARNINGS
``` Do not use in severe hepatic impairment • Do not use if GFR < 60 ml/min • Risk of infection • Risk of malignancy • Risk of thrombosis • Do not use if: – Hemoglobin < 8 mg/dL – ANC < 1000 cells/mm 3 – ALC < 500 cells/mm 3 ```
106
BARICITINIB AE
``` Upper respiratory – Nausea – Herpes simplex virus – Herpes zoster ```
107
BARICITINIB Monitoring Parameter
``` Lymphocyte count – Neutrophil count – Hemoglobin – Lipid profile – Liver enzymes ```
108
UPADACITINIB (Rinvoq®) Indication
Moderate to severe RA after inadequate response to MTX
109
UPADACITINIB (Rinvoq®) used...
Alone or in combination with MTX or another non biologic DMARD
110
UPADACITINIB (Rinvoq®) not used...
Not in combination with BRM, azathioprine, or cyclosporine

Therapeutics IV (19 decks)

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