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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
Q

What is key w/ RA?

A

early tx to decrease disease severity

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26
Q

RA non-pharmacologic tx

A

education

emotional support

rest

weight reduction

physical therapy

heat

splints/prosthetics

surgery

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27
Q

RA pharmacologic tx

A

NSAIDs

corticosteroids

DMARDs (more specific to RA)

biologic agents anti-TNF

biologic agents non-TNF

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28
Q

NSAIDs & COX-2 Inhibitors Facts

A 
Effective in reducing pain, swelling, and stiffness
•
Do NOT alter disease progression
•
Dose at anti inflammatory doses
•
Use in combination with DMARDs
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29
Q

NSAIDs & COX-2 Inhibitors cannot be used for…

A

…MONOTHERAPY

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30
Q

NSAIDs & COX-2 Inhibitors MOA

A

Inhibits COX and thus inhibits formation of
prostaglandins and inflammatory mediators
(involved in pain and inflammation)

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31
Q

Celecoxib (Celebrex) Dose + Caution

A

Dose: 100 200 mg by mouth twice daily
–
CAUTION with sulfa allergy

(know anti-inflammatory doses)

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32
Q

Don’t use Celecoxib (Celebrex) in patients with a…

A

SULFA ALLERGY

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33
Q

Corticosteroids

A 
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

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34
Q

Corticosteroids not used for…

A

…MONOTHERAPY

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35
Q

Use corticosteroids in patients with an…

A

ACUTE FLARE

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36
Q

Corticosteroids MOA

A

inhibit IL-1 production

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37
Q

NSAIDs and DMARDs have…

A

steroid sparing effects

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38
Q

Corticosteroid SHORT term effects

A

hyperglycemia

gastritis

mood changes

elevated BP

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39
Q

Corticosteroid LONG term effects

A

aseptic necrosis

cataracts

obesity

growth failure

HPA suppression

osteoporosis

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40
Q

DMARDs Facts

A 
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
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41
Q

Methotrexate is the DMARD…

A

OF CHOICE

GOLD STANDARD

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42
Q

Methotrexate (MTX) Facts

A 
Most predictable benefit
•
DMARD of choice
•
DMARD with best long term outcome
•
MOA: inhibit dihydrofolic acid reductase
(inhibits neutrophil adhesion and chemotaxis)
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43
Q

Methotrexate Preferred administration

A

PO

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44
Q

Methotrexate Unique Dosing

A

7.5 mg PO PER WEEK

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45
Q

Methotrexate AE

A 
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
Q

What are the worst methotrexate AE?

A

Gastrointestinal impacts = N/V/D

Decreases Pt Compliance

47
Q

What should patients always have with methotrexate?

A

FOLIC ACID ( 1 mg/day) to reduce symptoms

48
Q

What should women be taking while taking methotrexate?

A

Birth control if during child bearing age

49
Q

MTX Contraindications

A 
Pregnancy
•
Chronic liver disease (EtOH)
•
Immunodeficiency
•
Pre existing blood dyscrasias
•
Pleural/peritoneal effusions
•
Leukopenia/Thrombocytopenia
•
CrCL < 40 mL/min
50
Q

Leflunomide (Arava) is a _________

A

pro-drug

51
Q

Leflunomide (Arava) Patients need what?

A

Loading dose

52
Q

Leflunomide T1/2

A

14 - 16 days

hepatobiliary clearance

53
Q

Leflunomide AE

A

diarrhea

rash

alopecia

increased LFTs

teratogenicity

54
Q

Sulfasalazine is a _______

A

pro-drug

55
Q

Sulfasalazine MOA

A

inhibits IL-1

56
Q

Which drugs should you be cautious using in sulfa allergy patients?

A

sulfasalazine and celecoxib

57
Q

Sulfasalazine AE

A 
Gastrointestinal
–
N/V/D, anorexia
•
Dermatologic
–
Rash/ Urticaria/ Photosensitivity
•
Hematologic
–
Leukopenia, thrombocytopenia
–
Rare: Hemolytic and aplastic anemia
•
Caution for allergy
58
Q

Role of hydroxychloroquine?

A

Use in early or less aggressive disease

59
Q

Advantage of hydroxychloroquine

A

its less efficacious but it DOES NOT have bone marrow suppression (myelosuppression)

60
Q

Hydroxychloroquine unique AE

A

retinal toxicity (night/peripheral vision changes)

caution in elderly pts

need routine patients

inform patients take with food

61
Q

Traditional DMARDs are…

A

conventional and ORAL agents

62
Q

TNF Neutralizers (Biologic DMARDs)

A 
Etanercept
•
Infliximab
•
Adalimumab
•
Golimumab
•
Certolizumab
63
Q

Anti-TNFs should not be used in combination with other….

A

IL-1 inhibitors or T-cell co stimulation modulators

64
Q

Anti-TNFs Warnings/Precautions

A 
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
Q

If using an anti-TNF, make sure the patient is not getting…

A

…a live vaccine

66
Q

Anti-TNF AEs

A 
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
Q

Etanercept (Enbrel) is used…

A

…monotherapy OR in combination with MTX

68
Q

Infliximab (Remicade) has…

A

mouse and human portions to reduce antigenic potential

69
Q

Infliximab (Remicade) Dosage Form

A

IV

70
Q

Infliximab (Remicade) indicated to be used with…

A

MTX~!

71
Q

Adalimumab (Humira) indicated

A

if pts had inadequate response to previous therapy

72
Q

Adalimumab (Humira) can be used…

A

alone OR in combination

73
Q

Golimumab (Simponi) used…

A

used in combination w/ MTX

74
Q

Golimumab (Simponi) indicated

A

moderate to severe RA

75
Q

Golimumab (Simponi) is a…

A

…human monoclonal antibody specific for TNF-alpha

76
Q

Golimumab (Simponi) requires…

A

Laboratory monitoring:

CBC with PLT

LFTS

77
Q

Certolizumab (Cimzia) can be used

A

alone OR in combination with non-BRM DMARDs

for moderate to severe disease

78
Q

Anakinra (Kineret) can be used…

A

alone or with other agents (not anti-TNFs)

79
Q

For Anakinra (Kineret)…[dosing]

A

can decrease the dose if CrCl < 30 ml/min

80
Q

For Anakinra (Kineret) AE

A 
Injection site reactions
•
Headache, N/V, flu like symptoms
•
Hypersensitivity to e.coli derived proteins
•
Increased risk of serious infections
•
Decreased neutrophils
81
Q

For Anakinra, suggested to monitor

A 
Neutrophil count:
–
Prior to start
–
Monthly for 3 months
–
Quarterly for up to one year
82
Q

For Anakinra, its the only

A

IL-1 inhibitor

83
Q

Abatacept (Orencia) indication

A

moderate to severe RA

84
Q

Abatacept (Orencia) can be used

A

monotherapy or in combination

85
Q

Abatacept (Orencia) warnings

A 
Do not use with TNF antagonists or IL 1
antagonists
•
Increased risk of infection
•
No live vaccination administration
•
Caution in patients with COPD
86
Q

Abatacept (Orencia) warnings

A 
Headache
•
Nausea
•
Upper respiratory infection
•
Nasopharingitis
•
Infusion reactions
•
Serious infection
•
Malignancy
87
Q

IL-6 inhibitors

A

tocilizumab (Actrema ®) and sarilumab (Kevzara ®)

88
Q

IL-6 inhibitors indication

A

Moderate to severe RA after inadequate response to
one or more DMARDs
–
Alone or in combination with MTX or another
DMARD

89
Q

IL-6 inhibitors warnings

A

Black box warning : serious infections
•
Contraindicated in patients with liver
toxicity, thrombocytopenia, and neutropenia

90
Q

tocilizumab AE

A 
Serious infection
•
Liver toxicity
•
Thrombocytopenia
•
Neutropenia
•
Lipid abnormalities
•
Intestinal perforations (tocilizumab)
•
Infusion reactions (tocilizumab)
91
Q

Unique Tocilizumab AE

A

Lipid abnormalities

92
Q

IL-6 inhibitors Monitoring Parameters

A

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
Q

Rituximab (Rituxan) Indication

A 
For moderate to severe RA
–
In those with inadequate response to TNF
antagonists
–
In combination with MTX
94
Q

Rituximab used…

A

in combination with MTX

95
Q

Rituximab reserved…

A

…for those who failed or did not have adequate response to Anti-TNF

reserved for later in therapy

96
Q

Rituximab AE

A 
Tumor lysis syndrome
•
Mucocutaneous reactions
•
Viral infection
•
Hypersensitivity
•
Renal toxicity
•
Bowel obstruction
•
Hepatitis B reactivation
•
Cardiac arrhythmia
97
Q

Tafacitinib (Xeljanz, XR) Indication

A

Moderate to severe RA after inadequate response to MTX

98
Q

Tafacitinib (Xeljanz, XR) used…

A

Alone or in combination with MTX or another DMARD

99
Q

Tafacitinib (Xeljanz, XR) NOT used…

A

Not in combination with BRM, azathioprine, or cyclosporine

100
Q

Tafacitinib Warnings

A 
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
Q

Tafacitinib AE

A 
Upper respiratory
–
Headache
–
Diarrhea
–
Nasopharyngitis
102
Q

Tafacitinib Monitoring Parameters

A 
Lymphocyte count
–
Neutrophil count
–
Hemoglobin
–
Liver enzymes
–
Lipid profile
103
Q

BARICITINIB (Olumiant ® ) indication

A

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
Q

In order to use BARICITINIB (Olumiant ® )…

A

must have failed a anti-TNF therapy

105
Q

BARICITINIB WARNINGS

A 
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
Q

BARICITINIB AE

A 
Upper respiratory
–
Nausea
–
Herpes simplex virus
–
Herpes zoster
107
Q

BARICITINIB Monitoring Parameter

A 
Lymphocyte count
–
Neutrophil count
–
Hemoglobin
–
Lipid profile
–
Liver enzymes
108
Q

UPADACITINIB (Rinvoq®) Indication

A

Moderate to severe RA after inadequate response to MTX

109
Q

UPADACITINIB (Rinvoq®) used…

A

Alone or in combination with MTX or another non biologic DMARD

110
Q

UPADACITINIB (Rinvoq®) not used…

A

Not in combination with BRM, azathioprine, or cyclosporine

Therapeutics IV (19 decks)

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