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PMY2107 Applied Clinical Pharmacology and Therapeutics > Rheumatoid Arthritis > Flashcards

Rheumatoid Arthritis Flashcards

1
Q

What is the disease of the synovium characterised by?

A
  • infiltration of the synovium by lymphoid cells.
  • formation of new blood vessels.
  • synovial proliferation.
  • joint destruction.
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2
Q

What is the consequence of synovial proliferation?

A

Proliferation of the synovium leads to formation of granulation tissue (called pannus) which overgrows and invades certain adjacent cartilage and bone resulting in irreversible erosions on the bony surface.

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3
Q

What are the early signs of RA which occur within joint?

A

Swelling of the synovial membrane and connective tissue.

Effusion of watery fluid into joint space.

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4
Q

If RA signs are not controlled early enough, an inflammatory response can persist. What are the signs of this inflammatory response occurring in the joint?

A

Joint laxity (very flexible joints).
Severe erosion of bone.
Deformity due to dislocation.

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5
Q

What is the clinical presentation of RA (signs presented on appointment)?

A

Signs of inflammation (PRISH).
Pain on movement.
Later on in disease - pain on rest and morning stiffness.
Flare-ups - stiffness all day.
Non-articular presentation - symptoms not related to joint.

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6
Q

What can happen if RA of hands is left untreated?

A

Complete loss of function of hands.

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7
Q

List some non-articular presentations.

A

Vasculitis.
Anaemia.
Rheumatoid nodules (outgrowths in subcutaneous tissue).
Dry, gritty eyes.

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8
Q

What is vasculitis?

A

It is the inflammation of blood vessels.

  • seen in more severe disease
  • sign of poorer long-term prognosis
  • noticeable in fingers
  • lungs/kidneys can rapidly fail
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9
Q

ESR & CRP are useful to measure presence and severity of inflammation and response to treatment.
CRP and ESR levels decrease once drug is initiated. What is the normal and RA levels for both parameters?

A 
ESR: 
Normal = 2-5mm/hr
RA = 50mm/hr
CRP:
Normal = 0-6mg/l
RA = >10mg/l
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10
Q

What are csDMARDs?

A

Conventional synthetic DMARDs.

  • traditional drugs
    e. g. methotrexate, leflunomide, sulfasalazine, hydroxychloroquine
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11
Q

What does DMARDs stand for?

A

Disease Modifying Anti-Rheumatic Drugs.

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12
Q

What are tsDMARDs?

A

Targeted synthetic DMARDs.

  • target a particular molecular structure
    e. g. JAK inhibitors
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13
Q

What are bDMARDs?

A

Biological DMARDs.

  • biological therapies
    e. g. TNF alpha inhibitors
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14
Q

What is the most commonly prescribed csDMARD and describe the MOA?

A

Methotrexate.
By inhibiting dihydrofolate reductase and other intracellular enzymes, leading to inhibition of T and B cell activation. Not activated = reduced inflammation.

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15
Q

What is methotrexate contraindicated in?

A

Pre-existing hepatic disease.
Alcoholism/heavy drinking.
Impaired renal function.
Pregnancy.

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16
Q

What 3 drugs can methotrexate interact with and why?

A

NSAIDs, oral hypoglycaemics, phenytoin.

Methotrexate is highly protein bound, these drugs can free methotrexate, increasing conc., resulting in toxicity.

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17
Q

Why should folic acid be given to patients on methotrexate?

A

Folic acid 5mg. Given 48 hours after methotrexate administration.
Minimise side effects such as bone marrow suppression.

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18
Q

What are two side effects associated with sulfasalazine?

A

Haematological rash - settles with treatment.

Nausea - avoided by using enteric coated tablets.

19
Q

What is sulfasalazine contraindicated in?

A

Previous hepatic disease.

Pregnancy.

20
Q

List the side effects of leflunomide.

A

Skin disorders
Diarrhoea
Abdominal pain
Potential toxicity when used in combination with other DMARDs.

21
Q

What is the contraindication of leflunomide?

A

Pregnancy.

22
Q

What is the side effect of hydroxychloroquine use?

A

Retinopathy.

- regular retinal checks done - caused a decline in use.

23
Q

What is TNF alpha?

A

Tumour Necrosis Factor alpha.

- pro-inflammatory cytokine produced by macrophages and lymphocytes.

24
Q

Why would a person require a bDMARD?

A

Used for people who do not respond to csDMARDs.

25
Q

How are TNF alpha inhibitors administered and give examples?

A

IV or SC.
Infliximab - IV infusion.
Etanercept or Adalimumab - SC injection.

26
Q

What is the IV dose for influximab?

A

3mg/kg as IV infusion at 0, 2, 4 then every 8 weeks.

Can be increased in increments of 1.5mg/kg every 8 weeks to maximum of 7.5mg/kg every 8 weeks.

27
Q

Infliximab must be given with csDMARD, methotrexate. Why?

A

Improves symptoms and signs or inflammation.
Improves physical function and quality of life.
Reduces radiographic evidence of of progressive joint damage.

28
Q

Issue with using infliximab is the production of HACA. What is HACA and how can this be prevented?

A

HACA is Human Anti-Chimeric Antibodies. HACA blocks infliximab from binding to TNF alpha - allows inflammation to continue.
Can be prevented by taking methotrexate concurrently with infliximab.

29
Q

What are the 4 problems associated with infliximab?

A
  1. Causes production of HACA.
  2. Risk of allergy/anaphylactic shock - should be adm in hospital.
  3. Risk of infection or malignancy.
  4. Contraindicated in severe/moderate heart failure.
30
Q

What it is etanercept and why doesn’t it cause production of HACA?

A

Etanercept is a genetically engineered fusion protein. Due it being a protein, HACA is not produced.

31
Q

What is the administration and dosing like for etanercept?

A

Subcutaneously.
25mg injection twice weekly OR 50mg injection once a week.
Sef-administered.

32
Q

What are the side effects of etanercept?

A

Injection site reactions/infection.
Respiratory tract infection.
Blood disorders.

33
Q

What is the administration and dosing like for adalimumab?

A

Subcutaneously. Self-administered.
40mg injection fortnightly.
40mg injection every week (without methotrexate).
Onset of action = 1-2 weeks.

34
Q

What are the side effects of etanercept?

A

Injection site reactions/infection.
Respiratory tract infection.
Blood disorders.

35
Q

In what circumstance does NICE recommend bDMARDs to be given to treat active RA in adults?

A
  • If intensive therapy with 2 or more csDMARDs has not controlled the disease.
  • If disease is moderate.
36
Q

When should bDMARDs be withdrawn as said by NICE?

A

If side effects develop.

If no response after 6 months.

37
Q

What are 3 other options of drugs to be used if bDMARDs don’t work?

A

Rituximab.
Abatacept.
tsDMARDs - JAK inhibitors.

38
Q

Rituximab is often given as an alternative if csDMARDS and bDMARDs don’t work. What is it?

A

It is monoclonal antibody.

It depletes the B cell population - prevents production of pro-inflammatory immunoglobulins.

39
Q

What is the administration and dosing like for rituximab?

A

IV infusion.
Two 1000mg IV infusions given two weeks apart.
NICE recommends rituximab to be taken with methotrexate.

40
Q

What is the administration and dosing like for abatacept?

Dosing depends on weight

A

IV infusion.

  • up to 60kg = 500mg 0, 2, 4 weeks in 3 doses every two weeks. 500mg every 4 weeks after. Review at 6 months.
  • 60-100kg = 750mg…
  • above 101kg = 1000mg…
41
Q

According to NICE, in what conditions should abatacept be taken with methotrexate?

A

If patient has severe active RA.

Has insufficient response to at least 2 csDMARDs and at least one TNF alpha inhibitor.

42
Q

What is the role of JAK?

A

The binding of cytokines to their receptors on the cell surface results in JAK activation. This drives the expression of proteins involved in inflammatory processes.

43
Q

What do JAK inhibitors do?

A

Attenuate intracellular messaging of several different cytokines.

44
Q

Give 3 examples of JAK inhibitiors?

A

Baricitinib
Tofacitinib
Upadacitinib

PMY2107 Applied Clinical Pharmacology and Therapeutics (21 decks)

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