Rheumatoid Arthritis Flashcards
What type of disorder is rheumatoid arthritis (RA)?
It is an inflammatory autoimmune disorder which leads to painful & disabling joints
What is the cause of death in patients with RA?
CVD, because the inflammatory mediators associated with RA also speed up atherosclerosis
Which gender is more prone to RA?
Females
What happens in the joints to cause RA?
Synovium of joints gets infiltrated by chronic inflammatory cells, leading to the creation of their own environment and forming a tumour (pannus)
What are the symptoms of RA?
Pain/stiffness/swelling of small joints of hands/feet
Hammer toes
Swollen wrist joints
Other joint deformities
What conditions are RA patients more at risk of developing?
Osteoporosis
Anaemia
Depression
CVD
Dry eye syndrome
Why is paracetamol not an ideal option to give in RA?
Because paracetamol is not non-inflammatory, so not ideal.
Why do NSAIDs produce GI side effects?
Because they inhibit PGE2 from the COX-1 enzyme, which is responsible for protecting the gastric mucosa
Why are corticosteroids powerful anti-inflammatory drugs?
Because they inhibit phospholipase A2, so arachidonic acid formation is also inhibited & this blocks all inflammatory pathways.
What drug is given if a patient has had a previous ulcer history, but no CVD?
A COX2 inhibitor, e.g. celecoxib or etoricoxib
Which 2 NSAIDs provide CV protectivity (include doses)?
Naproxen 1g
Ibuprofen 1.2g
When are corticosteroids given in RA?
Only during flare ups as they have rapid anti-inflammatory effects.
What are some side effects of corticosteroids?
Weight gain
Diabetes
Depression
Increased BP - from fluid retention
GI side effects
Which corticosteroid (with dose) is given to RA patients, & for how long?
Prednisolone 7.5mg weekly for 2-3 years to reduce the rate of joint destruction
What are the 4 conventional DMARDs which can be used in RA?
Methotrexate
Sulfasalazine
Leflunomide
Hydroxychloroquine
Which DMARD is given to women who are planning on getting pregnant?
Sulfasalazine
Which cDMARD must be given with long-term contraception?
Leflunomide
What drugs are given in step 1 treatment of RA?
Methotrexate 7.5mg weekly (max 20mg weekly) + folic acid 5mg 24h after dose
Prednisolone 7.5mg daily for short-term use
If methotrexate if not tolerated/appropriate as 1st line, what other drugs could you start the patient with?
Any other cDMARD (hydroxychloroquine, sulfasalazine, or leflunomide)
What specific side effect should RA patients taking methotrexate look out for?
Shortness of breath, because it can cause pulmonary toxicity
Which cDMARD can cause retinopathy & hence needs regular eye screenings?
Hydroxychloroquine
Which cDMARD has the quickest onset of action (4-6 weeks)?
Leflunomide
What are some side effects of leflunomide?
Increased BP
Hepatotoxicity
Increased risk of infections
Bone marrow toxicity
What monitoring is required for methotrexate?
FBC
Renal function
LFTs
What side effects should RA patients report if they are taking sulfasalazine?
Why should they be reported?
Bleeding
Unexpected bruising
Sore throat/fever
They should be reported because sulfasalazine reduces WBCs, which can lead to further blood disorders.
What close monitoring should be done when taking sulfasalazine?
FBC + WBCs + platelet count
What is the mechanism of action of methotrexate?
It inhibits the enzyme dihydrofolate reductase, which reduces folic acid levels in the body
Why should NSAIDs/aspirin never be given with methotrexate?
Because NSAIDs/aspirin inhibit the renal excretion of MTX, causing toxicity.
What is step 2 of RA treatment, if methotrexate alone hasn’t worked?
You add a second cDMARD (leflunomide/sulfasalazine) + prednisolone 7.5mg
When do you add a biological DMARD or JAK inhibitor in RA treatment?
If methotrexate + other cDMARD has not worked.
What is the DAS28 score? What does it take into account?
Scoring system /10 which measures the disease activity of RA
It takes into account:
How many joints are tender, swollen, ESR, and how the person is feeling
What 2 DAS28 scores indicate moderate, & severe?
Moderate: >3.2
Severe: >5.1
What are the 4 Janus Kinase inhibitors (JAKi) which can be given?
Remember it as BARI & TOFA
Tofacitinib
Baricitinib
Upadacitinib
Filgotinib
What are the 3 bDMARDs which can be given?
Infliximab
Adalimumab
Etanercept
If a patients DAS28 score is >5.1, what drug options can you give them?
Any JAK inhibitor or bDMARD, except rituximab
What should you do if the patient is not responding to their bDMARD/JAK inhibitor?
Either change the bDMARD, or introduce rituximab (or switch to JAK inhibitor if not using it before)
What change in the DAS28 score indicates a good response?
1.2
What are the 4 drugs which can be used as the final step, if the patient cannot have rituximab/is intolerant?
Filgotinib (JAKi)
Updatacitinib (JAKi)
Sarilumab (IL-6 inhibitor)
Tocilizumab (IL-6 inhibitor)
Which drug is only given as part of clinical trials in RA?
Akinra
What is the whole step by step treatment for RA?
STEP 1: cMARD given (MTX 7.5mg weekly + 5mg folic acid+ prednisolone 7.5mg)
STEP 2: If cannot take MTX, then give either leflunomide, sulfalazine, or hydroxychloroquine
STEP 3: If above unresponsive, measure DAS28 score. If it is >3.2, you can choose either:
- bDMAD: infliximab, etanercept, or adalimumab
- JAK inhibitor: filgotinib, or upadacitinib
STEP 4: If above unresponsive, & their DAS28 is >5.1, you can give any JAK inhibitor (tofacitinib, baricitinib, upadacitinib, or filgotinib) or bDMAD
STEP 5: If their DAS28 is still high, either initiate rituximab or choose another drug
STEP 6: If their DAS28 is still >5.1, you HAVE to give rituximab
STEP 7: If rituximab not tolerated, then any medication can be given
STEP 8: if the above step does not work, you can choose from: filgotinib, upadacitinib, sarilumab, or tocilizumab
