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PY7020 REVISION > Rheumatoid Arthritis > Flashcards

Rheumatoid Arthritis Flashcards

1
Q

What type of disorder is rheumatoid arthritis (RA)?

A

It is an inflammatory autoimmune disorder which leads to painful & disabling joints

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2
Q

What is the cause of death in patients with RA?

A

CVD, because the inflammatory mediators associated with RA also speed up atherosclerosis

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3
Q

Which gender is more prone to RA?

A

Females

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4
Q

What happens in the joints to cause RA?

A

Synovium of joints gets infiltrated by chronic inflammatory cells, leading to the creation of their own environment and forming a tumour (pannus)

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5
Q

What are the symptoms of RA?

A

Pain/stiffness/swelling of small joints of hands/feet
Hammer toes
Swollen wrist joints
Other joint deformities

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6
Q

What conditions are RA patients more at risk of developing?

A

Osteoporosis
Anaemia
Depression
CVD
Dry eye syndrome

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7
Q

Why is paracetamol not an ideal option to give in RA?

A

Because paracetamol is not non-inflammatory, so not ideal.

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8
Q

Why do NSAIDs produce GI side effects?

A

Because they inhibit PGE2 from the COX-1 enzyme, which is responsible for protecting the gastric mucosa

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9
Q

Why are corticosteroids powerful anti-inflammatory drugs?

A

Because they inhibit phospholipase A2, so arachidonic acid formation is also inhibited & this blocks all inflammatory pathways.

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10
Q

What drug is given if a patient has had a previous ulcer history, but no CVD?

A

A COX2 inhibitor, e.g. celecoxib or etoricoxib

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11
Q

Which 2 NSAIDs provide CV protectivity (include doses)?

A

Naproxen 1g
Ibuprofen 1.2g

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12
Q

When are corticosteroids given in RA?

A

Only during flare ups as they have rapid anti-inflammatory effects.

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13
Q

What are some side effects of corticosteroids?

A

Weight gain
Diabetes
Depression
Increased BP - from fluid retention
GI side effects

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13
Q

Which corticosteroid (with dose) is given to RA patients, & for how long?

A

Prednisolone 7.5mg weekly for 2-3 years to reduce the rate of joint destruction

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14
Q

What are the 4 conventional DMARDs which can be used in RA?

A

Methotrexate
Sulfasalazine
Leflunomide
Hydroxychloroquine

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15
Q

Which DMARD is given to women who are planning on getting pregnant?

A

Sulfasalazine

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16
Q

Which cDMARD must be given with long-term contraception?

A

Leflunomide

17
Q

What drugs are given in step 1 treatment of RA?

A

Methotrexate 7.5mg weekly (max 20mg weekly) + folic acid 5mg 24h after dose
Prednisolone 7.5mg daily for short-term use

18
Q

If methotrexate if not tolerated/appropriate as 1st line, what other drugs could you start the patient with?

A

Any other cDMARD (hydroxychloroquine, sulfasalazine, or leflunomide)

19
Q

What specific side effect should RA patients taking methotrexate look out for?

A

Shortness of breath, because it can cause pulmonary toxicity

20
Q

Which cDMARD can cause retinopathy & hence needs regular eye screenings?

A

Hydroxychloroquine

21
Q

Which cDMARD has the quickest onset of action (4-6 weeks)?

A

Leflunomide

22
Q

What are some side effects of leflunomide?

A

Increased BP
Hepatotoxicity
Increased risk of infections
Bone marrow toxicity

23
Q

What monitoring is required for methotrexate?

A

FBC
Renal function
LFTs

24
Q

What side effects should RA patients report if they are taking sulfasalazine?

Why should they be reported?

A

Bleeding
Unexpected bruising
Sore throat/fever

They should be reported because sulfasalazine reduces WBCs, which can lead to further blood disorders.

25
Q

What close monitoring should be done when taking sulfasalazine?

A

FBC + WBCs + platelet count

26
Q

What is the mechanism of action of methotrexate?

A

It inhibits the enzyme dihydrofolate reductase, which reduces folic acid levels in the body

27
Q

Why should NSAIDs/aspirin never be given with methotrexate?

A

Because NSAIDs/aspirin inhibit the renal excretion of MTX, causing toxicity.

28
Q

What is step 2 of RA treatment, if methotrexate alone hasn’t worked?

A

You add a second cDMARD (leflunomide/sulfasalazine) + prednisolone 7.5mg

29
Q

When do you add a biological DMARD or JAK inhibitor in RA treatment?

A

If methotrexate + other cDMARD has not worked.

30
Q

What is the DAS28 score? What does it take into account?

A

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

31
Q

What 2 DAS28 scores indicate moderate, & severe?

A

Moderate: >3.2
Severe: >5.1

32
Q

What are the 4 Janus Kinase inhibitors (JAKi) which can be given?

A

Remember it as BARI & TOFA

Tofacitinib
Baricitinib
Upadacitinib
Filgotinib

33
Q

What are the 3 bDMARDs which can be given?

A

Infliximab
Adalimumab
Etanercept

34
Q

If a patients DAS28 score is >5.1, what drug options can you give them?

A

Any JAK inhibitor or bDMARD, except rituximab

35
Q

What should you do if the patient is not responding to their bDMARD/JAK inhibitor?

A

Either change the bDMARD, or introduce rituximab (or switch to JAK inhibitor if not using it before)

36
Q

What change in the DAS28 score indicates a good response?

A

1.2

37
Q

What are the 4 drugs which can be used as the final step, if the patient cannot have rituximab/is intolerant?

A

Filgotinib (JAKi)
Updatacitinib (JAKi)
Sarilumab (IL-6 inhibitor)
Tocilizumab (IL-6 inhibitor)

38
Q

Which drug is only given as part of clinical trials in RA?

A

Akinra

39
Q

What is the whole step by step treatment for RA?

A

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

PY7020 REVISION (42 decks)

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