Rheumatoid Arthritis Flashcards
What is Rheumatoid Arthritis? What are the causes?
a chronic inflammatory immune disorder
- genetics = HLA-DR4
- infective
- heat shock proteins
- immunological = rheumatic factor
- hormonal
- environmental
What is symptoms of RA?
slow onset of pain, stiffness and swelling in the small joints of the hands and feet
- worse when waking in the morning
= ask about swelling, stiffness and squeeze
spindling of the fingers and other deformities
- swan neck, ulnar deformities
hammer toes
cervical instability
swollen wrist joints
joint effusions (swelling) and wasting of muscles around the affected joints
bursitis
nodule formation
How do NSAIDs and COX-2 inhibitors work? What are the different types and when are they used? What are the side effects?
NSAIDs - inhibit both isoforms of COX (1/2) causing impaired production of prostaglandins, prostacyclins and thromboxanes as well as reducing inflammation
COX-2 inhibitors - inhibit the COX-2 isoform only causing reducing inflammation
NSAIDS - ibuprofen (1.2g daily for minimal CVD risk but not used in active CVD) and naproxen (1g daily - can be used in CVD)
COX-2 inhibitors - etoricoxib, celecoxib (cannot be used in active CVD)
side effects - GI discomfort, nausea, diarrhoea, hypersensitivity reactions (rashes/angioedema), fluid retention, raised blood pressure, renal failure (can cause AKI)
When are corticosteroids used? Which are used and how can they be taken?
in acute exacerbation/flares
- are used to induce remission then reduced gradually to avoid an adrenal crisis
for short term bridging when starting a new conventional DMARD
- provides symptomatic relief while waiting for the cDMARD to take effect
oral prednisolone - 7.5mg once daily (low dose)
intra-articular hydrocortisone acetate
= can be done only 4 times a year
What are the short and long term side effects of corticosteroids?
extreme increased appetite
weight gain
skin thinning
easily bruising
osteoporosis
cushing’s syndrome
diabetes
depression
increased susceptibility to infections
- septicaemia, tuberculosis
depression
insomnia
peptic ulceration
increased blood pressure
cataracts
- blurred vision = need an opthalmologist
What monitoring can be done while on cDMARDs?
inflammatory markers
- erythrocyte sedimentation rate
- C-reactive protein
marker of severity of rheumatoid arthritis
- rheumatoid factor
What is Sulfasalazine? How is it taken? What is the onset time? When should it be used? What are the side effects? What should be monitored?
is an aminosalicylate
- 1st line treatment (if methotrexate is contraindicated)
500mg (OD) initially and titrated up until 2-3g daily
8-12 weeks onset
- can use low dose ICS alongside
side effects
- rashes, GI intolerance, bone marrow toxicity (neutropenia, leucopenia, thrombocytopenia)
bone marrow toxicity - sore throat, bruising, mouth ulcer
monitor - FBC, LFTs
CAN be taken during pregnancy
What is Methotrexate? How is it taken? What is the onset time? When should it be used? What are the side effects? What should be monitored? What are the requirements?
is an antifolate/antimetabolite
7.5mg weekly (max dose is 20mg weekly)
must take 5mg folic acid weekly alongside on an alternate day
6-8 weeks onset
- can use low dose ICS (prednisolone 7.5mg OD) alongside
side effects - liver/bone/pulmonary toxicity, nausea, stomatitis (mouth ulcer - folic acid)
monitor - FBC, LFTs, renal function
avoid aspirin and other NSAIDs - compete for excretion causing methotrexate toxicity
avoid trimethoprim - is an antifolate
need contraception - during and 6 months after as it IS teratogenic
What is Hydroxychloroquine? When should it be used? What are the side effects? What should be monitored?
cDMARD
lowest toxicity but can cause ocular toxicity
- retinopathy
= need retinal screening
CAN be taken during pregnancy
monitor - FBC, LFTs, U+Es and Vision
What is Leflunomide? How is it taken? What is the onset time? When should it be used? What are the side effects? What should be monitored? What are the requirements?
cDMARD
4-6 weeks onset (rapid)
metabolite has a long half life - requires a washout period before conception, must be < 20mcg/L
side effects - hepatotoxicity, increased risk of infection/malignancy, bone marrow toxicity (neutropenia, leucopenia, thrombocytopenia)
bone marrow toxicity - sore throat, bruising, mouth ulcer
monitor - FBC, LFTs, BP
need contraception - during and after (2 years for women, 3 months for men) as it IS teratogenic
What is Azathioprine? What are the side effects? What should be monitored? What are the requirements?
is steroid sparing
monitor - FBC (for signs of myelosuppression - pale skin, cold extremities, SOB, fatigue)
cannot be take with allopurinol (gout treatment) as allopurinol inhibits metabolism of azathioprine
What are lesser used cDMARDs?
gold - sodium aurothiomalate, auronofin
pencillamine
ciclosporin
cyclophosphamide
How is RA response to treatment measured?
DAS28 score - looks at the disease activity in the joints
< 2.6 = in remission
2.6-3.2 = low disease activity
3.2-5.1 = moderate disease activity, can be stepped unto tsDMARD or bDMARD
>5.1 = severe disease activity
a reduction of >1.2 after treatment is a good response and <0.6 is no response
What are the 2nd line treatment options?
targeted synthetic DMARDs (tsDMARD)
- JAK inhibitors = tofacitinib, upadacitinib, filgonitib, baricitnib
- are taken orally = work on enzymes
biological DMARDs (bDMARDs)
- TNF inhibitors = adalimumab, certolizumab pegot, etanercept, golimumab, infliximab
- interleukin 6 antagonist = tocilizumba, sarilumab
- T-lymphocytes antagonist = abatacept
- B-lymphocyte lysis = rituximab
- are given via injection = work on immune cells
Which tsDMARD and bDMARD are added when DAS28 is between 3.2-5.1?
only 5 options alongside methotrexate
- filgotinib and upadacitinib = tsDMARD
- adalimumab, etanercept and infliximab = bDMARD
