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54 MSK > Rheumatoid arthritis > Flashcards

Rheumatoid arthritis Flashcards

1
Q

How does MTX cause bone marrow suppression and GI disturbances?

A

MTX inhibits dihydrofolate reductase (DHFR), reducing levels of tetrahydrofolate and thus synthesis of purines and pyrimidines. This inhibition leads to decrease in production of DNA, RNA & certain AAs, ultimately disrupting growth and pro-life of rapidly divings cells such as those found in bone marrow and walls of GIT.

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2
Q

Clinical presentation of RA

A
  1. Pain
  2. Swelling
  3. Redness and warm
    4. Early morning stiffness >30 min
    5. Symmetrical polyarthritis
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3
Q

Laboratory findings 1

A

Autoantibodies
- Rheumatoid factor RF +(ve)
- Anti citrullinated peptide antibodies ACPA , anti-CCP assays (+ve)

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4
Q

Laboratory findings 2

A

ESR increase
CRP increase

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5
Q

Laboratory findings 3

A

Hg decrease
Platelets increase
WBC increase

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6
Q

Diagnosis of RA

A

At least 4 of:
1. Early morning stiffness >1 hour >6 weeks
2. Swelling of >3 joints >6 weeks
4. Swelling of wrist/MCP/PIP joints >6 weeks
5. Rheumatoid nodules
6. +ve RF &/ anti-CCP tests
7. Radiographic changes

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7
Q

Drugs used in RA

A
  1. NSAIDs
  2. Glucocorticoids
  3. DMARDs
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8
Q

Drug class of MTX

A

csDMARDs

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9
Q

Drug class of Adalimumab

A

bDMARDs

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10
Q

Drug class of Tofacitinib

A

tsDMARDS

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11
Q

Drug class of Infliximab

A

bDMARDs

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12
Q

Drug class of Etanercept

A

bDMARDs

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13
Q

Drug class of Golimumab

A

bDMARDs

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14
Q

Drug class of Anakinra

A

bDMARDs (not available in SG)

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15
Q

Drug class of Rituximab

A

bDMARDs

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16
Q

Drug class of Abatacept

A

bDMARDs (not available in SG)

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17
Q

1st line treatment of RA

A

MTX monotherapy
Short term low-dose GC can be added when initiating

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18
Q

Dose of MTX

A

Initiation : 7.5mg once weekly
2.5-5mg/week increment every 4-12 weeks
Target: 15mg/week

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19
Q

What needs to be co-prescribed with MTX? Why?

A

Folic acid 5mg/week
Rescue therapy: Folic acid, a synthetic form of the naturally occuring vitamin B9, helps prevent MTX-induced side effects by counteracting the reduced level of tetrahydrofolate.

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20
Q

Dose adjustment of MTX

A

CrCl<50ml/min: 50%
CrCl<30ml/min: AVOID

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21
Q

SE/cautions of MTX

A

GI: N/V, diarrhoea
Increases liver transaminase
Myelosuppression
TENS/SJS
Teratigenic

22
Q

Monitoring of MTX

A

FBC
LFT (AST, ALT, albumin, bilirubin)
SCr

23
Q

MOA of sulfasalazine

A

Modulates leukotrienes
Inhibit TNF

24
Q

CI of sulfasalazine

A

Sulfonamides allergies
Caution in G6PD deficiency

25
MOA of hydroxychloroquine
Inhibits locomotion of neutrophils, chemotaxis of eosinophils, complement-dependent antigen-antibody reactions
26
MOA of leflunomides
Decrease lymphocyte action
27
Dose adjustment of leflunomides
ALT>2x ULN: AVOID
28
CI of hydroxychloroquine
Pre-existing retinopathy G^PD deficiency
29
Caution for leflunomides
Very long half life Requires wash out by cholestyramine *Teratogenic*
30
On MTX, but not at target
Add bDMARD/tsDMARD
31
With bDMARDs/tsDMARDs, not at target
Switch to bDMARD or tsDMARD of different class
32
MOA of bDMARD
Binds to cytokines or their receptors to down regulate or inhibit their functions, which reduces immune and inflammatory responses
33
MOA of tsDMARD
Binds to JAK proteins inside cells to prevent JAKs from transphosphorylating the associated cytokine and growth factor receptor
34
DMARDs with TNF-alpha target
1. Adalimumab 2. Etanercept 3. Golimumab 4. Infliximab
35
DMARDs with IL-1 target
Anakinra
36
DMARDs with IL-6 target
Tocilizumab
37
DMARDs with CD20 target
Rituximab
38
DMARDs with CD28 target
Abatacept
39
Initiating DMARDs
1. Pre-treatment screening - TB - Hepatitis B&C 2. Vaccination - Pneumococcal - Influenza - Hepatitis B - Varicella zoster 3. Laboratory screening - FBC - LFT - Lipid panel - SCr
40
Safety concerns of bDMARDs/tsDMARDs 1
Injection site/infusion reaction
41
Safety concerns of bDMARDs/tsDMARDs 2
Myelosuppression - Monitor FBC with WBC differentials & platelet count
42
Safety concerns of bDMARDs/tsDMARDs 3
Infections - URTI, TB, opportunistic infections
43
Safety concerns of bDMARDs/tsDMARDs 4
Malignancy risk
44
Safety concerns of bDMARDs/tsDMARDs 5
Autoimmune diseases
45
Safety concerns of bDMARDs/tsDMARDs 6
CVD - HF (Avoid TNF-a inhibitors in NYHA class III & IV), HTN
46
Safety concerns of bDMARDs/tsDMARDs 7
Hepatic - Monitor LFT
47
Safety concerns of bDMARDs/tsDMARDs 8
Metabolic effects - Hyperlipidemia: monitor lipid panel
48
Safety concerns of bDMARDs/tsDMARDs 9
Pulmonary diseases
49
Safety concerns of bDMARDs/tsDMARDs 10
GI perforation - Especially IL-6 & JAK inhibitors
50
Safety concerns of bDMARDs/tsDMARDs 11
Thrombosis - Especially IL-6 & JAK inhibitors

54 MSK (6 decks)

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