Rheumatoid Arthritis Flashcards
Prednisone counselling short term therapy
-insomnia take before 4pm
-stomach upset take w food
-monitor BP BG (inc both)
Prednisone side effects with long term therapy
-weight gain, moon face
-osteoporosis
-acne
-pancreatitis
-adrenal suppression
-increased risk of infection
-cataracts
-hyperglycemia
-hypertension
-muscle atrophy
-truncal obesity
-increased risk of MI
Arthrotec CI
Diclofenac/misoprostol
Abortifacient
csDMARDs include
methotrexate - gold standard
sulfasalazine - if MTX CI
hydroxychloroquine - mild disease
leflunomide - inc s/e
can csDMARDs be combined?
yes, tx can include MTX + adjunct sulfasalazine or hydroxychloroquine or leflunomide
which csDMARD treatment combination has the best evidence to support its use?
methotrexate, hydroxychloroquine and sulfasalazine (“triple therapy”) - superior in efficacy to methotrexate alone as initial therapy and similar to combination therapy
with methotrexate and a biologic
Improvement with csDMARDs may be
seen in ____ of therapy initiation and reach maximum effect in _____.
6–8 weeks
3–6 months
same for JAK inhibitors
Methotrexate dosing
dose: 20-25mg weekly with folic acid 5mg given 8-12h after (typically given the day after, or may also be daily)
Metoject IM but more commonly used SC in thigh or abdomen bc its less painful, safer, more effective than IM
Why give folic acid with Methotrexate?
reduces MTX toxicity - GI adverse effects, apthous ulcers, liver dysfunction
Methotrexate lab monitoring
baseline and monthly bloodwork (should be done 1-2 days just prior to the weekly MTX dose)
Methotrexate AE & DDI
side effects: Nausea/vomiting, diarrhea, mouth ulcers, flu-like aches, headache, pneumonitis (rare), sun sensitivity, hepatotoxicity
(elevated LFTs)
DDI: smoking may reduce efficacy, avoid alcohol at least within 24h of dose
Hydroxychloroquine administration
take w food or at bedtime to minimize flatulence
Hydroxychloroquine AE, DDI, monitoring
monitoring: eye exam at baseline then annually after 5 years for retinopathy
unique DDI: smoking may reduce efficacy
side effects: Nausea, abdominal cramping, diarrhea, flatulence, headache, skin rash, sun sensitivity, corneal and retinal deposition
with long term use at high dose
Sulfasalazine administration
take with food
Sulfasalazine AE
side effects: Dose related GI intolerance and headache. Hypersensitivity and sun sensitivity reactions (with or without fever),
diarrhea, can discolour urine (orange), oligospermia (reversible), bone marrow toxicity (rare), may affect fertility in men.
Leflunomide AE, DDI, monitoring
monitoring: labwork at baseline then every 2-3 months
side effects: Nausea, diarrhea, weight loss, hypertension, alopecia/hair thinning, hepatotoxicity (elevated LFTs), headache,
pneumonitis (rare)
DDI: avoid alcohol
other: loading dose not recommended
which csDMARDs require contraception?
MTX
leflunomide
JAK inhibitors names, brand names, mechanism, place in therapy
Tofacitinib Xeljanz®
Baricitinib Olumiant®
Janus kinase (JAK) inhibitor blocks signaling for several cytokines
are considered after bDMARD therapy has failed
JAK inhibitors counselling
Warning: TB screening required, Shingrix recommended prior, no live vaccines during, contraception recommended
Monitoring: regular labwork
Side effects: Headache, diarrhea, hepatotoxicity, bowel perforation, serious and opportunistic infections (including TB),
neutropenia, elevated lipids, malignancy, heart rate decrease and PR interval prolongation, interstitial lung disease,
liver enzymes elevation, increased CK, thrombosis risk
DDI: hold during antibiotic tx
Biologic DMARD considerations eg target TNF (infliximab, golimumab, etanercept, certolizumab, adalimumab), target T-cells
(abatacept), target B-cells (rituximab), and interleukin (tocilizumab, sarilumab)
may not be filled at regular pharmacy (IV or SC injections)
no live vaccines
screen for TB prior
hold while on antibiotics
TNF - Contraindicated with lupus, heart failure, demyelinating disease
T-Cell - may worsen COPD
considerations for vaccines while on DMARDs
There are no risks with killed vaccine. Vaccination should start when symptom burden and inflammatory
markers are low, ideally 2 weeks or more before DMARD initiation.
Live vaccines are safe for patients on methotrexate ≤25mg/week or glucocorticoids <20mg/day but not recommended while receiving Biologic DMARD therapy
considerations for vaccines while on DMARDs
There are no risks with killed vaccine. Vaccination should start when symptom burden and inflammatory
markers are low, ideally 2 weeks or more before DMARD initiation.
Live vaccines are safe for patients on methotrexate ≤25mg/week or glucocorticoids <20mg/day but not recommended while receiving Biologic DMARD therapy
NSAIDs role in therapy
NSAIDs have a role as an adjunct in relieving pain, but have no effect on underlying disease processes
Corticosteroids role in therapy
Corticosteroids rapidly reduce inflammation and can provide significant benefit as a bridging agent early on in RA treatment.[
Corticosteroids role in therapy
Corticosteroids rapidly reduce inflammation and can provide significant benefit as a bridging agent early on in RA treatment.
Patients on prolonged corticosteroid therapy should take calcium (total intake of 1200 mg/day, preferably from diet) and vitamin D supplementation
800–2000 units/day.
[100
Patients on prolonged corticosteroid therapy should take
-calcium (total intake of 1200 mg/day, preferably from diet) and vitamin D supplementation
800–2000 units/day.
-gastroprotective therapy, particularly with concomitant
NSAID use.
Corticosteroid injections can cause dysglycemia for
up to 10 days
