Rheumatoid Arthritis Flashcards by Keri Courtnage

which drugs are TNFa inhibitors

adalimumab
certolizumab
etanercept
golimumab
infliximab

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which drugs are anti-IL-6

tocilizumab
sarcilumab

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which drugs are anti IL-1

anakinra

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which drugs are anti CD-20

rituximab

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which drugs are JAK inhibitors

tofacitinib
baricitinib
upadacitinib

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which drug binds to CD80/CD86 and inhibits T cell activation

abatacept

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in RA, the inflammatory pathway is _____

multifactorial

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role of T lymphocytes in RA?

stimulate the release of more inflammatory cytokines, matrix enzymes, osteoclasts, and B lymphocytes

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how are T lymphocytes activated
(*note: which drug works here)

require 2 signals: stimulation by proinflammatory cytokines, binding of CD28 (on T cell) with CD80/86 on APC
abatacept works here

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general role of proinflammatory cytokines in RA?

creates an imbalance, inflammation results

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B lymphocytes are the _____ component

humoral

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role of B lymphocytes in RA?

producing autoantibodies (antibodies directed against self; not pathogenic)

activation of complement system; stimulating further release of proinflammatory cytokines

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what are autoantibodies associated with RA?

rheumatoid factor (RF) and anti-cyclic citrullinated protein antibody (ACPA)

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______ is a transmembrane protein on B lymphocytes involved with their activation, proliferation, and differentiation
(*note: which drug works here)

CD20
rituximab

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what is the role of janus kinase in RA?

regulates leukocyte maturation and activationi

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when synovium becomes enlarged/thick, it is called ____

pannus

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key notes of the clinical presentation of RA

morning stiffness >30 min
fatigue, weakness
joint pain at rest
synovitis/inflamed joints
soft and spongey

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key notes of clinical presentation of OA

morning stiffness <30 min
crepitus
deep aching pain
pain aggravated with use
pain relieved by rest
hard and body (osteophytes)

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which joints are involved in RA

more proximal joints: MCP, PIP

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which joints are involved in OA

more distal joints: PIP, DIP

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2 key points of value in differentiating RA from OA

symmetry, noninvolvement of DIP joints

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what is a common extraarticular manifestation of RA

rheumatoid nodules

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what are the extra-articular manifestations of RA

cardiac, rheumatoid nodules, pulmonary, vasculitis, ocular, hematologic, osteopenia

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what are the KEY lab findings to RA (four)

ESR, CRP, RF, ACPA

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what does seropositive mean

presence of RF or ACPA

what are the factors of a worse RA prognosis

seropositive, elevated ESR, extra-articular involvement (including nodules), poor functional status initially, bone erosion per X-ray, older age, female, genotype, cigarette smoking

2 requirements for RA diagnosis

1. patient with at least one joint with definite clinical synovitis 2. synovitis is not better explained by another disease (gout, SLE)

define remission in RA

- not more than one tender or swollen joint - CRP<1 - positive patient global assessment

you should initiate DMARDs within what time frame

3 months of diagnosis

what are the nonbiologic DMARDs

methotrexate, leflunomide, hydroxychloroquine, sulfasalazine

which nonbiologic DMARD is preferred

methotrexate

which two nonbiologic DMARDs can never be combined together

methotrexate & leflunomide (liver toxicity)

methotrexate can be used to _____ with biologics

reduce the formation of antibodies to biologics

how is methotrexate dosed

weekly, oral or injectable 50% dose reduction when CrCL<50

how to improve methotrexate tolerability at high doses

give the weekly dose split by 12 hours

onset of nonbiologic DMARDs?

1-2 months

absolute contraindication methotrexate/leflunomide

pregnancy/lactation

relative contraindications methotrexate

acute bacterial infection, latent TB, chronic liver dx, CrCL<30, pleural/peritoneal effusions, immunodeficiency, leukopenia, thrombocytopenia

adverse effects of methotrexate

stomatitis, n/d, increased liver enzymes, rash, alopecia, hematologic, pulmonary infiltrates

how to reduce adverse effects of methotrexate

folic acid 5 mg/week or 1 mg/day

methotrexate drug interactions

TMP/SMZ, PPI's

clinical pearls for leflunomide?

avoid pregnancy for TWO YEARS after stopping. cholestyramine or activated charcoal is recommended to help lower plasma levels of leflunomide more quickly

which nonbiologic DMARD has a loading dose

leflunomide

toxicity with leflunomide

hepatotoxicity (inc. with MTX), diarrhea, alopecia, rash, HA, peripheral neuropathy

which nonbiologic DMARDs are typically used in early/less aggressive disease or as adjunct

hydroxychloroquine, sulfasalazine

clinical pearl for hydroxychloroquine

complete an eye exam within the first year of treatment to monitor for macular damage, start an annual exam after 5 years

adverse reactions of hydroxychloroquine

GI, derm, macular damage, potential QT prolongation

which nonbiologic DMARDs CAN be used in pregnancy

hydroxychloroquine and sulfasalazine

contraindications for sulfasalazine

platelets <50,000, liver disease, sulfa allergysi

side effects for sulfasalazine

GI, derm, myelosuppression, LFTs, may cause urine to turn orange/yellow

drug interactions with sulfasalazine

antibiotics, iron, warfarin

all biologics are associated with an increased risk of ____

infection

with all biologics, you need to screen for ___

TB, HepB/C

with biologics, you need to avoid ____

live vaccines

when switching biologics, how do you know when to give the new agent

initiate it when the patient is due for their previous biologic

the onset of symptom relief is _____ with biologics

FASTER

what are the first line biologics

TNF antagonists

the time frame to MAX effect with TNF is ___, but there is a faster onset of symptom relief

3 months

DO NOT USE TNF antagonists in ____

patients with moderate to severe heart failure (NYHA III/IV)

which TNF is IV only and you have to go to an infusion center

infliximab (remicade)

adverse effects TNF

reaction to injection/infusion, infections and malignancies, new onset/exacerbation multiple sclerosis

use caution with use of abatacept in patients with ____

COPD

abatacept adverse effects

site reaction, headache, URTI, nasopharyngitis, nausea, COPD worsening, infections and malignancies

rituximab is first line for patients with ____

lymphoproliferative disorders

how is rituximab dosed

2 infusions given 2 weeks apart, recovery of B cells can take months; give q16-24 weeks

adverse effects rituximab

site reaction, URTIs, nasopharyngitis, UTI, bronchitis, bowel obstruction, blood cell disorders, CV events

niche with IL-6

don't typically need addition of methotrexate to improve efficacy

JAK inhibitors dosage form

oral

boxed warning JAK inhibitors

thromboembolism

true/false: NSAIDs alter course of RA disease and prevent joint erosion

false

what dose corticosteroids to use for RA

lowest dose as possible, <10 mg of prednisone or equivalent, short term to control flares or bridge