Rheumatoid Arthritis Flashcards
RA - Prodromal Symptoms
fatigue, weakness
fever
weight loss
decreased mood
myalgias
RA - Signs
symmetric swelling of hands / wrists / ankles / feet
synovitis, erythematous, warm
rheumatoid nodules present
grip weakness, muscle atrophy
RA - Symptoms
occur with use and rest
joint pain and stiffness last > 6 wks
decreased range of motion
joint deformity
RA - Complications
hematologic involvement
pulmonary involvement
cardiac involvement
ocular involvement
amyloidosis
vasculitis
osteoporosis
RA - Diagnosis
elevated ESR, CRP
elevated rheumatoid factor
elevated ANAs, ACPAs
RA - Goals of Therapy
decrease pain, maintain joint mobility, maintain ADLs
slow destructive joint changes
achieve low disease activity
RA - Conventional Synthetic DMARDs
methotrexate
leflunomide
hydroxychloroquine
sulfasalazine
RA - Biologic TNF Inhibitors
etanercept
infliximab
adalimumab
golimumab
certolizumab
RA - Biologic Non-TNF Inhibitors
abatacept
rituximab
tocilizumab
anakinra
sarilumab
RA - Targeted Synthetic DMARDs
JAK inhibitors (tofacitinib, baricitinib, upadacitinib)
Methotrexate - Adverse Reactions
stomatitis
dyspepsia
immunosuppression
Methotrexate - Boxed Warnings
GI toxicity
dermatological reactions
pulmonary fibrosis
myelosuppression
increased LFTs
Methotrexate - CIs
pregnancy & breastfeeding
renal & liver disease
immunodeficiency
myelosuppression
RA - Methotrexate’s Place in Therapy
first-line treatment, csDMARD of choice
except DMARD-naive with low disease activity
Leflunomide - Boxed Warnings
embryofetal toxicity
hepatotoxicity
Leflunomide - Adverse Reactions
NVD
alopecia
rash (SJS / TEN potential)
peripheral neuropathy
hypertension
Leflunomide - DDIs
warfarin (decreases INR)
inhibits OAT3 and OATP1B1/3
Leflunomide - Drug Elimination
with the help of cholestyramine
Sulfasalazine - Adverse Reactions
NV, abdominal pain
weight loss
headache
oligospermia
rash, pruritis, urticaria
hemolytic anemia
Sulfasalazine - CIs
intestinal or urinary obstruction
porphyria
sulfa allergy
Hydroxychloroquine - Adverse Reactions
NVD
irreversible retinal damage
QT prolongation
dermatological reactions
Hydroxychloroquine - Monitoring
ophthalmologic exam at baseline and every 3 months
Methotrexate - Monitoring
rule out pregnancy and check X-ray at baseline
Leflunomide - Monitoring
rule out pregnancy at baseline
Sulfasalazine - Monitoring
rule out G6PD deficiency at baseline
csDMARD - Monitoring
CBC
LFTs
SCr
DMARD-naive Recommendations - Moderate-to-High Disease Activity
csDMARD monotherapy
methotrexate recommended first line
DMARD-naive Recommendations - Low Disease Activity
csDMARD monotherapy
hydroxychloroquine recommended first line
RA - Biologic Therapy Indications
moderate-high disease activity despite csDMARD monotherapy
intolerance / CI to csDMARD
use in combination with MTX
RA - DMARD Recommendations at Target
continue regimen (do not reduce dose)
continue at least 1 DMARD
must be at target for 6 months before considering dose reduction
RA - DMARD Recommendation NOT at Target
try MTX if haven’t tried before
switch to SQ MTX if used PO before
add another csDMARD
add bDMARD or tsDMARD
TNF Inhibitors - Adverse Reactions
infections
injection site reactions
URTIs
rash
TNF Inhibitors - BBWs
malignancy
serious infections (TB, sepsis, fungal, opportunistic)
Rituximab - Monitoring
CBC with each dose
Biologic DMARDs - Monitoring
latent TB at baseline and throughout treatment
JAK Inhibitors - BBWs
opportunistic infections
malignancies
thrombosis
JAK Inhibitors - Adverse Reactions
increased HDL / LDL
headache
URTI
infections
RA - Drugs to Avoid in Pregnancy
methotrexate
leflunomide
RA - Drugs to Use in TB
JAK inhibitor or biologic after 1 month of TB treatment
RA - Drugs to Use in HF
non-TNF inhibitor or JAK inhibitor
RA - Drugs to Use in Lymphoproliferative Disorder
rituximab
RA - Drugs to Avoid in Liver Disease
methotrexate
leflunomide
RA - Vaccines Before Treatment Initiation
pneumococcal
influenza
hepatitis B
HPV
live Herpes Zoster
