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702 > Rheumatoid Arthritis > Flashcards

Rheumatoid Arthritis Flashcards

1
Q

What are prodromal symptoms of RA?

A
  • Fatigue
  • Fever
  • Weakness
  • Weight loss
  • Decreased mood
  • Myalgias before joint swelling
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2
Q

What are disease flares?

A

Sudden increases in s/s that can last days to months

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3
Q

When does RA go from early to established?

A

6 months

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4
Q

What are signs of RA?

A
  • Synovitis
  • Joint erythema
  • Rheumatoid nodules
  • Potential grip weakness, deformity, muscle atrophy
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5
Q

What are symptoms of RA?

A

Occur with use AND at rest***
- Joint pain and stiffening >6 weeks
- Prodromal symptoms
- Decreased ROM
- Joint deformity (late in disease)

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6
Q

What are the most common joints involved in RA?

A

Hands, wrists, ankles, and feet (often bilaterally)

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7
Q

What extra-articular involvement can occur in RA?

A
  • Rheumatoid nodules
  • Pulmonary complications
  • Vasculitis
  • Ocular manifestations
  • Cardiac involvement
  • Hematologic involvement
  • Lymphadenopathy
  • Amyloidosis
  • Osteoporosis
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8
Q

What are the four domains of the ACR/EULAR scoring system?

A

Joint involvement
Serology
Acute-phase reactants
Duration of symptoms

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9
Q

What are pearls of RA as opposed to OA?

A
  • Variable age and onset
  • Generalized malaise
  • Smaller joints
  • Prolonged stiffness >1 hour
  • With use and at rest
  • Bilateral
  • Auto-antibodies present
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10
Q

What are the goals of RA therapy?

A
  • Improve/maintain functional status (pain, joint mobility, ADLs)
  • Slow destructive joint changes (treat early and aggressive)
  • Achieve disease remission
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11
Q

What are non-pharm treatments for RA?

A
  • Rest
  • Weight loss
  • Pain coping skills
  • PT or OT
  • Surgery for severe RA
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12
Q

What are pharmacologic treatments of RA?

A

NSAIDs (not monotherapy)
Corticosteroids (not monotherapy)
DMARDs

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13
Q

In early RA, what is first line for moderate or severe disease activity?

A

Methotrexate

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14
Q

In early RA, what is first line for low disease activity?

A

Hydroxychloroquine

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15
Q

A patient is experiencing moderate-high disease activity despite DMARD therapy, what are our options?

A
  • csDMARDs
  • bDMARD +/- methotrexate
  • tsDMARD +/- methotrexate

Consider short-term corticosteroids

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16
Q

A patient is not at target with oral MTX and is experiencing moderate-high disease activity, what should we do?

A

Switch to SQ MTX

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17
Q

A patient is using a csDMARD other than MTX and is experiencing moderate-high disease activity, what should we do?

A

Switch to MTX monotherapy

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18
Q

After trying a DMARD, a patient is experiencing moderate-high disease activity and has no poor prognostic factors or preference, what should we do?

A

Add additional csDMARD

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19
Q

After trying a DMARD, a patient is experiencing moderate-high disease activity and has poor prognostic factors, what should we do?

A

Add tsDMARD or bDMARD

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20
Q

What are examples of poor prognostic factors?

A
  • High disease activity
  • Early presence of erosion
  • Autoantibody positivity
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21
Q

What are bDMARDs?

A

Biologics: -mabs, -cepts

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22
Q

What are tsDMARDs?

A

Targeted synthetics: -citinib

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23
Q

What are csDMARDs?

A

Methotrexate, leflunomide, hydroxychloroquine, sulfasalazine, gold salts, minocycline, CsA, cyclophosphamide, D-penicillamine

… just remember the other DMARDs lol

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24
Q

When do you want to start a DMARD?

A

Within 3 months of onset of persistent symptoms

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25
Q

What is the first line DMARD of choice?

A

Methotrexate (1-2 month onset of effect)

26
Q

What can be given to reduce methotrexate ADRs without reducing efficacy?

A

Folic acid supplement 1 day after methotrexate dose

27
Q

What are ADEs of methotrexate?

A
  • GI toxicity
  • Derma reactions
  • Lung fibrosis/infection
  • Myelosuppression
  • Increased LFTs
28
Q

What are contraindications for MTX?

A
  • Pregnant/breastfeeding
  • Renal/liver disease
  • Immunodeficiency
  • Myelosuppression
29
Q

What are the BBWs for leflunomide?

A
  • Embryo-fetal toxicity
  • Hepatotoxicity
  • Drug elimination may be necessary with cholestyramine
30
Q

What are some possible drug/enzyme interactions with leflunomide?

A

Warfarin
OAT3
CYP2C8
Statins

31
Q

What are contraindications to sulfasalazine?

A
  • Intestinal or urinary obstruction
  • Porphyria
  • Sulfa allergy
32
Q

What are unique side effects of sulfasalazine?

A

Reversible oligospermia
Hemolytic anemia
Weight loss
Rashes

33
Q

When is HCQ used as monotherapy?

A

Low disease activity

34
Q

What are some unique side effects of HCQ?

A

QT prolongation
Irreversible retinal damage
Serious skin reactions

35
Q

When should monitoring be done for most csDMARDs?

A

q2-4w for the first 3 months

q8-12w until 6 months

q12w thereafter

36
Q

Which csDMARD does not require significant monitoring after baseline?

A

Hydroxychloroquine

37
Q

What should be ruled out at baseline for sulfasalazine?

A

G6PD deficiency

38
Q

What should be done at baseline and every 3 months for HCQ?

A

Ophthalmologic exam

39
Q

When should we use biologics?

A
  • In combo with MTX
  • Moderate-high disease activity despite DMARD therapy
  • Unable to tolerate or contraindicated to csDMARD
40
Q

What is an adequate trial for a bDMARD?

A

TNF: 3 months
non-TNF: 6 months

41
Q

Which SC TNFi biologic must be given with MTX?

A

Golimumab

42
Q

Which biologics are SC TNFis?

A
  • Adalimumab
  • Etanercept
  • Golimumab
  • Certolizumab
43
Q

Which TNFi biologics can be given IV?

A
  • Infliximab
  • Golimumab
44
Q

What are the BBWs on TNFis?

A

Malignancy (lymphoma, others)
Serious infections (test for latent tuberculosis, HepB)

45
Q

What are safety concerns with TNFis?

A
  • MS or MS-like symptoms
  • Lupus-like syndrome
  • Worsening or new onset HF
  • Hep B reactivation
46
Q

Which biologics are SC non-TNFIs?

A
  • Abatacept
  • Sarilumab
  • Tocilizumab
  • Anakinra (worst)
47
Q

What is the only SC non-TNFi that targets T cells instead of IL-6?

A

Abatacept

48
Q

Which non-TNFi biologics can be given IV?

A
  • Abatacept
  • Rituximab
  • Tocilizumab
49
Q

What is the MOA of rituximab?

A

Anti-CD20

50
Q

What are some pearls of rituximab?

A
  • Give with MTX
  • Infusion reactions (premedicate)
51
Q

How often should monitoring be done for TNFIs?

A

Baseline and every 4-8 weeks

52
Q

What additional monitoring is required for infliximab?

A

LFTs

53
Q

How often should a CBC be drawn for rituximab?

A

Baseline and with each dose

54
Q

What should be tested prior to all biologics and throughout treatment?

A

Latent tuberculosis

55
Q

What are BBWs on JAKis (-citinibs)

A
  • Opportunistic infections
  • Lymphoma, malignancies
  • Thrombosis
56
Q

Which therapies should be avoided in pregnancy or liver disease?

A

MTX, LEF

57
Q

Which therapy is recommended in lymphoproliferative disorder?

A

Rituximab

58
Q

In which therapies are live vaccines NOT recommended?

A

TNFi and non-TNFi biologics

59
Q

On triple therapy of SSZ, HCQ, and MTX, which should be gradually discontinued first if indicated?

A

Sulfasalazine

60
Q

Between MTX or a b/tsDMARD, which should be discontinued first if indicated?

A

Methotrexate

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