Rheumatoid Arthritis Flashcards
What are prodromal symptoms of RA?
- Fatigue
- Fever
- Weakness
- Weight loss
- Decreased mood
- Myalgias before joint swelling
What are disease flares?
Sudden increases in s/s that can last days to months
When does RA go from early to established?
6 months
What are signs of RA?
- Synovitis
- Joint erythema
- Rheumatoid nodules
- Potential grip weakness, deformity, muscle atrophy
What are symptoms of RA?
Occur with use AND at rest***
- Joint pain and stiffening >6 weeks
- Prodromal symptoms
- Decreased ROM
- Joint deformity (late in disease)
What are the most common joints involved in RA?
Hands, wrists, ankles, and feet (often bilaterally)
What extra-articular involvement can occur in RA?
- Rheumatoid nodules
- Pulmonary complications
- Vasculitis
- Ocular manifestations
- Cardiac involvement
- Hematologic involvement
- Lymphadenopathy
- Amyloidosis
- Osteoporosis
What are the four domains of the ACR/EULAR scoring system?
Joint involvement
Serology
Acute-phase reactants
Duration of symptoms
What are pearls of RA as opposed to OA?
- Variable age and onset
- Generalized malaise
- Smaller joints
- Prolonged stiffness >1 hour
- With use and at rest
- Bilateral
- Auto-antibodies present
What are the goals of RA therapy?
- Improve/maintain functional status (pain, joint mobility, ADLs)
- Slow destructive joint changes (treat early and aggressive)
- Achieve disease remission
What are non-pharm treatments for RA?
- Rest
- Weight loss
- Pain coping skills
- PT or OT
- Surgery for severe RA
What are pharmacologic treatments of RA?
NSAIDs (not monotherapy)
Corticosteroids (not monotherapy)
DMARDs
In early RA, what is first line for moderate or severe disease activity?
Methotrexate
In early RA, what is first line for low disease activity?
Hydroxychloroquine
A patient is experiencing moderate-high disease activity despite DMARD therapy, what are our options?
- csDMARDs
- bDMARD +/- methotrexate
- tsDMARD +/- methotrexate
Consider short-term corticosteroids
A patient is not at target with oral MTX and is experiencing moderate-high disease activity, what should we do?
Switch to SQ MTX
A patient is using a csDMARD other than MTX and is experiencing moderate-high disease activity, what should we do?
Switch to MTX monotherapy
After trying a DMARD, a patient is experiencing moderate-high disease activity and has no poor prognostic factors or preference, what should we do?
Add additional csDMARD
After trying a DMARD, a patient is experiencing moderate-high disease activity and has poor prognostic factors, what should we do?
Add tsDMARD or bDMARD
What are examples of poor prognostic factors?
- High disease activity
- Early presence of erosion
- Autoantibody positivity
What are bDMARDs?
Biologics: -mabs, -cepts
What are tsDMARDs?
Targeted synthetics: -citinib
What are csDMARDs?
Methotrexate, leflunomide, hydroxychloroquine, sulfasalazine, gold salts, minocycline, CsA, cyclophosphamide, D-penicillamine
… just remember the other DMARDs lol
When do you want to start a DMARD?
Within 3 months of onset of persistent symptoms
What is the first line DMARD of choice?
Methotrexate (1-2 month onset of effect)
What can be given to reduce methotrexate ADRs without reducing efficacy?
Folic acid supplement 1 day after methotrexate dose
What are ADEs of methotrexate?
- GI toxicity
- Derma reactions
- Lung fibrosis/infection
- Myelosuppression
- Increased LFTs
What are contraindications for MTX?
- Pregnant/breastfeeding
- Renal/liver disease
- Immunodeficiency
- Myelosuppression
What are the BBWs for leflunomide?
- Embryo-fetal toxicity
- Hepatotoxicity
- Drug elimination may be necessary with cholestyramine
What are some possible drug/enzyme interactions with leflunomide?
Warfarin
OAT3
CYP2C8
Statins
What are contraindications to sulfasalazine?
- Intestinal or urinary obstruction
- Porphyria
- Sulfa allergy
What are unique side effects of sulfasalazine?
Reversible oligospermia
Hemolytic anemia
Weight loss
Rashes
When is HCQ used as monotherapy?
Low disease activity
What are some unique side effects of HCQ?
QT prolongation
Irreversible retinal damage
Serious skin reactions
When should monitoring be done for most csDMARDs?
q2-4w for the first 3 months
q8-12w until 6 months
q12w thereafter
Which csDMARD does not require significant monitoring after baseline?
Hydroxychloroquine
What should be ruled out at baseline for sulfasalazine?
G6PD deficiency
What should be done at baseline and every 3 months for HCQ?
Ophthalmologic exam
When should we use biologics?
- In combo with MTX
- Moderate-high disease activity despite DMARD therapy
- Unable to tolerate or contraindicated to csDMARD
What is an adequate trial for a bDMARD?
TNF: 3 months
non-TNF: 6 months
Which SC TNFi biologic must be given with MTX?
Golimumab
Which biologics are SC TNFis?
- Adalimumab
- Etanercept
- Golimumab
- Certolizumab
Which TNFi biologics can be given IV?
- Infliximab
- Golimumab
What are the BBWs on TNFis?
Malignancy (lymphoma, others)
Serious infections (test for latent tuberculosis, HepB)
What are safety concerns with TNFis?
- MS or MS-like symptoms
- Lupus-like syndrome
- Worsening or new onset HF
- Hep B reactivation
Which biologics are SC non-TNFIs?
- Abatacept
- Sarilumab
- Tocilizumab
- Anakinra (worst)
What is the only SC non-TNFi that targets T cells instead of IL-6?
Abatacept
Which non-TNFi biologics can be given IV?
- Abatacept
- Rituximab
- Tocilizumab
What is the MOA of rituximab?
Anti-CD20
What are some pearls of rituximab?
- Give with MTX
- Infusion reactions (premedicate)
How often should monitoring be done for TNFIs?
Baseline and every 4-8 weeks
What additional monitoring is required for infliximab?
LFTs
How often should a CBC be drawn for rituximab?
Baseline and with each dose
What should be tested prior to all biologics and throughout treatment?
Latent tuberculosis
What are BBWs on JAKis (-citinibs)
- Opportunistic infections
- Lymphoma, malignancies
- Thrombosis
Which therapies should be avoided in pregnancy or liver disease?
MTX, LEF
Which therapy is recommended in lymphoproliferative disorder?
Rituximab
In which therapies are live vaccines NOT recommended?
TNFi and non-TNFi biologics
On triple therapy of SSZ, HCQ, and MTX, which should be gradually discontinued first if indicated?
Sulfasalazine
Between MTX or a b/tsDMARD, which should be discontinued first if indicated?
Methotrexate
