Rheumatoid Arthritis Flashcards
3 lab tests to diagnose RA
- rheumatoid factor
- erythrocyte sedimentation rate
- C reactive protein
(x rays of hands and feet)
Physical examination for RA
- Swelling of 3 or more joints
- Tenderness along the joint line
- “Squeeze test”
- Synovitis
Drug classes for pain relief in RA
- COX 2 selective inhibitors
- NSAIDs
- Glucocorticoids can be used in flare ups
What is the protocol for treatment of newly diagnosed RA patients?
Pain relief - NSAIDs/COX-2
cDMARD (methotrexate, leflunomdie, sulfasalazine)
+/- short term glucocorticoids
When disease control not achieved with treatment with methotrexate and one of more other DMARD: introduce biological agent
Can prescribe biologic and methotrexate
List 9 adverse effects of Corticosteroids
- Diabetes
- Osteoporosis
- Avascular necrosis of the femoral head
- Muscle wasting
- Peptic ulcer
- Psychosis
- Immunosuppression
- Cushing syndrome
- Ophthalmic effects
Patient information for Corticosteroid treatment
- Carry steroid card (prescriber, dose, duration)
- Take single daily dose in the morning
- Do not stop taking abruptly - taper down dose if:
Treatment > 3 weeks
Prednisolone 40mg >7 days
Possible adrenal suppression of another cause
Repeated evening doses
Repeated courses
Short course within 1 year of stopping long term steroid treatment
First line treatment with DMARDs
Methotrexate + one or more other DMARDs (sulphasalazine, hydroxychloroquinine)
Once disease is controlled, can reduce dose
4-6 months to full response, 50% of patients on long term treatment
What is the dose of methotrexate?
7.5mg - 25mg once weekly orally or s/c
Parenteral methotrexate available if patient fails to respond or if extreme nausea on oral therapy
Methotrexate interactions
- Excretion is affected - leads to toxicity
- Avoid aspirin and NSAIDs (but can be used if monitored?)
- Trimethoprim
- Alcohol
- Take folic acid on different day
Which methotrexate tablets should you keep in stock
2.5mg tablets
Name the 3 major methotrexate adverse effects and signs of them
Blood Disorders
- Sore throat/ Other infections (neutropenia sign)
- Fever/ chills (neutropenia sign)
- Mouth ulceration
- Easy bruising or bleeding
Liver toxicity
- Diarrhea
- Vomiting
- Unexplained rash
Respiratory Effects
- Breathlessness
- Dry persistent cough
When should blood tests, renal function, hepatic function be done on Methotrexate
- Every 1-2 weeks until stable
- Then monthly for one year
- Then every 2-3 months
Contraception and Methotrexate
- Men and women must use effective contraception during treatment and for 6 months after stopping
- Cannot be used if you might be pregnant or wish to start a family
How long does it take to notice effects of Methotrexate?
up to 12 weeks
Dose of sulphasalazine
- 500mg daily initially
- increase in 500mg increments weekly, up to a max dose of 2g-3g daily in divided doses
7 adverse effects of sulphasalazine
- blood disorders (leukopenia, thrombocytopenia, neutropenia)
- taste disturbances
- tinnitus
- GI disturbances
- staining of soft contact lenses
- orange discolouration of skin/ urine/ bodily fluids
- hepatotoxicity
Monitoring on sulfasalazine
full blood count and liver function initially, then once monthly for 3 months, then every 3 months
renal function
Dosage of hydroxychloroquinine
200-400mg daily
increased to max dose of 6.5mg/kg/day
4 adverse effects of hydroxychloroquine
- ocular toxicity - v. important
- GI disturbances
- skin rash
- discoloration of skin, nails, mucous membranes
Monitoring on hydroxychloroquinine
ask patient re. visual impairment prior to commencing treatment
only start treatment if no eye abnormality is present
review annually during treatment
Hydroxychloroquinine interaction
do not take antacids 4 hours before or 4 hours after hydroxychloroquinine
Anti-TNF-α antibodies
Adalimumab, Infliximab
TNF-α receptor fusion protein
Etanercept
Newer TNF-α therapies
Certolizumab pegol
Golimumab
