Rheumatoid arthritis Flashcards
most commonly affected joints in RA
metacarpopharyngeal joint
intercarpopharyngeal joint
Acute arthritis - symptomatic treatment
doc is anti inflammatory drugs ( NSAIDs except Paracetamol)
nephrotoxic
if resistent - corticosteroid (intrarticular inj) - Prednisolone, Triamcinolone
adv- renal safe
Definitive treatment of RA
retard joint destruction
DOC- DMARD’s (disease modifying antirheumatic drugs) or SAARD’s (slowly acting anti rheumatic drugs)
Conventional DMARD’S
Methotrexate
Sulfasalazine
Penicillamine
Azathioprine and miscellaneous
Gold
Leflunomids (100mg)
Chloroquine/hydroxy chloroquine
(Mallika Sherawat PAGAL C)
DOC for RA
Methotrexate
Management
mild RA- hydroxy chloroquine+ sulfasalazine
severe RA/no response - Methotrexate
still no response - add other drugs to Methotrexate
DOC for RA in pregnancy
NSAIDS
avoid DMARD’S in pregnancy
but if you have to give, safest - hydroxy chloroquine
Methotrexate is contraindicated
Biologics DMARD’S with target anti TNF alpha
Infliximab - iv (doc for Methotrexate resistant rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis & azathioprine resistant ulcerative colitis and Crohn’s disease) SE: reactivation of latent TB
Certolizumab -sc
Adalimumab -sc
Golimumab - sc
Eternecept - sc (decoy receptor)
Biologics DMARD’S with target anti IL6
Tolicizumab (methotrexate resistant rheumatoid arthritis and treatment of cytokines storm in COVID 19
Sarilumab
Biologics DMARD’S with target anti CD20
Rituximab
Biologics DMARD’S with target anti IL1
Anakinra
Biologics DMARD’S with target recombinant CTLA4
Abatacept
new: Belatacept: organ transplantation
JAK inhibitor
JAK is receptor for inflammatory mediators like IL
JAK 1,3- Tofacitinib - RA, IBD SE- bone marrow suppression
JAK 1,2- Baricitinib
JAK 1 - Upadacitinib
given orally
(rest DMARD’S are all injection)
Methotrexate
immunosuppressive action
antifolate - inhibitor of DHFR enzyme
increase adenosine efflux by inhibiting adenosine deaminase (adenosine kills lymphocytes)
Methotrexate low dose in RA (30-70 mg)week)
Methotrexate high dose in cancers (100mg/day)
Doc for RA, ankylosing spondylitis, psoriatic arthritis, erythrodermic psoriasis
SE- megaloblastic anemia, hepatotoxic, pneumonia or lung damage
Monitor CBC, LFT, chest x-ray
contraindicated in lactation and pregnancy (category X) - neural tube defects
Sulfasalazine
Prodrug
1. Sulfapyridine attached to
2. 5 amino salicylic acid
attached by azo bond
azon bond broken down by colonic bacteria
sulfapyridine gets absorbed in blood, goes to synovial joints and shows immunosuppressive action in RA
SE: decrease sperm count, causes sulfa allergy
5ASA acts locally for the treatment of ulcerative colitis
5ASA only drug for treatment of ulcerative colitis
Mesalazine
Olsalazine
Basalazide
Penicillamine
Gold
old drug
rarely used
gold - Aurofin, Aurothiomalate
SE:
nephrotoxic - most dangerous
dermatitis - most common
diarrhoea - 2nd most common
DLE (drug induced SLE)
RA. + other systemic involvement
Azathioprine
Cyclosporin
Tacrolimus
Leflunomide
dose-100mg
inhibitors of DHOD (inhibits pyrimide synthesis)
antifolate
SE- megaloblastic anemia, hepatotoxic
contraindicated in pregnancy
Leflunomide (prodrug) - treatment of RA
Active form- Teriflunomide - treatment of multiple sclerosis
Chloroquine/ hydroxy chloroquine (more preferred in RA)
Chloroquine:
immunosuppressive - reduces IL1, IL6, TNF alpha
highest volume of distribution - deposits in all organs- bull’s eye retinopathy (permanent blindness) , QT prolongation
Hydroxy chloroquine
more water soluble, less volume distribution, longer and better immunosuppressant
Methotrexate resistant cases
rheumatoid arthritis
psoriatic arthritis
ankylosing spondylitis
Infliximab is DOC
DOC for azathioprine resistant ulcerative colitis and Crohn’s disease
Infliximab
latent TB test
Montoux test or PPD (purified protein derivative) test
