Rheumatoid Arthritis Flashcards
Explain the pharmacist’s role in RA. (7)
Know how to identify referral points and signposting.
Management of high risk drugs
OTC support for LT conditions e.g. analgesia, eye drops.
General advice/lifestyle advice e.g. alcohol, vaccinations.
Support on taking medications e.g. physical dexterity.
Specialist pharmacists
What are the main features of RA? (6)
An autoimmune condition where the body begins to attack the joint spaces causing pain and inflammation.
1st onset occurs over a number of weeks and presents as sever and possibly widespread swelling in a number of joints (e.g. hands, feet, knees and wrists)
Px may present with fatigue, fever and general malaise.
High inflammatory markers = RA
RA can cause structural changes to the joints overtime e.g. new blood vessels, cartilage damage and narrowing, joint erosion and deformities.
Associated conditions: Sjörgrens syndrome, vasculitis, increased CV/OP risk.
What are the implications of physical dexterity for RA tx? (4)
Compromised (RA), additional support for taking medicines may be needed.
Child resistant containers may be difficult. (Px can opt not to have these)
Supportive cutters, easy to open containers e.g. Salazopryin.
MDT - occupational therapist support px to maintain independent living.
Explain the treatment options for pain in RA. (3)
DMARDs + Biologics = NOT painkillers.
Painkillers = NSAIDs and COX-2 inhibitors
Steroids used to treat flares = reducing inflammation and pain.
Give e.g. of DMARDs. (5)
MTX
Sulfasalazine
Leflunomide
Hydroxychloroquine
Biologics
Explain the NICE NG100 guidelines for RA. (5)
Initial tx:
- Monotherapy = recommended
- Oral MTX, Leflunomide, Sulfasalazine (Hydroxychloroquine = alternative)
- Bridging tx with oral, IM or IA glucocorticoids when starting DMARDs.
- Escalate DMARDs monotherapy (increase dose)
- If target not reached:
- Add 2nd DMARD (MTX, Sulfasalazine, Leflunomide, Hydroxychloroquine) or sequential monotherapy.
- Inadequate response to conventional DMARDs: Biologics or JAKi usually with MTX. Provided NICE criteria is met.
What general points do you need to consider for DMARDs? (3)
Takes weeks/months to work.
MTX used first line unless c/i
Most DMARDs has a s/e profile (regular bloods, counselling and recognising ADR.)
What general advice regarding vaccinations when taken DMARDs? (3)
Immunosuppressive therapy e.g. Leflunomide, MTX, Biologics = high risk of infections.
- Flu, pneumococcal recommended.
- Avoid live vaccine (give 2-4 weeks before starting immunosuppressive where possible.)
- Avoid contact with chicken pox, shingles, measles. Ensure household contact immune to measles: offer MMR.
- Significant contact with chicken pox: VZ immunoglobulin can be given within 7 days of contact, measles: urgent measles IgG testing.
For biologics, reactivation of latent TB is a concern all px screened before commencing therapy.
What practical points are considered for DMARDs? (3)
If concomittant infections, immunosuppressive agents for RA is stopped until infection has cleared e.g. MTX, Leflunomide.
- Long half-life of Leflunomide may limit benefit of stopping, withhold temporarily.
When uncertain/complex causes, contact rheumatology for further advice.
All px should be advised to let their rheumatologist know if they experience any signs of infection.
What general points is considered for pregnancy in RA tx? (6)
MTX + Leflunomide = C/I
Azathioprine, Hydroxychloroquine = +/-
Effective contraception should be used during treatment and for 2 years after before becoming pregnant, for men it should be for 3 months after tx ends.
If necessary, a washout protocol can be undertaken to shorten this period.
What are the key features of MTX? (4)
Dose: Once weekly.
Only 2.5mg tablets dispensed 10mg (rare)
Doses up to 27.5mg SC seen in practice.
Purple book (monitoring)
Only Rx when +/- are considered.
Explain the use of folic acid with MTX. (4)
Given to reduce ADR but not on MTX day.
E.g. once a week on a different day to MTX, three times a week, every day apart from MTX day.
What bloods are taken for MTX? (6)
When blood are out of range, contact Rxer.
Look for trends/ red flags.
FBC (monthly for 1st year then 2 months)
U+Es/ Serum Creatinine (monthly for 1st year then 2 months)
LFTs (monthly for 1st year then 2 months)
ESR/CRP (rheumatology + gastroenterology px only)
What points is considered when carrying out a clinical check in MTX? (5)
Check and compare to previous dose.
If dose is altered then check with the px/purple book. If the dose change isn’t expected contact the Rxer.
Check blood have been done recently in the purple book.
Medication interaction check (Antifolate e.g. trimethoprim and phenytoin)
Lifestyle advice (alcohol can cause liver issues with MTX
What are the risks associated with NSAIDs and MTX? (3)
NSAIDs reduce renal excretion of MTX - increased risk of toxicity.
Avoid inappropriate clinical use of NSAIDs e.g. post surgical pain relief, OTX/self-medication.
+/- for RA pain control = some px find it difficult to manage, rheumatologist should be aware.
Monitor of bloods/awareness of s/s of haem/liver/pulmonary toxicity.
Counsel a px on taking MTX.
Indication: Medication is to reduce inflammation relating to RA it is not a pain killer.
Dose: Taken ONCE weekly.
You should also be prescribed folic acid to reduce the side effects of MTX (can be taken once weekly not on the same day as MTX, three times a week, every days except MTX day)
Both tablets are yellow make sure to keep them in the original package to avoid mixup.
Purple book will be given to you as you need regular monitoring whilst taking this medication.
Possible S/E: Nausea, upset stomach or diarrhoea.
Serious S/E: Stop and tell your doctor on the same day if:
- Unexplained SOB and dry cough (can occur gradually or over a few days)
- If whites of eyes become yellow or you develop severe itching.
- You have fever, chills, or severe sore throat/mouth.
- You have severe mouth ulcers, bleeding gums, bruising or skin ulcers.
- Experiencing severe sickness or upset stomach.
- If have never had chicken pox and come into close contact with someone who has chicken pox or shingles.
- You think you/your partner have become pregnancy whilst on tx.
What are the main features of MTX rescue therapy? (4)
Acute toxicity (Folinic acid given as calcium folinate)
Folinic acid counteracts anti-folate activity of MTX, speeds recovery of myelosuppression/mucositis etc.
Granulocyte-colony stimulating factors (GCSF) e.g. SC Filgrastim (severe neutropenia = specialist only)
Fluid/electrolyte balance, blood products.
What are the main features of sulfasalazine? (6)
Enteric coated formulation taken with glass of water, swallow whole.
Dose Titration: Usually 500mg OD daily for 1 week, 500mg BD daily for 1 week, 1g BD. (Can go up to 3g if needed).
Can turn urine orange, soft contact lenses + tears can stain yellow.
Common s/e: Nauseaa, Diarrhoea, Stomach Upset, Dizziness, Headache, Skin Rashes etc.
Bloods: FBC, LFTs, U+Es regular monitoring in first 2 years only.
Haemotological/liver toxicity: Report unexplained cough, breathelessness, abnormal bruising/bleeding, severe sore throat, severe nausea/dizziness/headache, unexplained acute widespread rash, oral ulceration.
What are the key features of Leflunomide? (4)
Dose: 100mg OD for 3 days then 10-20mg OD.
Not for liver impairment or hypo proteinaemia present.
BP (hypertension) and weight monitoring (wt loss)
Interactions (high toxicity risk with MTX, caution with phenytoin, warfarin, tolbutamide.)
Counsel a patient taking Leflunomide.
Used to treat… It works by dampen down the disease process and reduce inflammation that can lead to pain, swelling, stiffness and joint damage.
It is taken as a 10 or 20mg tablet OD.
It may take 6 weeks or longer before you feel the full effect so persist with tx.
Common S/e: Nausea, diarrhoea, mouth ulcers, weight loss, stomach upset, rash or headache.
Serious s/e: Stop tx and contact doctor if you experience sore throat, fever, infection, unexplained bruising/bleeding, rash, breathlessness, unusual fatigue, stomach pain, yellowing of the whites of eyes/skin.
Because the drug dampens down the immune system, if you never had chicken pox, you should avoid anyone who has.
You should ideally avoid alcohol, if you do decide to drink, small amounts should be okay.
Explain the Leflunomide wash out process. (4)
Colestyramine 8g TDS for 11 days OR
Activated Charcoal 50g QDS 11 days.
Can measure concentration of active metabolite (< 20mcg/L on 2 occasions, 2 weeks apart)
Men and women.
What are the main points for Hydroxychloroquine? (6)
Dose: 200mg OD or BD depending weight (max 6.5mg/kg based on IBW)
SE: GI disturbances, headache, skin reactions can cause ocular disturbances (less common = monitor)
Caution: Epilepsy, severe GI disorders, psoriasis exacerbations.
Monitoring: Renal/Liver function before tx bot no specific routine blood monitoring online other DMARDs. Visual acuity tested annually. If high risk, if not then once before starting and repeated after 5 years. See ophthalmologist if any issues occur.
Interactions: Amiodarone, Moxifloxacin (high risk ventricular arrhythmias), digoxin (high digoxin levels), Ciclosporin (increased levels), some anti malarials.
What are the key features of Biologics? (9)
Pharmaceutical products manufactured in, extracted from or semi-synthesised from biological sources.
Reduces pain, stiffness, inflammation and joint damage.
May take up to 3 months for full effect.
When used with MTX = better results.
Failure to respond to DMARD tx.
Continue only if adequate response at 6m following initiation (DAS-28 1.2 points or more)
After initial response monitor at least 6 monthly and withdraw if adequate response not maintained.
What is a s/e of biologic? (1)
High risk of infection:
- Delay administration/withhold if signs of active infection requiring ABx.
- May reactivate TB, HIV, Hep B or C infection = all px screened before commencing therapy.
- C/I in active TB, severe hepatic failure (Class II/IV)
- High risk of lymphoma
- Injection site reactions
- Infusion reactions e.g. anaphylactic shock, delayed hypersensitivity reactions, pre-tx with steroids, chlorphenamine.
- VTE with JAKi.
Explain the use of biologics in surgery. (3)
Delays wound healing.
Omit for at least 1 full dosing interval pre-surgery.
Can restart when good wound healing, all sutures and staples are out and no infection is present.
Give e.g. of biosimilars . (4)
Infliximab
Etanercept
Rituximab
Adalimumab
What are the main features of JAKi? (3)
Oral Immunomodulators
Tofacitinib, Baricitinib (Updacitinib)
Withdraw after 4 months if no benefit.
VTE risk
Briefly outline the main points of RA tx. (1)
DMARDs = high risk drugs
Increasing use of biologics in practice.
