Rheumatoid arthritis

Question 1

RA presentation

Answer 1

fatigue, weakness, warm, red swollen joints, joint pain, low fever, stiffness, muscle ache

Question 2

RA manifestations

Answer 2

nodules, vasculitis, pulmonary (fibrosis, PE),, ocular, cardiac (arrhythmias, pericarditis), lymphadenopathy, renal disease, anemia

Question 3

Non-pharm treatment

Answer 3

education, rest, wt reduction, PT/OT, heat/ice

Question 4

NSAIDs

Answer 4

Reduce pain, swelling, stiffness, do not alter course of disease, use in combo with DMARDs, give higher anti-inflammatory doses

Question 5

DMARDs

Answer 5

Methotrexate, hydroxychloroquine (Plaquenil), Sulfasalazine (Azulfidine), Azathioprine (Imuran), Leflunomide (Arava)

Question 6

DMARD PEARLs

Answer 6

timing is important, possibility to reduce damage, delay onset (months)

Question 7

Methotrexate MOA

Answer 7

inhibits dihydrofolate reductase which inhibits neutrophil adhesion and chemotaxis, once weekly dosing

Question 8

Methotrexate ADRs

Answer 8

hematologic (bone marrow suppression), N/V/D, stomatitis, mucositis, cirrhosis, hepatitis, increased LFTs, pneumonitis, fibrosis, ract, urticaria, alopecia

Question 9

Methotrexate contraindications

Answer 9

Teratogenic, even if male, liver disease, immunodeficient pts, baseline blood dyscrasias, renal disease

Question 10

Methotrexate PEARLs

Answer 10

considered to have best outcome, not expensive, hepatic metabolism, renal excretion

Question 11

Hydroxychloroquine MOA

Answer 11

modification of inflammatory cytokine infiltration in to joint, PO, onset 2-4 months

Question 12

Hydroxychloroquine ADRs

Answer 12

no myelosuppression, hepatic or renal (Advantage!), NVD, monitor for ocular toxicity

Question 13

Sulfasalazine (Azulfidine) MOA

Answer 13

interleukin-1 inhibitor, prodrug, PO, 1-2 month onset

Question 14

Sulfasalazine (Azulfidine) ADRs

Answer 14

NVD, hematologic leukopenia, thrombocytopenia, better tolerate than MTX

Question 15

Azantioprine (Imuran)

Answer 15

Purine analogue that interferes w/ RNA/DNA synthesis and inhibits chemotaxis, PO, 2-3 month onset, short T1/2

Question 16

Gold

Answer 16

Inhibits phagocytosis, given PO or injection, onset 4-6 months, not used much, last line, NVD, cramping and more!

Question 17

Cyclosporine (Neoral, Sandimmune)

Answer 17

inhibits cytokine production to stop inflammation, usually for organ transplant pts, lot ADRs and DI, high pt sensitivity

Question 18

Cyclophophamide (Cytoxan)

Answer 18

inhibits cell growth, very toxic, use limited, hemmorrhagic cystitis, GI upset, alopecia

Question 19

Corticosteroids

Answer 19

used for anti-inflammatory and immunosuppressive, not monotherapy, short term until DMARDs kick in

Question 20

What is considered most efficacious

Answer 20

Biologics

Question 21

Biologics common

Answer 21

Etanercept (Enbrel), Infliximab (Remicade), Rituximab (rituxan), Adalimumab (Humira)

Question 22

Biologics not as common

Answer 22

Golimumab (Simponi), certolizumab pergol (Cimzia), Tocilizumab (Actemra), Anakinra (Kineret), Tofacitinib (Xeljanz), Abatacept (Orencia)

Question 23

Biologics clinical uses

Answer 23

Ankylosing spondylitis, Crohn’s, plaque psoriasis, RA, ulcerative colitis

Question 24

Risks with biologics

Answer 24

increased risk of infection (TB, fungal), pancytopenia, be careful w/ live vaccines, demyelinating disorders (MS, ALS), bone marrow suppression, HF, lymphoma, CA

Question 25

Etanercept (Enbrel)

Answer 25

first one, TNF inhibitor, subcut injection once weekly, no monitoring

Question 26

Infliximab (Remicade

Answer 26

TNF inhibitor, IV only as outpt, not be monotherapy,

Question 27

Adalimumab (Humira)

Answer 27

TNF inhibitor, subcut every 2 weeks, self injectiable, decreases CRP, ESR, IL-6 and inflammatory mediators

Question 28

Rituximab (Rituxan)

Answer 28

chimeric, monoclonal ab, binds to antigen CD20 located on pre-B and mature B cells, antigen is expressed on 90% of B cell non-hodgkin’s lymphomas, used in chemo

Question 29

Golimumab (Simponi)

Answer 29

TNF inhibitor, once monthly in combo with MTX

Question 30

Anakinra (Kineret)

Answer 30

IL inhibitor, sub cu Daily, no combo w/ TNF inhibitors

Question 31

Abatacept (Orencia)

Answer 31

T-cell immunoglobulin, IV once monthly, subcut weekly, useful for pts that fail TNF inhbitors