Rheumatoid arthritis Flashcards
RA presentation
fatigue, weakness, warm, red swollen joints, joint pain, low fever, stiffness, muscle ache
RA manifestations
nodules, vasculitis, pulmonary (fibrosis, PE),, ocular, cardiac (arrhythmias, pericarditis), lymphadenopathy, renal disease, anemia
Non-pharm treatment
education, rest, wt reduction, PT/OT, heat/ice
NSAIDs
Reduce pain, swelling, stiffness, do not alter course of disease, use in combo with DMARDs, give higher anti-inflammatory doses
DMARDs
Methotrexate, hydroxychloroquine (Plaquenil), Sulfasalazine (Azulfidine), Azathioprine (Imuran), Leflunomide (Arava)
DMARD PEARLs
timing is important, possibility to reduce damage, delay onset (months)
Methotrexate MOA
inhibits dihydrofolate reductase which inhibits neutrophil adhesion and chemotaxis, once weekly dosing
Methotrexate ADRs
hematologic (bone marrow suppression), N/V/D, stomatitis, mucositis, cirrhosis, hepatitis, increased LFTs, pneumonitis, fibrosis, ract, urticaria, alopecia
Methotrexate contraindications
Teratogenic, even if male, liver disease, immunodeficient pts, baseline blood dyscrasias, renal disease
Methotrexate PEARLs
considered to have best outcome, not expensive, hepatic metabolism, renal excretion
Hydroxychloroquine MOA
modification of inflammatory cytokine infiltration in to joint, PO, onset 2-4 months
Hydroxychloroquine ADRs
no myelosuppression, hepatic or renal (Advantage!), NVD, monitor for ocular toxicity
Sulfasalazine (Azulfidine) MOA
interleukin-1 inhibitor, prodrug, PO, 1-2 month onset
Sulfasalazine (Azulfidine) ADRs
NVD, hematologic leukopenia, thrombocytopenia, better tolerate than MTX
Azantioprine (Imuran)
Purine analogue that interferes w/ RNA/DNA synthesis and inhibits chemotaxis, PO, 2-3 month onset, short T1/2
Gold
Inhibits phagocytosis, given PO or injection, onset 4-6 months, not used much, last line, NVD, cramping and more!
Cyclosporine (Neoral, Sandimmune)
inhibits cytokine production to stop inflammation, usually for organ transplant pts, lot ADRs and DI, high pt sensitivity
Cyclophophamide (Cytoxan)
inhibits cell growth, very toxic, use limited, hemmorrhagic cystitis, GI upset, alopecia
Corticosteroids
used for anti-inflammatory and immunosuppressive, not monotherapy, short term until DMARDs kick in
What is considered most efficacious
Biologics
Biologics common
Etanercept (Enbrel), Infliximab (Remicade), Rituximab (rituxan), Adalimumab (Humira)
Biologics not as common
Golimumab (Simponi), certolizumab pergol (Cimzia), Tocilizumab (Actemra), Anakinra (Kineret), Tofacitinib (Xeljanz), Abatacept (Orencia)
Biologics clinical uses
Ankylosing spondylitis, Crohn’s, plaque psoriasis, RA, ulcerative colitis
Risks with biologics
increased risk of infection (TB, fungal), pancytopenia, be careful w/ live vaccines, demyelinating disorders (MS, ALS), bone marrow suppression, HF, lymphoma, CA
Etanercept (Enbrel)
first one, TNF inhibitor, subcut injection once weekly, no monitoring
Infliximab (Remicade
TNF inhibitor, IV only as outpt, not be monotherapy,
Adalimumab (Humira)
TNF inhibitor, subcut every 2 weeks, self injectiable, decreases CRP, ESR, IL-6 and inflammatory mediators
Rituximab (Rituxan)
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
Golimumab (Simponi)
TNF inhibitor, once monthly in combo with MTX
Anakinra (Kineret)
IL inhibitor, sub cu Daily, no combo w/ TNF inhibitors
Abatacept (Orencia)
T-cell immunoglobulin, IV once monthly, subcut weekly, useful for pts that fail TNF inhbitors
