Rheumatoid Arthritis

Question 1

Who is affected by most by rheumatoid arthritis, risk factors

Answer 1

Women between 50 and 75/ smoking, genetics, presence of autoantibodies

Question 2

What is Rheumatoid arthritis

Answer 2

autoimmune disease that causes inflammation that can lead to bone surface erosions

Question 3

Clinical presentation of rheumatoid arthritis

Answer 3

symmeterical joint swelling (synovitis). morning stiffness lasting more than one hour

Question 4

What should be monitored when giving therapy for Rheumatoid arthritis

Answer 4

acute phase reactants ( C-reactive protien and erythrocyte sedimentation rate)

Question 5

What are goals of treatment for rheumatoid arthritis

Answer 5

control disease activity, alleviate pain, maximize quality of rate, induce complete remission

Question 6

What is the best way evaluate the disease activity of rheumatoid arthritis

Answer 6

DAS/DAS28 (ESR or CRP, patient global assessment)

Question 7

What non-pharmacologic therapy for rheumatoid arthritis

Answer 7

rest, physical therapy, achieve ideal body weight, stop smoking

Question 8

What is an important Non-Disease-Modifying therapy for Rheumatoid arthritis, benefits

Answer 8

Corticosteroids, controls symptoms quickly, used in flares, can be used intraarticularly

Question 9

What is the biggest complication with using corticosteroids

Answer 9

Long term adverse affects

Question 10

T/F: All vaccines should be avoided when patients are on DMARDs

Answer 10

False: Live attenuated vaccines should be avoided while on biologic DMARDs

Question 11

What are the non-biologic DMARDs

Answer 11

Methotrexate, Sulfasalazine, Hydroxychloroquine, Leflunomide

Question 12

What drug is the cornerstone of rheumatoid arthritis therapy, what is the MOA

Answer 12

methotrexate, dihydrofolate reductase inhibitor while also inhibiting production of IL-1

Question 13

What is the biggest adverse effect of methotrexate

Answer 13

hepatotoxicity

Question 14

What is the dosing for methotrexate

Answer 14

10-25 mg per week (as 2.5 mg tablets)

Question 15

What is the drug that can be used as an alternative to methotrexate, MOA

Answer 15

Leflunomide, inhibits dihydroorotate dehydrogenase

Question 16

What non-biologic DMARD is often used in combination, what is a possible drug interaction

Answer 16

Sulfasalzine, warfarin

Question 17

What are common adverse effects, what side effect could lead to a larger problem

Answer 17

Nausea, vomitting and diarrhea/ Rash

Question 18

Which of the non biological DMARDs is an antimalarial, MOA

Answer 18

Hydroxychloroquine, interferes with antigen processing in APCs

Question 19

What drug is a severe adverse effects of hydroxchloroquine

Answer 19

Ocular toxicity and retinopathy

Question 20

T/F: Ocular toxicity caused by hydroxychloroquine is reversible through reducing use of medication while the retinopathy is irreversible

Answer 20

True

Question 21

What are the risk factors of hydroxychloroquine causing retinopathy

Answer 21

Daily dose greater than 5mg/kg, duration of use after 5 years

Question 22

How should retinopathy be monitored when using hydroxychloroquine

Answer 22

Eye exam within the first year and every year

Question 23

When should DMARD therapy be modified

Answer 23

repetitive flares, unacceptable disease activity, progressive joint damage

Question 24

What are biologic DMARDs

Answer 24

Etanercept, Infliximab, Adalimumab, Certolizumab, Golimumab

Question 25

What are the basics of biologic DMARDs

Answer 25

administered parenterally, work quickly, potential for serious side effects

Question 26

Which biological DMARDS work on the T-cell receptor resulting in down regulation of T cells, which work on CD20 of B cells, which are IL-6 receptor inhibitors

Answer 26

Abtacept, Rituximab, Tocilizumab and Sarilumab

Question 27

When would biologic DMARDS used

Answer 27

used for moderate to severe rheumatoid arthritis , often used in patients who fail MTX, can be added as a steroid sparing agent

Question 28

T/F: It is fine to combine more than one Biologic DMARD

Answer 28

False: Do not combine more than one biologic DMARDS due to overlapping side effects

Question 29

What is the first line biologic DMARD for rheumatiod arthritis

Answer 29

Anti-TNF agents

Question 30

T/F: If one biological DMARD from its class is not working it is reasonable to use a 2nd biological DMARD from the same class as long as it's not at the same time

Answer 30

True

Question 31

What must be monitored when using Anti-TNF agents

Answer 31

TB skin or blood test, Hep B reactivation, histoplasmosis, malignancy

Question 32

What is the MOA of abatacept, what patients should avoid this medication

Answer 32

binds B7 using the extracellular domain of CTLA-4 therefore down regulating T cells, patients with COPD and/or smoke

Question 33

T/F: There is no evidence of increased incidence of TB in patients and no evidence of increased incidence of cancer when taking rituximab

Answer 33

True

Question 34

What are the ADRs for rituximab

Answer 34

infusion reaction, reaction of Hep B, Stevens-Johnson, PML caused by JC virus

Question 35

What must be monitored before using Tocilizumab and Sarilumab

Answer 35

Do not start if ANC is less than 2000, PLT is less than 100,000 (tocilizumab) or 150,000 (Sarilumab)

Question 36

What are adverse efffects of Tocilizumab and Sarilumab

Answer 36

GI perforation and dyslipidemia

Question 37

What are the JAK Kinase inhibitors, how are they taken

Answer 37

Tofacitinib and baricitinib, by mouth

Question 38

T/F: Janus Kinase inhibitors can be combined with a biologic and potent immunosuppresive drugs for peak efficacy

Answer 38

False: Do not combine Jak/Stat inhibitors with biologics and avoid in patients who are taking tacrolimus, cyclosporine, and azathioprine

Question 39

Which Jak/Stat inhibitor goes through extensive liver metabolism and may be effected by CYP induces or inhibitors

Answer 39

Toacitinib

Question 40

Which Jak/Stat inhibitor is not recommended due to the CrCl less than 60

Answer 40

Baricitinib

Question 41

What are the ADRs of Janus Kinase inhibitors

Answer 41

Thrombosis (baricitinib), GI perforation, lipid changes