Rheumatoid arthritis Flashcards
What are the treatment options for Rheumatoid Arthritis?
MEDICATIONS THAT ALTER THE DISEASE
1- Conventional DMARDs (MTX, sulfasalazine, leflunomide, hydroxychloroquine)
2a-Biologic DMARDs (TNF-Alpha inhibitors: infliximab, adalimumab, etanercept, golimumab, certolizumab)
2b-Biologic DMARDs (IL6- tocilizumab and sarilumab; IL1- Anakinra)
3- Targeted synthetic DMARDs JANUS kinase inhibitors: Tofacitinib, baricitinib and upadacitinib
4- Other: Abatacept (t-cell inhibitor); rituximab (B cell depeletor)
MEDICATIONS THAT SLOW DISEASE PROGRESSION
1- Corticosteroids
MEDICATIONS THAT RELIEF PAIN
1- NSAIDS
What are the safety concerns of each medications used in RA treatment?
1- MTX: liver toxicity; teratogenic; not in renal sufficiency or lung disease
2- Sulfasalazine: not in sulfa allergy; G6PD deficiency; DRESS reaction; decreases DIGI absorption; DONOT combine with Abx; use ENTERIC COATED to prevent GI side effects
When do we opt for Sulfa-salazine?
in those with severe liver disease, who cannot take MTX
in pregnant women, folic acid supplementation is necessary
How do we compare MTX to sulfasalazine?
Sulfasalazine is a low potency DMARD, for early mild RA, with short-term efficacy, not in those with poor prognostic factors
Sulfasalazine is not as good as MTX, will likely need to be changed or combined
MTX works better than Sulfasalazine
What are the MAIN safety concerns related to Hydroxychloroquine?
Eye check q5yrs of therapy as ophthalmic changes occur if doses are too high or used for long periods
if patient has arrhythmia, stay away
if patient is on other meds that cause QTc prolongation, such as escitalopram, then stay away
What are the advantages of Hydroxychloroquine?
Least toxic of all DMARDs
Lacks renal and liver toxicity
Safe in pregnancy
Does not require LFT monitoring Sulfasalazine’s sister in that it is used in mild RA
When do we opt for Leflunomide?
when use of MTX produced failed outcome
What are the MAIN safety concerns related to Leflunomide?
LFTs require to be monitored qmonth for first 6 months, as it can cause DEATH from LIVER FAILURE
NOT in pregnancy or liver failure
If planning to conceive then wash out period for 11 days w/cholestyramine
Do Azathioprine, cyclosporine and GOLD have any role in RA management?
very uncommon
In brief, what are the monitoring parameters for conventional DMARDs?
MTX; Leflunomide; sulfasalazine:
baseline serology for HIV HBV and HCV
LFTs at baseline
in addition for Leflunomide: check ALT, AST, CBC, Cr EVERY month for 1st 6 months then q6-8 weeks
Hydroxychloroquine: Baseline retinal screen; then yearly ophthalmologic exam
What are clinical pearls of Anti-TNF biologics? Inflix Etaner Adali Golimu Certoli
0- Are immuno-suppressives
1- CANNOT combine 2 biologics
2- CAN only combine a DMARD with a BIOLOGIC
3- VERY effective in preventing RADIO-graphic damage when COMBINED with MTX
4- CONTRA-INDICATED in ACTIVE infection or RECURRENT infection
5- Rule OUT TB prior starting
6- Associated with SERIOUS bacterial and opportunistic infections
7- Takes 2-3 months for response to be seen
OTHER BIOLOGICAL DMARD: B cell depletor
What are the MAIN prescribing and safety points related to RITUXIMAB use?
1- Used when anti-TNF failed
2- CANNOT be combined with anti-TNFs but OK with non-biologic DMARDs
3- VERY expensive
4- Re-ACTIVATES Hep B virus
5- DOESN’T reactivate TB
6- Baseline CBC, LFTs, Cr, Hep B and C
7- IV painful drug infusion, before each infusion need to pre-medicate with methylprednisolone, acetaminophen and diphenhydramine
OTHER BIOLOGICAL DMARD: IL6-inhibitor
What are the MAIN safety and prescribing concerns related to TOCILIZUMAB?
1- Used when anti-TNF failed 2- when other DMARDs failed 3- Used with MTX 4- Used as MONOTHERAPY 5- NOT 1st line agent 6- Causes Hyperlipidemia and HTN 7- Has adverse effect on KIDNEYS 8- Causes infusion reactions 9- need to monitor LFTs, baseline serology for HepB&C and TB
What are RELATIVE CONTRAINDICATIONS to TNF-alpha inhibitors (etanercept, adalimumab, certolizumab, golimumab, infliximab)?
Serious current infection
Systemic lupus erythematous
Demyelinating disease
Heart failure
Why INFLIXIMAB require co-administration with MTX?
Infliximab should be co-administered with MTX to PREVENT development of antibodies and development of allergic reactions
