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PHA332 > Rheumatoid Arthritis In Practice > Flashcards

Rheumatoid Arthritis In Practice Flashcards

1
Q

What is the pharmacists role in rheumatoid arthritis?

A

1.knowing how to identify referral points and where to signpost
2.management of high risk drugs ensuring drugs are used safely, informing patients on side effects interactions and monitoring.
3.over the counter support for long term conditions e.g. pain relief
4.general advice/advice on lifestyle e.g. vaccinations and consumption of alcohol
5.support with taking medication
6.be aware of certain risk factors

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2
Q

Rheumatoid arthritis can cause increase risks of …..

A

Cardiovascular problems= assess with QRISK score and appropriate medication initiation

Osteoporosis risk= assess with FRAX/DXA and appropriate medication initiation

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3
Q

What lifestyle support is given to patients suffering with rheumatoid arthritis?

A
  1. Child resistant containers can be difficult to open so patients can request to not have these rather obtain easier opening containers.
  2. Supportive cutters to easily open containers

3.MDT -occupational therapists support patients to maintain independent living -splints and gloves

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4
Q

How is pain managed in RA?

A

The long term medications named DMARDS are not pain relief, so pain relief such as NSAIDs and cox 2 inhibitors. These medications should only be allowed to be prescribed by the doctor and not purchased over the counter.\

Steroids can be used to treat flares which will reduced inflammation and pain.

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5
Q

What are the commonly used DMARDs?

A

Methotrexate
Sulfasalazine
Leflunomide
Hydroxychloroquine
Biologics

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6
Q

What is the aim when treating a patient with rheumatoid arthritis?

A

1.aim ideally for remission (no flares and good pain relief)

  1. Low disease activity if remission cannot be achieved

3.regular reviews e.g. monthly CRP ( c reactive protein) and DAS-28 (disease activity score) until target is reached

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7
Q

What is the initial treatment for rheumatoid arthritis?

A

-mono therapy recommended
-oral methotrexate, leflunomide and sulfasalazine
-consider bridging treatment with oral,IM or IA glucocorticoids when initiating DMARDs -reduces the progression of RA

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8
Q

What is the next step in treatment of RA?

A

-increase the dose of mono therapy DMARD
-if the target is not achieved add a second DMARD
-inadequate response to conventional DMARDs try biologics usually in combination with methotrexate.

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9
Q

What are some general key points regarding DMARDs ?

A

-take weeks to months for the medication to have its effect.
-methotrexate is usual first choice unless contraindicated
-most DMARDs have significant side effects
-need regular monitoring:
Regular bloods (sometimes every fortnight, stop prescribing if no blood tests are carried out)
Patient counselling
Recognition and awareness of signs and symptoms of serious adverse effects

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10
Q

What advice would be given to patients suffering RA in regards top vaccinations?

A

A patient on DMARDs are more susceptible to infections and flus etc,
-flu and pneumonia flus are recommended
-avoid live vaccines ( if you are to give the patient this wait 2-4 weeks before starting immunosuppressive where possible)
-avoid contact with chicken pox/shingles and measles (offer MMR)
-if there is significant contact with chicken pox VZ immunoglobulin can be given within 7 days of contact
-if a patient contracts measles urgent igG testing required
-for biologics, reactivation of latent TB is cornering, thus should be screened before commencing therapy.

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11
Q

If a patient is to contract an infection what is the next steps?

A

The patient is asked to stop the immunosuppressive agent for RA until the infection is cleared up.
-leflunomide has a longer half life compared to the other DMARDs and it may limit the benefit of stopping however in practice it is still withheld.

Rheumatologists should be told by patient.

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12
Q

If a women is pregnant and is suffering with RA what’s medication would be given and why?

A

AZATHIOPRINE AND HYDROXYCHLOROQUINE- this is because the benefits outweigh the risks.

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13
Q

What immunosuppressive drugs are contraindicated in pregnancy?

A

METHOTREXATE AND LEFLUNOMIDE

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14
Q

There is a risk with all DMARDs what should the patient discuss with the specialist?

A

They should discuss with a specialist if they are planning for a baby

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15
Q

What precautions need to be taken when on DMARDs ?

A

FEMALE= effective contraception should be used during treatment and for 2 years after before becoming pregnant.

MALE= Men should be using barrier methods after treatment ends.

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16
Q

Why are DMARDs contraindicated in pregnant women?

A

-pregnancy can affect a patients conditions thus more flare ups and infections
-many women may find that their Rheumatoid arthritis is improved during the first few trimesters of pregnancy experiencing fewer flare ups and management with lower doses are effective.

In Lupus, this is different, patients can experience more severe diseases which are dangerous if not related correctly.

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17
Q

What is the first line treatment for rheumatoid arthritis and what advice is give to patients taking it?

A

METHOTREXATE
-it is taken once weekly, on the same day
-maximum of 20mg weekly.
-ask to see the patient monitoring books, this will help to observe if the patient has had their regular blood tests, methotrexate should not be given if the patient has not had their blood tests within 3-6months then this should not be given to the patient.

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18
Q

In conjunction with taking methotrexate what should be given and what advice would you give the patient ?

A

FOLIC ACID (5mg)
-this is given to reduce the side effects of methotrexate
-it is taken on a different day to methotrexate, should not be taken on the same day as it may reduce the effectiveness.
-can be taken up to 3 times a week

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19
Q

What medications are most likely to interact with methotrexate?

A

-phenytoin and trimethoprim
These are anti folate drugs
Risk of bone marrows suppression

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20
Q

Why should patients on methotrexate avoid alcohol?

A

Alcohol can cause liver issues with methotrexate

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21
Q

What tests are required for monitoring purposes whilst on methotrexate?

A

Blood tests
Liver function tests
Renal function
Look out for any red flags such as severe mouth ulcers, jaundice and shortness of breathe.

22
Q

Why are methotrexate and NSAIDs contraindicated ?

A

NSAIDs reduce the renal excretion of methotrexate thus increased risk of toxicity.

23
Q

How to counsel a patient on methotrexate?

A

-this medication is not for pain relief
-take one 2.5mg tablet once weekly on the same day every week
-folic acid on a different day than taking methotrexate
-purple book shows monitoring is being routinely done
-side effects e.g. upset stomach,diarrhoea and feeling sick

24
Q

When to notify a patient to stop taking methotrexate?

A

Stop and notify you doctor if….
-unexplained shortness of breathe and dry cough (it can gradually appear over a few days)
-if the whites of your eyes are yellow and develop severe itching
-yellowing of the skin
-if you have the chills, fever or sore throat
-severe mouth ulcers,bleeding gums, bruising
-severe sickeness
-never had chickenpox and have come into contact with them or with shingles
-if you think you or your partner have become pregnant whilst on treatment

25
Q

If a patient has had too much methotrexate what is given?

A

The patient will require folinic acid given as calcium folinate rescue therapy
This will counteract anti folate activity of methotrexate and speeds up recovery of myelosuprresion.

26
Q

What is second line treatment if methotrexate is not tolerated?

A

Sulfasalazine take with a full glass of water and swallow whole.

27
Q

What dose of sulfasalazine is given?

A

Usually 500mg once once daily for 7 days
Then
500mg twice a day for 7 days
Then
1g on a morning and 500mg on a night for 7 days
Then
1g twice a day

CAN GO UP TO 3 GRAMS

28
Q

How would you counsel a patient on sulfasalazine?

A

-this medication can turn your urine an orange colour or contact lenses an orange colour also but nothing to be worried about.
-common side effects include: dizziness,headaches, skin rashes etc
-report any unexplained cough,breathlessness,abnormal bruising ,severe sore throat,severe nausea

29
Q

What monitoring is required with sulfasalazine?

A

Bloods:
FBC
LFTs
U&E

Regular monitoring for the first 2 years only

30
Q

What must a patient inform there doctor about immediately when on sulfasazine?

A

Report:
-unexplained cough
-breathlessness
-abnormal bruising
-severe sore throat
-severe dizziness and headaches
-unexplained acute widespread rash
-oral ulceration

31
Q

What is next line treatment for RA and what dose is given?

A

LEFLUNOMIDE
- 10-20g once daily
-or 100mg once daily for 3 days but isn’t used very often.

32
Q

When can you not used leflunomide?

A

Cannot be used in patients with liver impairment or hypo protein anemia.

33
Q

What monitoring is required when on leflunomide?

A

-bloods
-blood pressure
-weight monitoring

34
Q

What drugs interact with leflunomide?

A

-methotrexate, increased risk of toxicity with methotrexate
-phenytoin
-warfarin
-tolbutamide

35
Q

What counselling would you give to a patient on leflunomide?

A

Dose:10 or 20mg tablet once daily
It might take 6 weeks or longer to see an effect
Due tot he drug dampening the immune system avoid people with chickenpox
Ideally avoid or limit alcohol intake

36
Q

How does leflunomide work?

A

It works by dampening down the disease process and reduce inflammation that can lead to pain,swelling,stiffness and joint damage.

37
Q

What side effects can occur from taking leflunomide?

A

-diarrhoea
-mouth ulcers
-weight loss
-stomach upset
-rash
-headache

38
Q

What is leflunomide wash out and what needs to be taken to do so?

A

-if the side effects are too severe, the leflunomide can be washed out the body (has a long half life)

Take COLESTYRAMINE 8G three times a day for 11 days or activated charcoal 50g four times daily for 11 days

39
Q

What is another treatment that can be used in rheumatoid arthritis (4th line) and what is the dose?

A

Hydroxychloroquine
-200mg once daily or twice daily depending on the patients weight (max. 6.5mg/kg)

40
Q

What side effects can be experienced with hydroxychloroquine?

A

-GI disturbances
-headaches
-skin reactions

41
Q

What patient is Hydroxychloroquine used with caution?

A

-epilepsy
-severe GI disorders
-may exacerbate psoriasis

42
Q

What monitoring is required with hydroxychloroquine?

A

-asses renal function
-liver function
-no routine bloods or monitoring for this drug compared to other DMARDs.
-visual eye checks tested annually only if high risk, if not every 5 years

43
Q

What drugs interact with hydroxychloroquine?

A

-amiodarone
-moxifloxacin (increased risk of ventricular arrthymias)
-digoxin (increased levels of digoxin and thus can lead to toxicity)
-ciclosporin( increased levels of this drug is taken with leflunomide
-antimalarias

44
Q

What biologics are available in the treatment of RA?

A

TNF inhibitors
Interleukin inhibitors
JAK inhibitors (Baracitinib)
-inhibitors of V or T lymphocytes activity
-PDE4 inhibition( apremilast)

45
Q

When is a patient placed on a biologic?

A

Only place a patient on a biologic if two or more DMARDs failed, but remain the patient on methotrexate.
(DAS-28>3.2)

Only continue the biologics if adequate response is seen at 6 months following initiation. Monitor every 6 months and remove a patient off this if adquate response is not received.

46
Q

What advice would you give a patient regarding a biologic in the treatment of rheumatoid arthritis?

A

-they are not pain killers
-they work to reduce stiffness, inflammation and joint damage

47
Q

Why is a biologic used with methotrexate as combined therapy?

A

It gives better results compared to mono therapy, and it also means less likely to form autoantibodies.

48
Q

What are the adverse effects of biologics?

A

-increased risk of infections
-delay the treatment of biologics whilst the patient is on antibiotics, it is only when the patient is feeling better they can restart.
-injection site reaction( switch around the injection sites)
-headaches, flushing, GI disturbances,elevated LFTs
-increased VTE risk with JAK inhibitors.
-may reactivate TB,HIV etc so all patients screened before commencing therapy.

49
Q

If a patient is on biologics what concerns would we have with surgery?

A

-these can delay the healing process following surgery
-stop it for one full dosing interval pre surgery and re start ashen wound healing improves and no evidence of infection

50
Q

What are JAK inhibitors and what are the complications ?

A

It is an oral immunomodulatory drugs
-withdraw if after 6 months there is insufficient benefit
-high VTE risk

PHA332 (25 decks)

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