Rheumatoid Arthritis - Therapeutic aspects

Question 1

RA - Therapeutic categories?

Answer 1

1) Non steroidal anti inflammatory drugs (NSAID)
2) Disease Modifying anti Rheumatic drugs (DMARD)
3) Biologics
4) Corticosteroids (oral, i-m, i-a)

Question 2

RA Therapeutics, what is - Disease modifying anti-rheumatic drugs (DMARD)?

Answer 2

A group of structurally unrelated, typically small molecule drugs which have been demonstrated to have slow onset effect on disease activity and retard disease progression.

Traditionally, these have been associated with identifiable toxicity profiles and risk of occasional serious adverse event.

Question 3

RA Therapeutics, examples -Disease modifying anti-rheumatic drugs (DMARD)?

Answer 3

Methotrexate
Sulfasalazine
Hydroxychloroquine
Leflunomide

Question 4

RA Therapeutics, why is penicillamine no longer used?

Answer 4

Highly toxic

Question 5

Current approach to RA management?

Answer 5

> Early and aggressive intervention is the key to obtaining optimal outcomes in the management of RA

> Effective suppression of inflammation will improve symptoms and prevent joint damage and disability

Question 6

What is the most common used drug in RA, why?

Answer 6

Methotrexate (a DMARD

• Effective
• Well tolerated
• Cheap

this means people stay on it

Question 7

RA Therapeutics, what are - Biologics?

Answer 7

Biologic DMARDs have been developed from improved understanding of immunology to target key aspects of inflammatory cascade.

Typically these are large complex proteins which need to be given parenterally. Compared to traditional DMARD, they work rapidly, are generally well tolerated although with important toxicities (eg infection and come at high cost.

Question 8

RA Therapeutics, examples- Biologics?

Answer 8

Biologics in 2017
> TNFα inhibitors (x5)

> IL-1 inhibitors (Anakinra)

> Anti B Cell therapies (CD20, Rituximab)

> Anti T Cell therapies (Abatacept)

> IL-6 inhibitors (Tocilizumab)
Other

Question 9

What is Tocilizumab?

Answer 9

An IL-6 inhibiter (Biologic used in RA)

Question 10

What is Abatacept?

Answer 10

An anti-T cell therapy (A biological used in RA)

Question 11

What is Rituximab?

Answer 11

An anti-B cell therapy (A biologic used in RA)

Question 12

What is Anakinra?

Answer 12

An IL-1 inhibitor (A biologic used in RA)

Question 13

What is Sulfasalazine?

Answer 13

A Disease modifying anti-rheumatic drug (DMARD)

Question 14

What are the main issues surrounding using biologics in RA treatment?

Answer 14

> Efficacy: enhanced response when co prescribed with Mtx

> Toxicity: minor eg injection site reaction: Infection; Malignancy

> Cost

Question 15

Corticosteroids in RA?

Answer 15

Corticosteroids
> Corticosteroids can be prescribed by mouth, by i-a or i-m injection and by i-v infusion

> Short term benefit v long term toxicity

> Rarely appropriate as single drug therapy

Question 16

Drugs that ease symptoms in RA?

Answer 16

NSAIDs (COX inhibitor)

Question 17

Drugs That Slow Disease Activity in RA?

Answer 17

> Corticosteroids eg prednisolone = Fast acting and can be used whilst waiting for NSAIDs or DMARDs to take effect

> DMARDs e.g. methotrexate, hydroxycholorquine, sulfasalazine, leflunomide, cyclophosphamide and azathioprine

> Biologics (Require injection)

> JAK inhibitors e.g. Tofacitinib (Can be taken orally)

Question 18

What is tofacitinib?

Answer 18

A JAK inhibitor (Can be used in RA treatment to slow progression)

Question 19

What is a last option in RA therapy sometimes?

Answer 19

Surgery - Joint replacement

Question 20

Complications with RA?

Answer 20

Orthopaedic intervention
> Chronic synovitis
> Mechanical deformities
> Secondary osteoarthritis
> Poor function
> Pain 

Extra-articular involvement
> Rheumatoid nodules
> Interstitial lung disease
> Vasculitis

Cardiovascular risk

Socio-economic

Question 21

Socio-economic impact of RA?

Answer 21

Direct costs to the NHS and associated healthcare support services

Indirect costs to the economy, including the effects of early mortality and lost productivity

Personal impact and subsequent complications for patients and their families

Approximately one third of people stop work within 2 years of onset

Question 22

Functional impairment within RA?

Answer 22

Vertebral fractures