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GI/Rheumatology Module > Rheumatoid Arthritis Treatment > Flashcards

Rheumatoid Arthritis Treatment Flashcards

1
Q

What is the goal of RA Treatment?

A

Low disease activity or remission

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2
Q

What is DMARDs and what is included?

A

Disease modifying anti rheumatic drugs
1. Nonbiologic
2. Biologic

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3
Q

NSAIDs have what main effect in RA treatment?

A

Anti-Inflammatory

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4
Q

HPA Axis Steps

A

Hypothalamus: Corticotropin releasing hormone –> Pituitary: Corticotropin ACTH –> Adrenals: Cortisol –> neg feedback on Pituitary

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5
Q

What are the indications of Corticosteroids?

A
  1. Extaarticular disease
  2. Vasculitis
  3. Active RA during pregnancy or breastfeeding
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6
Q

What are the AEs of Corticosteroids?

A
  1. 2-4x increased GI risks when given with NSAIDs
  2. Moon face
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7
Q

What can be accelerated with corticosteroids?

A

Atherosclerosis or Osteoporosis

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8
Q

How can you prevent osteoporosis when taking corticosteroids?

A
  1. Calcium
  2. Vitamin D
  3. Weight baring exercise
  4. Bisphosphonate if moderate/high fracture risk
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9
Q

When is pulse dose IV methylprednisolone used?

A

Lupus

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10
Q

When is IM depot methylprednisolone used?

A

Immediate relief of pain

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11
Q

What are the Nonbiologic DMARDs csDMARDs?

A
  1. Methotrexate
  2. Sulfasalazine
  3. Leflunomide
  4. Hydroxychloroquine
  5. Minocycline
  6. Cyclosporine
  7. Azathioprine
  8. Gold
  9. D-Penicillamine
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12
Q

What is the primary nonbiological drug for RA?

A

Methotrexate

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13
Q

Methotrexate absorption decreases with what?

A

Increased doses and food

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14
Q

What is the onset of effect for Methotrexate?

A

Onset 3-6 weeks, max effect 3-6 months

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15
Q

What is the hepatic concern with Methotrexate?

A

Fibrosis and Cirrhosis

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16
Q

What is the pulmonary concern with Methotrexate?

A

Acute hypersensitivity pneumonitis vs. toxic drug reaction
Dyspnea, drug cough, and fever

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17
Q

What are the toxicities of Methotrexate?

A
  1. Fetal abnormalities/abortifacient
  2. Oligospermia
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18
Q

How do you decrease toxicity of Methotrexate?

A

Take with Folic Acid 1 mg/day

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19
Q

What are the drugs that can cause decreased renal clearance and increased risk of toxicity of Methotrexate?

A
  1. Probenecid
  2. Salicylate
  3. NSAIDs
  4. Diuretics
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20
Q

What are the drugs that displace Methotrexate from binding sites?

A
  1. Salicylate
  2. Sulfonamides
  3. Phenytoin
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21
Q

What are the CIs of Methotrexate?

A
  1. Acute or chronic liver disease
  2. Excessive alcohol consumption
  3. Pregnanc
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22
Q

What is precaution of Methotrexate?

A

Obesity, diabetes aka Fatty Liver, which the risk of fatty liver can be increased with Methotrexate

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23
Q

What is the dosing frequency of Methotrexate?

A

EVERY WEEK
PUT DAY of week on the Rx Label

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24
Q

What are the monitoring concerns with Methotrexate?

A
  1. CBC
  2. Cr
  3. Liver Enzymes
    Q2-4 wks every 3 months, then q8-12 weeks for 3-6 months, and then q12 weeks after 6 months
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25
Q

What is the main takeaway of Methotrexate in RA?

A

Initial drug of choice, anchor for most combinations

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26
Q

What is the efficacy monitoring of Sulfasalazine?

A
  1. Improvement detectable at 4-8 weeks
  2. Failure identifiable within 3 months
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27
Q

What is the CI of Sulfasalazine?

A

Hypersensitivity to salicylate or sulfonamide

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28
Q

What is the monitoring for Sulfasalazine?

A
  1. Baseline G6PD
  2. CBC and LFTs within 1 month
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29
Q

What is the main toxicity of Sulfasalazine?

A

GI Effects 19%

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30
Q

What is the concern of Sulfasalazine during pregnancy?

A

Safe during pregnancy, but NOT safe AT TERM because it can cause Kernicterus: jaundice in the newborn

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31
Q

What are the PK parameters of Leflunomide?

A

Prodrug for Teriflunomide and still detectable 2 years later

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32
Q

What is the main toxicity of Leflunomide?

A

Increased LFTs, Severe Liver Injury
Stop is ALY 3x ULN

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33
Q

What are the CIs of Leflunomide?

A
  1. Teratogenicity
  2. Prior to pregnancy, drug is eliminated with cholestyramine until plasma concentration <0.02 ng/L
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34
Q

What is the monitoring of Leflunomide?

A
  1. Baseline Hep B and C
  2. Same as MTX and SAS
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35
Q

How long does it take to determine efficacy of Hydrochloroquine?

A

6 months to determine failure

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36
Q

In mild RA, how is Hydrochloroquine utilized?

A

Monotherapy

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37
Q

What is the elimination half life of Hydrochloroquine?

A

40 days

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38
Q

What is the main side effect of hydrochloroquine, and what is a side effect that Dr. Resman-Targoff was surprised by?

A
  1. Retinal Damage
  2. Skin Hyperpigmentation (dr. resman)
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39
Q

What are the counseling points of Hydroxychloroquine?

A
  1. Considered safe in pregnancy
  2. Take with food or milk
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40
Q

What are the monitoring parameters of Hydroxychloroquine?

A
  1. CBC
  2. LFTs
  3. Creatinine
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41
Q

What is Minocycline?

A
  1. Not currently in ACR RA treatment guidelines
  2. Previously used for Mild RA off label
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42
Q

What is the plasma half life of Cyclosporine?

A

1-45 hrs

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43
Q

What is the efficacy of Cyclosporine?

A

Seen at 2-12 weeks
Peaks at 6 months

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44
Q

What are the toxicities of Cyclosporine?

A
  1. Nephrotoxicity
  2. Hypertension
  3. Gingival Hyperplasia
  4. Hyperkalemia
  5. Hypomagnesemia
  6. Hyperuricemia
  7. GI
  8. Neuropathies
  9. Hirsutism
45
Q

What are the monitoring parameters of Cyclosporine?

A
  1. Cr
  2. BP
  3. K
  4. Uric Acid
46
Q

There is a high risk of toxicity for Azathioprine is what?

A

Low or Absent TPMT

47
Q

What is the concern in pregnancy for Azathioprine?

A

Considered safe in pregnancy but use CI by manufacturer?

48
Q

What is the efficacy of Azathioprine?

A

Onset 6-12 weeks
Peak 6 months

49
Q

What are the Targeted Synthetic DMARDs/Oral Janus Kinase JAK Inhibitors?

A
  1. Xeljanz
  2. Olumiant
  3. Rinvoq
50
Q

How to spell Tofacitinib brand name?

A

X E L J A N Z

51
Q

How to spell Baricitinib brand name?

A

O L U M I A N T

52
Q

How to spell Upadacitinib brand name?

A

R I N V O Q

53
Q

What can you NOT combine JAK Inhibitors with?

A
  1. Azathioprine
  2. Cyclosporine
  3. Tacrolimus
  4. Biologics
  5. Other JAK Inhibitors
54
Q

What is the toxicity of JAK Inhibitors?

A
  1. Thrombosis
  2. Zoster
  3. GI Perforation
  4. Increased LDL Cholesterol
  5. Increased LFTs
55
Q

What is a risk of JAK Inhibitors?

A

Risk of Major CV Events and malignancy

56
Q

What should monitor for with JAK Inhibitors?

A
  1. CLOTS
  2. CBC
  3. Lipid Panel
  4. Infections
57
Q

Xeljanz dosing is what?

A

PO

58
Q

Olumiant dosing and caution is what?

A

PO
Not used for GFR <60

59
Q

Rinvoq dosing and caution is what?

A

PO
AVOID if severe hepatic impairment

60
Q

What are the Anti-TNF Monoclonal Antibodies?

A
  1. Infliximab
  2. Adalimumab
  3. Golimumab
  4. Certolizumab Pegol
  5. Entanercept
  6. Rituximab
  7. Abatacept
61
Q

What does (I)I mean?

A

Immune target

62
Q

What does xi mean?

A

Chimeric

63
Q

What does (m)u mean?

A

Fully human

64
Q

What does zu mean?

A

Humanized

65
Q

What should you avoid when taking TNFa Inhibitors?

A

Avoid foods with listeria risk

66
Q

What happens to the fetus when mother is taking TNFa Inhibitors?

A

Immunosuppression after birth

67
Q

What is the MOA of Etanercept and its dosing?

A

Soluble TNF receptor, binds TNFa, blockers interaction
SUB Q

68
Q

What is the main drug warning of Entanercept?

A

CNS Demyelinating disorders

69
Q

What is the MOA of Infliximab and its dosing?

A

Chimeric, binds to TBFa
IV INFUSION

70
Q

What are the toxicities of Infliximab?

A
  1. TB Reactivation
  2. Acute infusion reaction
  3. Hypesensitivity
  4. Increased infection risk
71
Q

What is the MOA of Adalimumab and its dosing?

A

HUMAN IgG1, binds TNFa
SUB Q, Without or without MTX

72
Q

What is the MOA of Golimumab and its dosing?

A

HUMAN IgG1, binds TNFa
SUB Q or IV WITH MTX in RA

73
Q

What is the MOA of Certolizumab Pegol and its dosing?

A

Peglayted Fab Fragment
SUB Q, alone or with nonbiologic DMARD in RA

74
Q

What is the MOA of Rituximab?

A

CHIMERIC, directed against B cell surface antigen CD20, depletes B Cells

75
Q

When do you use Rituximab in RA?

A
  1. Active RA
  2. Inadequate response or intolerance to TNF inhibitors
76
Q

Can you use Rituximab in pregnancy?

A

NO, not recommended

77
Q

What is the dosing of Rituximab?

A
  1. With MTX
  2. IV Infusion day 1 and 15
  3. Q 24 weeks
78
Q

What is the MOA of Abatacept?

A

Selective Costimulation Modulator

79
Q

What are the toxicities of Abatacept?

A

COPD Exacerbations

80
Q

What is the dosing of Abatacept?

A

IV Infusion or SUB Q
Avoid silicone syringes

81
Q

What are the Il-6 Antagonists?

A
  1. Tocilizumab
  2. Sarilumab
  3. Anakinra
82
Q

What is the MOA of Tocilizumab?

A

HUMANIZED IL-6 Receptor inhibiting monoclonal antibody

83
Q

What is the toxicity of Tocilizumab?

A
  1. Gastrointestinal perforation
    Increased liver enzymes and lipids, decreased neutrophils and platelets
84
Q

Can you use Tocilizumab in pregnancy?

A

NO

85
Q

What is the dosing of Tocilizumab?

A

IV Infusion or SUB Q

86
Q

What is the MOA of Sarilumab?

A

FULLY HUMAN IL-6 receptor inhibiting monoclonal antibody

87
Q

What are the toxicities of Sarilumab?

A
  1. GI Perforation
    Increased liver enzymes and lipids
88
Q

What is the dosing for Sarilumab?

A

SUB Q

89
Q

What is the MOA of Anakinra?

A

RECOMBINANT IL-6 receptor antagonist

90
Q

What is the dosing of Anakinra?

A

SUB Q DAILY

91
Q

Is Anakinra recommended in pregnancy?

A

NO

92
Q

What is Comorbidity?

A

2 simultaneous diseases that occur together more often than by chance

93
Q

What is Multimorbidity?

A

2 simultaneous disease that occur together randomly

94
Q

What should be in lab monitoring of RA?

A
  1. ESR
  2. CRP
  3. Hemoglobin/Hamtocrit
  4. Platelets
  5. X-Rays
95
Q

Do you use RF in monitoring of RA?

A

NO, only used to establish diagnosis

96
Q

What are the RA Treatment Strategies?

A
  1. Combo therapy
  2. A+B+C+D
  3. Methotrexate Anchor
97
Q

Why do you want to give Chimeric monoclonal antibodies with Methotrexate?

A

To decrease formation

98
Q

Can Biologics and JAK Inhibitors be combined?

A

NO

99
Q

Which drug needs an elimination procedure prior to pregnancy and what is it?

A

Leflunomide, eliminate with Cholestryramine

100
Q

What is the initial treatment guideline?

A
  1. DMARD naive, low disease activity = HCQ>MTX>LEF
  2. DMARD naive, mod/high disease activity = MTX mono>HCQ mono, SAS, bDMARD, tsDMARD, or combo
  3. csDMARD without glucocorticoid preferred
101
Q

What is methotrexate admin guideline?

A

Initial oral MTX preferred over SUB Q

102
Q

What is the treatment modification guideline?

A
  1. Max tolerated MTX dose, adding bDMARD or tsDMARD preferred over cs DMARD triple therapy
  2. Adding/switching DMARDs preferred over continuing/adding glucocorticoid to stay at target
103
Q

What is the tapering of DMARD guideline?

A
  1. Gradually DC Drugs
  2. If on triple csDMARDs, gradually DC SAS>HCQ
  3. Gradually DC MTX>stopping bDMARD or tsDMARD
104
Q

How long should RA treatment be at target prior to tapering?

A

At target >6 months before tapering

105
Q

When should you screen TB?

A

Before biologic or JAK inhibitor

106
Q

Which drugs have the highest reactivation of tuberculosis?

A

TNFa Inhibitors Infliximab or Adalimumab

107
Q

What is the screening for TB?

A
  1. Screen with PPD or IGRA, if positive get CXR
  2. If CXR positive, get sputum for AFB
  3. If AFB positive, treat for TB >3 months before starting biologic/JAK
  4. If AFB or CXR neg, treat for latent Tb 1 month before biologic/JAK
108
Q

Immunosuppressed patients may have diminished response to vaccines and increased risk for infections. Vaccine may trigger autoimmune diseases and therefore,

A

Should be administered before starting

109
Q

For patients older than 50 yrs what vaccine should you consider?

A

Shingrix, especially before JAK inhibitors

GI/Rheumatology Module (18 decks)

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