Rheumatoid Arthritis Treatment 3

Question 1

what does the chronic inflammation of the synovium lead to

Answer 1

leads to the destruction of cartilage and bone
- inflammation leads to increase in T and B cells

Question 2

what is involved in synovitis in the RA joint

Answer 2

macrophage like synoviocytes are recruited and retained

Question 3

give an example of a B cell depletor

Answer 3

Retuximab

Question 4

describe the inflammatory response of RA

Answer 4

inflammation in the joint leads to cytokine production
- cytokines form a complex network

Question 5

outline the management of synovitis in RA

Answer 5

1. complete remission is the goal
2. aggressive therapy is important
3. erosions possible in 2 years without good treatment
4. prognostic indictors should drive most aggressive therapy
5. step up paradigm most common

Question 6

what is the step up paradigm

Answer 6

1. use an anchor drug first (methotrexate)
2. then add another
3. permits graded escalation of therapy with minimum number of medicines
4. when tradition DMARDs are ineffective, add a ts or bDMARD

Question 7

what is the mechanism of action of methotrexate

Answer 7

• inhibition of purine biosynthesis and cytokine expression
• induction of monocyte apoptosis

Question 8

what is the mechanism of action of infliximab

Answer 8

chimeric anti-TNf-a antibody
- inhibits TNF-a

Question 9

what is the mechanism of action of tsDMARDs

Answer 9

inhibits the JAK-STAT signalling pathway responsible for inflammatory response

Question 10

give examples of tsDMARDs

Answer 10

tofacitinib, baricitinib

Question 11

why does NICE limit access to ts/bDMARDs

Answer 11

expensive
- only used if disease is severe/not responded to intensive therapy with a combination of conventional DMARDs

Question 12

what is the multidisciplinary approach to RA

Answer 12

1. a team approach improves outcome
2. many different professions are involved in the care of a RA patient

Question 13

outline the principles of opioid treatment of chronic musculoskeletal pain

Answer 13

1. MSK pain significantly impacts quality of life
2. opioids are often spared because of the worry of tolerance and ADRs
3. a proactive approach when applying the pain ladder is advocated
4. ADRs like constipation can be managed with good pharmaceutical care

Question 14

what are the problems with opioids

Answer 14

1. have been abused in the past
   - oxycodone is one of the most widely abused prescription drug
2. correct patient selection is imperative
3. right patient, right drug, right time
4. can use an opioid risk questionnaire
5. beware of renal impairment with morphine
   - easy for patients with AKI to accumulate morphine and become toxic
6. role of naloxone protocols
7. constipation managed proactively with softener and stimulant laxative

Question 15

describe how the choice of agent and titration is managed

Answer 15

1. in naive patients, use short acting agents first
2. start at lowest dose
3. titrate by 30-50% and assess pain
4. once stable, convert total daily dose of short acting to long acting preparation

Question 16

a patient presents with a DAS score of 5.3 despite intensive therapy with a combination of DMARDS. describe what this score means and why it influences the decision around next steps in treatment plan

Answer 16

1. DAS: disease activity score, measures the rheumatoid levels in a set of joints
2. 5.3 indicates severely active disease
3. combination therapy isn’t working because they still have active disease
4. so it influences the decision around the treatment plan because they meet criteria for access to biologic agents, which would be an appropriate treatment choice for this patient