Rheumatoid Athritis Flashcards by Eresi Obewu

Presentation of Rheumatoid arthritis

Chronic

Symmetrical

Systemic

Progressive

How well did you know this?

Not at all

Perfectly

What Rheumatoid Arthritis

Immune system unable to differentiate native from non-native tissues attacking mostly synovial and other connective tissues

How well did you know this?

Not at all

Perfectly

What is pannus

Inflammation and proliferation of synovial tissue lining the joints

How well did you know this?

Not at all

Perfectly

What is the pathophysiology of Rheumatoid Arthritis

Macrophages release cytotoxins activating free oxygen radicals inducing cellular damage and inflammation

How well did you know this?

Not at all

Perfectly

True/false: RA can manifest in areas outside the joints

True

How well did you know this?

Not at all

Perfectly

Where does RA most commonly occurs

In diseases that are longstanding, and active

Rheumatoid factor positive

Anti-cyclic citrullinated peptide positive

How well did you know this?

Not at all

Perfectly

What are the systemic involvement of RA

Rheumatoid nodules

Vascular

Pulmonary

Ocular

Cardiac

Hematologic

How well did you know this?

Not at all

Perfectly

How is RA compared to OA

Proximal fingers joints, wrist, toes and elbow

Symmetric

Inflammation of soft connective tissue and accumulation of fluid

Better with activity

Affects 1% of the population

How well did you know this?

Not at all

Perfectly

OA compared to RA

Hips, knees, lower back

Asymmetric

Wearing of cartilage

Worse with activity

15% of the population

How well did you know this?

Not at all

Perfectly

To Hal one patients major complaint in the clinic for RA (Clinical presentation)

Diffuse pain > 6 weeks

Morning stiffness < 1 hour

Tenderness with warmth and swelling of affected joints

How well did you know this?

Not at all

Perfectly

What labs factors are used to diagnose RA

Rheumatoid factor

ACPA positive

ESR elevated and CRP marker

CBC with differential to identify mild/ moderate thrombocytopenia or anemic

Turbid synovial find

How well did you know this?

Not at all

Perfectly

What imaging are used to diagnose and track progression of the disease

Radiography

Ultrasonography

MRI

How well did you know this?

Not at all

Perfectly

What is the criteria for RA

Synovitis of at least one joint with no other explanation

A score greater than 6 in 2010 ACR/EULAR classification criteria

How well did you know this?

Not at all

Perfectly

What are the nonpharmacologic approach to addressing RA

Rest

PT/OT

Exercise

Surgery

How well did you know this?

Not at all

Perfectly

Synthetic DMARDS csDMARDs

Hydroxychloroquine

Methotrexate

Leflunomide

Sulfasalazine

How well did you know this?

Not at all

Perfectly

Synthetic targeted DMARDs

Tofacitinib

Upadacitinib

Baricitinib

How well did you know this?

Not at all

Perfectly

Biologic DMARDS TNFi

Adalimumab and biosimilars

Certolizumab

Etanercept and biosimilars

Golimumab

Infliximab and biosimilars

How well did you know this?

Not at all

Perfectly

Biologic DMARDS non-TNFi

Abatacept

Anakinra

Rituximab

Tocilizumab

Sarilumab

How well did you know this?

Not at all

Perfectly

Supportive medication

NSAIDs

Steroids

How well did you know this?

Not at all

Perfectly

NSAIDs

Work quickly

Systemic or oral

Does not impact disease progression

How well did you know this?

Not at all

Perfectly

Steroids

Work quickly

Systemic or intra-articular injections

Long term risks

How well did you know this?

Not at all

Perfectly

Methotrexate MOA

Increase AMP to suppress inflammatory actions of neutrophils, macrophages and lymphocytes

How well did you know this?

Not at all

Perfectly

Methotrexate dosing

7.5-25 mg/week

How well did you know this?

Not at all

Perfectly

Methotrexate PK

Absorption: 60%

1/2 life: 8 hours

Renally excreted

How well did you know this?

Not at all

Perfectly

Methotrexate ADR

Mucositis GI ulcers Alopecia Photosensitivity Hepatotoxicity Nausea/vomiting/ diarrhea Myelosuppression

Which vitamin is giving to reduce ADR methotrexate

B9 = folic acid

How often is methotrexate administered

Weekly

What is methotrexate onset

2-3 weeks of onset use corticosteroids in the meantime

What other formulation is methotrexate available in

Injections

What is important to know when using methotrexate

Not for pregnancy = teratogenic Do not use with alcohol

For whom is methotrexate contraindicted tor

CrCL < 30 ml/min

What should be monitored for methotrexate

Liver transaminases Serum creatinine CBC

Leflunomide MOA

Inhibits pyrimidine synthesis in lymphocytes and osteoclasts activity

How is leflunomide closed

100 mg TID followed by 20 mg daily

Leflunomide PK

Absorption: 80% 1/2 life: 14 days Renal and hepatic elimination

Leflunomide toxicity

Hepatotoxicity Alopecia GI upset NVD Rash

What should be monitored of leflunomide is giving in combination with methotrexate

Hepatotoxicity

If leflunomide full dose is intolerable what should be done

Reduce dose by 10 mg and loading dose may be omitted

Why leflunomide not giving to pregnant women

Teratogenic

What should be monitored with leflunomide

Liver transaminases CBC with platelets

Hydroxylchloroquine MOA

Anti-inflammatory and immunomodulatory effects

Hydroxychloroquine dosing

200-300 mg twice daily

Hydroxychloroquine PK

Absorption: 70% 1/2 life: 40 days Renally excreted

Hydroxychloroquine ADR

NVD Rash Weakness Macular damage Pigmentation changes

When is hydroxychloroquine used in RA therapy

Less active form of RA

Should hydroxylchloroquine be taken with food

Yes

What is the onset for hydroxychloroquine

Delayed for upto 6 weeks

What should be monitored with hydroxychloroquire

CBC Vision Liver transaminases

Sulfasalazine MOA

Modulate local chemical mediators of inflammatory response

Sulfasalazine MOA

0.5-1 g daily

Sulfasalazine MOA

Absorption:10% 1/2 life: 14 hours Renally excreted

Sulfasalazine ADR

Myelosuppression Rash Headache NVD Anorexia Skin and urine pigmentation

When is the effects of Sulfasalazine seen

2 months

What can decrease absorption of Sulfasalazine

Antibiotic that destroy colonic bacteria

Who should avoid Sulfasalazine

Patient with sulfa allergy

Should Sulfasalazine be taking with full glass of water and food

Yes

What vitamin can be supplemented with Sulfasalazine 1 mg daily

Folic acid

What should be monitored in Sulfasalazine

CBC Liver transaminases

What is Tofacitinib , Baricitinib, Upadacitinib MOA

Janus kinase inhibitors preventing cytokine/ growth factor signaling

Tofacitinib dosing

5 mg BID

Tofacitinib PK

Absorption; 70% 1/2 life: 3 hours Renally excreted

Tofacitinib ADR

Myelosuppression Infection Diarrhea Headache GI perforations Increased lipids

What should patient that use tofacitinib avoid

biologic or potent immunosuppressant Strong CYP450 inducers

What changes to dose of tofacitinib should be made when taking with 3A4 and 2C19 inhibitors

Reduce to 5 mg daily

Baricitinib dosing

2 mg daily

Baricitinib and upadacitinib PK

Absorption: 80% Half life:.12 hours Elimination: Kidney and feces

Baricitinib ADR

URTI Hepatic dysfunction Infections and increased lipids

Upadacitinib dosing

15 mg daily

Upadacitinib MOA

URTI Nausea Cough Pyrexia

What should not be used in patients taking: Tofacitinib, Baricitinib, upadacitinib

Biologics or potent immunosuppressants

What should patient taking; tofacitibinib, Baricitinib or upadacitinib be instructed to monitor

Infection Shortness of breath Signs of bleeding

What should be monitored in patients taking: Tofacitinib, Baricitinib, upadacitinib

CBC Liver transaminases Lipids Hemoglobin

BBW: thrombosis and tuberculosis

Upacitinib and Baricitinib

Avoid use with strong CYP3A4 inducers/inhibitors

Baricitinib and upadacitinib

What are the dual of therapy MTX

Leflanomide HCQ Sulfasalazine Tofacitinib

Dual therapy for Sulfasalazine

HCQ

Triple therapy

Sulfasalazine + MTX + HCQ

TNF alpha inhibitors MOA

Suppress inflammatory actions of TNF

TNF alpha inhibitors ADR

Immunosuppression Heart failure Hepatotoxicity Abdominal pain Infection site reactions Rash

For whom is TNF alpha inhibitor contradicted

Congestive heart failure relative

What should patient who require TNF alpha inhibitor be tested and treated for?

What type of vaccines should not be used in patients on TNF alpha inhibitors

Live vaccines

TNF alpha inhibitors can increase the risk of?

Serious bacterial and fungal infections

True/false: more than one biologic can be used concomitantly

False

All TNF alpha inhibitor require refrigeration except

Etanercept

What should be monitored in patients on TNF alpha inhibitors

TST Hepatitis screening Sx of infections

Which TNF-alpha inhibitors is IV

Infliximab

Which TNF alpha inhibitors are subcut

Adalimumab Etanercept Certolizumab Golimumab

Which TNF-alpha inhibitors is used in combination with metothrexate

Infliximab Adalimumab Golimumab Rituximab

Which TNF-alpha inhibitor requires premedication

Infliximab

For patients with congestive heart failure for whom infliximab recommended what is the dose needed

Not greater than 5 mg/kg

Which has high rate of injection site reaction

Infliximab

Inhibit t-cell activation

Abatacept

Abatacept PK

1/2 life: 13 days renally excreted

Abatacept ADR

Infection Infusion reaction False hyperglycemia

Can use csDMARDs

Abatacept Tocilizumab Sarilumab Rituximab (MTX)

Can worsen COPD

Abatacept

Monitor for TST and signs of infections

Abatacept Rituximab

Chimeric monoclonal CD-20 antibody Targets b-cells

Rituximab

Rituximab PK

1/2 life: 18 days

Rituximab ADR

Arthralgias Myelosuppression Hyperphosphatemia Hypertension

Infusion requires premedication

Rituximab

IL-6 receptor antagonist

Tocilizumab Sarilumab

Tolicizumab PK

1/2 half: 6 days

Tocilizumab MOA

Hypersensitivity reactions Immunosuppression GI perforation Dyslipidermia Infections

Tocilizumab monitoring parameters

Liver transaminases CBC Lipids Sx of infection

IL-1 receptor antagonist

Anakinra

Anakinra Dosing

100 mg subcut daily

Anakinra PK

1/2 half:4-6 hours

Anakinra ADR

Neutropenia Diarrhea Influenza like reaction Injection site reaction

Which drugs require renal adjustment

Anakinra

Anakmira monitoring parameter

Neutrophil count Symptoms of infection

Sarilumab dosing

200 mg subcut every 2 weeks

Sarilumab PK

1/2 life concentration dependent: 8-10 days

Sarilumab ADR

Injection site reactions Dyslipidemia Infection Neutropenia Hepatotoxicity GI perforation

Sarilumab monitoring parameters

TST Sx of infections Liver transaminases Lipids