Rheumatology Flashcards
gout is characterized by a serum uric acid
> 6.8 mg/dL
which disease states can increase risk of gout (7)
T2DM, hyperlipidemia, obesity, renal insufficiency, HTN, organ transplant, CHF
which foods increase risk of gout (5)
meat, seafood, beer, soft drinks, fructose
which foods decrease gout risk (3)
coffee, dairy, vit C
which medications increase gout risk (4)
thiazides, loops, nicotinic acid, aspirin
which medications lower gout risk (2)
losartan, fenofibrate
which 4 things can precipitate a gout flare
alcohol or high purine ingestion, stress, meds
3 drugs used for acute gout management
NSAIDs, colchicine, steroids
colchicine need dose adjustment for
renal & hepatic
AEs of colchicine
GI, hematologic, rhabdo
strong CYP3A4 inhibitors that interact with colchicine?
how to adjust dose?
clarithromycin, itraconazole, ketoconazole, darunavir/ritonavir
1/2 the doses
moderate 3A4 inhibitors that interact with colchicine?
how to adjust dose?
diltiazem, erythromycin, fluconazole, verapamil
single 1.2 dose for flares, prophy dose is 1/2 QD or QoD
p-gp inhibitors that interact with colchicine
how to adjust dose?
cyclosporine, amiodarone, ranolazine
single 0.6 for flare, prophy dose 1/2 QD or QoD
intraarticular steroid dose for large, medium, small joint?
lg- 40 mg
med- 30 mg
sm- 10 mg
2 xanthine oxidase inhibitors used chronically for gout
allopurinol, febuxostat
starting dose for allopurinol and how increase dose
start 50-100 mg QD and inc Q3-5W until achieve goal SUA
AEs of allopurinol
rash, DRESS
which medications can increase the risk of rash when taking allopurinol
amoxicillin, ampicillin, thiazides, ACEi
what should you do if you get a rash from taking allopurinol
d/c the drug
aside from drugs causing rash, which medications have a DDI with allopurinol
warfarin, 6-MP, azathioprine, theophylline
dose of febuxostat
40 mg to start and can increase to 80 mg QD if not at goal after 2 weeks
AEs of febuxostat
HA, arthralgias, abdominal pain, nausea, abnormal LFTs, flushing, dizziness
BBW febuxostat
CV death
DDI with febuxostat
concurrent 6-MP, azathioprine, theophylline
uricosuric that inhibits reabsorption of uric acid used for chronic gout
probenecid
dose of probenecid
250 mg bid x1week then can inc to 500 mg bid
max 2g/day increased in 500 mg increments Q4W
when should probenecid be avoided
Crcl <50, hx of nephrolithiasis
DDI with probenecid where it should be avoided
penicillin, methotrexate, carbapenems, salicylates
uricase agent used for chronic gout refractory to other treatments
pegloticase
dose of pegloticase
IV 8 mg Q2W over 2 hours
BBW for pegloticase
infusion reactions
what is recommended 1st line for UA lowering in chronic gout therapy
allopurinol
goal serum urate level for gout treatment
<6 mg/dl
what is next step after allopurinol for chronic gout
switch to febuxostat, inc dose, add probenecid
what is used when all options fail for chronic gout therapy
pegloticase
monitoring for chronic UA lowering therapy for gout
reassess levels Q2-5W, increase intensity until goal is reached
when should prophylaxis be used for chronic gout therapy and for how long
when ULT is initiated and continue for 3-6 months
1st line for prophylaxis for chronic gout therapy
colchicine 0.6 mg QD or BID
or
low dose NSAIDs - naproxen 250 mg BID
when should gout prophylaxis therapy be continued
activity of symptoms, flare in last 3 mos, tophi present
gout flare therapy for mild-mod pain with 1-2 joints involved
monotherapy
gout flare therapy for severe pain with >2 joints involved
combo therapy
3 options for gout flare therapy
colchicine 1.2 mg then 0.6 mg one hour later then start prophy dosing 12 hours later
full dose NSAID
steroids
when should colchicine not be used for gout flare therapy
on it prophylactically and had an acute regimen in the last 14 days
intraarticular steroids can be considered for gout flare therapy if
1-2 large joints involved
3 main steroid options for gout flare and dose
PO prednisone 0.5 mg/kg/day for 5-10 days
PO medrol
IM triamcinolone acetonide 60 mg then PO pred
combo therapy options for gout flare (4)
nsaid + colchicine
po steroid + colchicine
IA steroid + nsaid +/- colchicine
IA steroid + po steroid +/- colchicine
risk factors for osteoarthritis
obesity, genetics, trauma/injury, anatomic factors, female, non-caucasian, age >40F or >50M
main patho mechanism of OA
cartilage breakdown causes change to bone and joint tissue
affected joints for OA
hand, knee, hip
features of OA presentation
pain/stiff (AM, idleness), decreased range of motion, mono/oligoarticular, asymmetrical
1st line option for hand, knee, and hip OA
oral NSAIDs
what can be used for knee OA only
topical NSAIDs
what can be considered for knee and hip OA
IA steroids
APAP is used conditionally for OA and should be taken
650-100 mg PO Q4-6H
AROUND THE CLOCK NOT PRN
3 main complications from PO nsaid use
gastropathy, CV events, nephrotoxicity
how to approach PO NSAIDs in OA if they have bleed history?
>1 yr ago?
<1 yr ago?
> 1 yr— COX2 selective or non w/ PPI
<1 yr— COX2 selective w/ PPI
nsaids should be avoided in patients at high risk for
CV events
conditional option for OA with BBW for addiction, misuse, resp depression
tramadol
conditional topical option for KNEE OA that depletes substance P?
how is it used? how long to work?
topical capsaicin
AAA 3-4x QD
2 weeks to work
SNRI used conditionally for OA
duloxetine
minimum injection interval for IA steroids in OA
minimum 3 mos
how long for IA steroids to work for OA? how long to last?
onset 1-3 days
peak 1 week
works 1-2 mos
OTC that is not recommended in OA
glucosamine
nonpharm option for hand, knee, and hip OA
exercise, self-efficacy, self-management programs
risk factors for RA
smoking, coffee, obesity, infections, autoantibodies
____ positive is associated with a poorer prognosis for RA
ACPA
affected joints in RA
hands, wrists, ankles, feet
key articular presenting features of RA
warmth, swelling w/o pain, decreased range of functionality, morning stiffness, symmetrical
extraarticular presentations of RA
fatigue, weakness, mood change
what can be used for burst therapy or bridging in RA but is NOT recommended for maintenance use
glucocorticoids
1st line for RA treatment?
if that is CI then?
methotrexate 1st
leflunomide or sulfasalazine if CI
after 1st line RA therapy if not improved at 3 mos or at target at 6 mos then what??
if poor prognostic factors?
not poor?
poor prog- add bDMARD or consider JAKi
not poor prog- change to or add 2nd conventional dMARD
if after phase II of RA therapy still not improving then
change the bDMARD or JAKi
4 conventional DMARDS for RA
methotrexate, hydroxychloroquine, sulfasalazine, leflunomide
methotrexate RA dose
10-25 mg PO SQ or IM WEEKLY
AEs of methotrexate
NV, stomatitis, alopecia, BMS
what can be coadministered with methotrexate to mitigate AEs
folic acid 1-5 mg QD
csDMARD that works best for mild disease
hydroxychloroquine
AEs of hydroxychloroquine
one requires what monitoring
vision changes, skin pigmentation
routine eye exam
what can be given when taking leflunomide to block EHC and promote rapid elimination in event of serious AEs or toxicity
cholestyramine wash
AEs of sulfasalazine
NVD, discoloration of bodily fluids, blood cell abnormalities
what should be screened for when taking sulfasalazine and why
glucose-6-phosphate dehydrogenase deficiency
mitigate risk of hemolytic anemia
5 TNFi that are bDMARDs for RA
adalimumab
etanercept
infliximab
golimumab
certolizumab pegol
BBW for TNFi
malignancy, serious infection, TB
IL-1 receptor inhibitor used for RA
anakinra
AE of anakinra
should it be used? when?
ISR
not effective, may be good if concomitant gout
2 IL-6 receptor inhibitors used for RA
tocilizumab, sarilumab
AEs of tocilizumab and sarilumab
infusion rxn, infection risk, anemias, INC LIPIDS, inc liver enzymes, GI perforation
BBW for tocilizumab, sarilumab
infection, TB, inf rxn
tocilizumab, sarilumab have which AE so it should be avoided in
gi perforation—- avoid in IBD
tocilizumab, sarilumab monitor for what (among others)
LIPIDS
T cell costimulation modulator for RA
abatacept
which RA med has a very delayed onset
abatacept
abatacept may be avoided in patients with
COPD
B cell modulator (acts at CD20) used for RA
rituximab
BBW for rituximab
inf or cutaneous rxn, HBV, PML
retreatment with rituximab is based on
resurgence of symptoms
3 JAKi used for RA
tofacitinib, baracitinib, upadacitinib
reduce dose of JAKi for
renal/hep insufficiency, combo with 3A4 inhibitors
BBW for JAKI
serious infection, malignancy, MACE, thrombosis, mortality
interventions for injection site rxn
cold compress, hydrocortisone cream, oral H2Ri or antihistamine
interventions for infusion reactions
premedicate, decrease inf rate, fluids PRN
who is most commonly affected by SLE
women of childbearing years, black or hispanic
5 triggers of SLE
sunlight, stress, smoking, medications, viruses
which 3 medications can trigger SLE
hydralazine, sulfa drugs, procainamide
main 3 initial presentations for SLE
fever, arthralgias, rash
3 serologic tests for lupus
ANAs
anti-dsDNA Ab
Anti-Sm Ab
presentation of lupus nephritis
foamy urine, peripheral edema, concomitant HTN
SLE manifestation with kidney inflammation due to complex deposition
lupus nephritis
Ab in SLE where when positive you are in a hypercoaguable state
antiphospholipid + antibodies
what can be used in SLE to treat rash
topical steroids
used in SLE for acute or chronic pain and inflammation
NSAIDs
medication used in all SLE patients unless CI
hydroxychloroquine
is hydroxychloroquine safe in pregnancy
low risk- ok to use
adjunctive SLE med for mod-sev initial presentation, organ/life threatening, poor response to HCQ/NSAIDs, or poor QoL without
glucocorticoids
adjunctive med for SLE given in combo with standard therapy via IV infusion or SQ QM
belimumab
4 criteria for belimumab use
non-active CNS
autoantibody +
musculoskeletal or cutaneous disease unresponsive to HCG/NSAID/steroid
LN III IV V
AEs of belimumab
nausea, diarrhea, allergic rxn, infusion rxn, depression, suicidality, PML
adjunctive med for SLE given in combo with standard therapy IV infusion Q4W
anifrolumab
anifrolumab is not indicated in
LN or CNS disease
when are immunosuppressants used in SLE
poor sx control refractory to HCQ/NSAIDs/steroids and indicated for organ threatening SLE (mainly LN)
immunosuppressant used for SLE with concomitant RA or primary presentation of arthritis
methotrexate
immunosuppressant used in SLE 2nd line after steroids for more moderate disease, safest in class for pregnancy
azathioprine
when is mycophenolate used for SLE
proliferative (II-IV) LN
2nd line for membranous (V) LN
AEs of mycophenolate
diarrhea, abdominal pain, anorexia, nausea
immunosuppressant used in SLE for organ threatening cardiopulmonary, renal, or neuropsychiatric disease
cyclophosphamide
AEs of cyclophosphamide
very toxic, permanent infertility
immunosuppressant used in SLE for MEMBRANOUS (V) LN
cyclosporine
immunosuppressant for SLE used for PROLIFERATIVE (V) LN
tacrolimus
immunosuppressant for SLE used off-label for severe renal, hematologic, or neuropsych SLE refractory to other agents
rituximab
immunosuppressant for SLE used as an adjunct to immunosuppressants in active LN
voclosporin
1st line for all patients in SLE
hydroxychloroquine, steroids
what are the best options for refractory/severe SLE when wanting steroid-sparing immunosuppression
methotrexate, mycophenolate
1st line for mainly skin disease in SLE
topicals, hydroxychloroquine
induction therapy for LN in SLE is
immunosuppressant (MMF,CYC) + a steroid
if SLE patient has glomerular disease and persistent proteinuria +/- HTN give them
ACE or ARB
if LDL >100 in SLE give
statin
antiphospholipid Ab + with no event in SLE gets what?
preg- LDA +/- LMWH
not preg- LDA
antiphospholipid syndrome gets what?
preg- LDA +/- LMWH
not preg- warfarin
INR goal for warfarin for antiphospholipid syndrome
inr 3-4 arterial
inr 2-3 venous
most important non-pharm measure for SLE
limit sun exposure, use sun protection
