Rheumatology Flashcards
1
Q
gout is characterized by a serum uric acid
A
> 6.8 mg/dL
2
Q
which disease states can increase risk of gout (7)
A
T2DM, hyperlipidemia, obesity, renal insufficiency, HTN, organ transplant, CHF
3
Q
which foods increase risk of gout (5)
A
meat, seafood, beer, soft drinks, fructose
4
Q
which foods decrease gout risk (3)
A
coffee, dairy, vit C
5
Q
which medications increase gout risk (4)
A
thiazides, loops, nicotinic acid, aspirin
6
Q
which medications lower gout risk (2)
A
losartan, fenofibrate
7
Q
which 4 things can precipitate a gout flare
A
alcohol or high purine ingestion, stress, meds
8
Q
3 drugs used for acute gout management
A
NSAIDs, colchicine, steroids
9
Q
colchicine need dose adjustment for
A
renal & hepatic
10
Q
AEs of colchicine
A
GI, hematologic, rhabdo
11
Q
strong CYP3A4 inhibitors that interact with colchicine?
how to adjust dose?
A
clarithromycin, itraconazole, ketoconazole, darunavir/ritonavir
1/2 the doses
12
Q
moderate 3A4 inhibitors that interact with colchicine?
how to adjust dose?
A
diltiazem, erythromycin, fluconazole, verapamil
single 1.2 dose for flares, prophy dose is 1/2 QD or QoD
13
Q
p-gp inhibitors that interact with colchicine
how to adjust dose?
A
cyclosporine, amiodarone, ranolazine
single 0.6 for flare, prophy dose 1/2 QD or QoD
14
Q
intraarticular steroid dose for large, medium, small joint?
A
lg- 40 mg
med- 30 mg
sm- 10 mg
15
Q
2 xanthine oxidase inhibitors used chronically for gout
A
allopurinol, febuxostat
16
Q
starting dose for allopurinol and how increase dose
A
start 50-100 mg QD and inc Q3-5W until achieve goal SUA
17
Q
AEs of allopurinol
A
rash, DRESS
18
Q
which medications can increase the risk of rash when taking allopurinol
A
amoxicillin, ampicillin, thiazides, ACEi
19
Q
what should you do if you get a rash from taking allopurinol
A
d/c the drug
20
Q
aside from drugs causing rash, which medications have a DDI with allopurinol
A
warfarin, 6-MP, azathioprine, theophylline
21
Q
dose of febuxostat
A
40 mg to start and can increase to 80 mg QD if not at goal after 2 weeks
22
Q
AEs of febuxostat
A
HA, arthralgias, abdominal pain, nausea, abnormal LFTs, flushing, dizziness
23
Q
BBW febuxostat
A
CV death
24
Q
DDI with febuxostat
A
concurrent 6-MP, azathioprine, theophylline
25
uricosuric that inhibits reabsorption of uric acid used for chronic gout
probenecid
26
dose of probenecid
250 mg bid x1week then can inc to 500 mg bid
max 2g/day increased in 500 mg increments Q4W
27
when should probenecid be avoided
Crcl <50, hx of nephrolithiasis
28
DDI with probenecid where it should be avoided
penicillin, methotrexate, carbapenems, salicylates
29
uricase agent used for chronic gout refractory to other treatments
pegloticase
30
dose of pegloticase
IV 8 mg Q2W over 2 hours
31
BBW for pegloticase
infusion reactions
32
what is recommended 1st line for UA lowering in chronic gout therapy
allopurinol
33
goal serum urate level for gout treatment
<6 mg/dl
34
what is next step after allopurinol for chronic gout
switch to febuxostat, inc dose, add probenecid
35
what is used when all options fail for chronic gout therapy
pegloticase
36
monitoring for chronic UA lowering therapy for gout
reassess levels Q2-5W, increase intensity until goal is reached
37
when should prophylaxis be used for chronic gout therapy and for how long
when ULT is initiated and continue for 3-6 months
38
1st line for prophylaxis for chronic gout therapy
colchicine 0.6 mg QD or BID
or
low dose NSAIDs - naproxen 250 mg BID
39
when should gout prophylaxis therapy be continued
activity of symptoms, flare in last 3 mos, tophi present
40
gout flare therapy for mild-mod pain with 1-2 joints involved
monotherapy
41
gout flare therapy for severe pain with >2 joints involved
combo therapy
42
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
43
when should colchicine not be used for gout flare therapy
on it prophylactically and had an acute regimen in the last 14 days
44
intraarticular steroids can be considered for gout flare therapy if
1-2 large joints involved
45
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
46
combo therapy options for gout flare (4)
nsaid + colchicine
po steroid + colchicine
IA steroid + nsaid +/- colchicine
IA steroid + po steroid +/- colchicine
47
risk factors for osteoarthritis
obesity, genetics, trauma/injury, anatomic factors, female, non-caucasian, age >40F or >50M
48
main patho mechanism of OA
cartilage breakdown causes change to bone and joint tissue
49
affected joints for OA
hand, knee, hip
50
features of OA presentation
pain/stiff (AM, idleness), decreased range of motion, mono/oligoarticular, asymmetrical
51
1st line option for hand, knee, and hip OA
oral NSAIDs
52
what can be used for knee OA only
topical NSAIDs
53
what can be considered for knee and hip OA
IA steroids
54
APAP is used conditionally for OA and should be taken
650-100 mg PO Q4-6H
AROUND THE CLOCK NOT PRN
55
3 main complications from PO nsaid use
gastropathy, CV events, nephrotoxicity
56
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
57
nsaids should be avoided in patients at high risk for
CV events
58
conditional option for OA with BBW for addiction, misuse, resp depression
tramadol
59
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
60
SNRI used conditionally for OA
duloxetine
61
minimum injection interval for IA steroids in OA
minimum 3 mos
62
how long for IA steroids to work for OA? how long to last?
onset 1-3 days
peak 1 week
works 1-2 mos
63
OTC that is not recommended in OA
glucosamine
64
nonpharm option for hand, knee, and hip OA
exercise, self-efficacy, self-management programs
65
risk factors for RA
smoking, coffee, obesity, infections, autoantibodies
66
____ positive is associated with a poorer prognosis for RA
ACPA
67
affected joints in RA
hands, wrists, ankles, feet
68
key articular presenting features of RA
warmth, swelling w/o pain, decreased range of functionality, morning stiffness, symmetrical
69
extraarticular presentations of RA
fatigue, weakness, mood change
70
what can be used for burst therapy or bridging in RA but is NOT recommended for maintenance use
glucocorticoids
71
1st line for RA treatment?
if that is CI then?
methotrexate 1st
leflunomide or sulfasalazine if CI
72
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
73
if after phase II of RA therapy still not improving then
change the bDMARD or JAKi
74
4 conventional DMARDS for RA
methotrexate, hydroxychloroquine, sulfasalazine, leflunomide
75
methotrexate RA dose
10-25 mg PO SQ or IM WEEKLY
76
AEs of methotrexate
NV, stomatitis, alopecia, BMS
77
what can be coadministered with methotrexate to mitigate AEs
folic acid 1-5 mg QD
78
csDMARD that works best for mild disease
hydroxychloroquine
79
AEs of hydroxychloroquine
one requires what monitoring
vision changes, skin pigmentation
routine eye exam
80
what can be given when taking leflunomide to block EHC and promote rapid elimination in event of serious AEs or toxicity
cholestyramine wash
81
AEs of sulfasalazine
NVD, discoloration of bodily fluids, blood cell abnormalities
82
what should be screened for when taking sulfasalazine and why
glucose-6-phosphate dehydrogenase deficiency
mitigate risk of hemolytic anemia
83
5 TNFi that are bDMARDs for RA
adalimumab
etanercept
infliximab
golimumab
certolizumab pegol
84
BBW for TNFi
malignancy, serious infection, TB
85
IL-1 receptor inhibitor used for RA
anakinra
86
AE of anakinra
should it be used? when?
ISR
not effective, may be good if concomitant gout
87
2 IL-6 receptor inhibitors used for RA
tocilizumab, sarilumab
88
AEs of tocilizumab and sarilumab
infusion rxn, infection risk, anemias, INC LIPIDS, inc liver enzymes, GI perforation
89
BBW for tocilizumab, sarilumab
infection, TB, inf rxn
90
tocilizumab, sarilumab have which AE so it should be avoided in
gi perforation---- avoid in IBD
91
tocilizumab, sarilumab monitor for what (among others)
LIPIDS
92
T cell costimulation modulator for RA
abatacept
93
which RA med has a very delayed onset
abatacept
94
abatacept may be avoided in patients with
COPD
95
B cell modulator (acts at CD20) used for RA
rituximab
96
BBW for rituximab
inf or cutaneous rxn, HBV, PML
97
retreatment with rituximab is based on
resurgence of symptoms
98
3 JAKi used for RA
tofacitinib, baracitinib, upadacitinib
99
reduce dose of JAKi for
renal/hep insufficiency, combo with 3A4 inhibitors
100
BBW for JAKI
serious infection, malignancy, MACE, thrombosis, mortality
101
interventions for injection site rxn
cold compress, hydrocortisone cream, oral H2Ri or antihistamine
102
interventions for infusion reactions
premedicate, decrease inf rate, fluids PRN
103
who is most commonly affected by SLE
women of childbearing years, black or hispanic
104
5 triggers of SLE
sunlight, stress, smoking, medications, viruses
105
which 3 medications can trigger SLE
hydralazine, sulfa drugs, procainamide
106
main 3 initial presentations for SLE
fever, arthralgias, rash
107
3 serologic tests for lupus
ANAs
anti-dsDNA Ab
Anti-Sm Ab
108
presentation of lupus nephritis
foamy urine, peripheral edema, concomitant HTN
109
SLE manifestation with kidney inflammation due to complex deposition
lupus nephritis
110
Ab in SLE where when positive you are in a hypercoaguable state
antiphospholipid + antibodies
111
what can be used in SLE to treat rash
topical steroids
112
used in SLE for acute or chronic pain and inflammation
NSAIDs
113
medication used in all SLE patients unless CI
hydroxychloroquine
114
is hydroxychloroquine safe in pregnancy
low risk- ok to use
115
adjunctive SLE med for mod-sev initial presentation, organ/life threatening, poor response to HCQ/NSAIDs, or poor QoL without
glucocorticoids
116
adjunctive med for SLE given in combo with standard therapy via IV infusion or SQ QM
belimumab
117
4 criteria for belimumab use
non-active CNS
autoantibody +
musculoskeletal or cutaneous disease unresponsive to HCG/NSAID/steroid
LN III IV V
118
AEs of belimumab
nausea, diarrhea, allergic rxn, infusion rxn, depression, suicidality, PML
119
adjunctive med for SLE given in combo with standard therapy IV infusion Q4W
anifrolumab
120
anifrolumab is not indicated in
LN or CNS disease
121
when are immunosuppressants used in SLE
poor sx control refractory to HCQ/NSAIDs/steroids and indicated for organ threatening SLE (mainly LN)
122
immunosuppressant used for SLE with concomitant RA or primary presentation of arthritis
methotrexate
123
immunosuppressant used in SLE 2nd line after steroids for more moderate disease, safest in class for pregnancy
azathioprine
124
when is mycophenolate used for SLE
proliferative (II-IV) LN
2nd line for membranous (V) LN
125
AEs of mycophenolate
diarrhea, abdominal pain, anorexia, nausea
126
immunosuppressant used in SLE for organ threatening cardiopulmonary, renal, or neuropsychiatric disease
cyclophosphamide
127
AEs of cyclophosphamide
very toxic, permanent infertility
128
immunosuppressant used in SLE for MEMBRANOUS (V) LN
cyclosporine
129
immunosuppressant for SLE used for PROLIFERATIVE (V) LN
tacrolimus
130
immunosuppressant for SLE used off-label for severe renal, hematologic, or neuropsych SLE refractory to other agents
rituximab
131
immunosuppressant for SLE used as an adjunct to immunosuppressants in active LN
voclosporin
132
1st line for all patients in SLE
hydroxychloroquine, steroids
133
what are the best options for refractory/severe SLE when wanting steroid-sparing immunosuppression
methotrexate, mycophenolate
134
1st line for mainly skin disease in SLE
topicals, hydroxychloroquine
135
induction therapy for LN in SLE is
immunosuppressant (MMF,CYC) + a steroid
136
if SLE patient has glomerular disease and persistent proteinuria +/- HTN give them
ACE or ARB
137
if LDL >100 in SLE give
statin
138
antiphospholipid Ab + with no event in SLE gets what?
preg- LDA +/- LMWH
not preg- LDA
139
antiphospholipid syndrome gets what?
preg- LDA +/- LMWH
not preg- warfarin
140
INR goal for warfarin for antiphospholipid syndrome
inr 3-4 arterial
inr 2-3 venous
141
most important non-pharm measure for SLE
limit sun exposure, use sun protection
