Rheumatology

Question 1

If you wish to use NSAID in a patient with osteoarthritis what can be done to guard against GI problems?

Answer 1

1. Add misoprostol
2. Add PPI or H2 blocker
3. Switch to Cox-2

Question 2

Most common symptom in osteoarthritis?

Answer 2

• pain

- pain relief is the primary objective

Question 3

What do NSAIDs and ASA affect?

Answer 3

cyclooxygenase

Question 4

1st line treatment for osteoarthritis

Answer 4

Acetaminophen 4g/day

Question 5

2nd line treatment for osteoarthritis

Answer 5

topical or oral NSAID

Question 6

What are the uses/benefits of using Choline and magnesium trisalicylate?

Answer 6

strategy to reduce GI toxicity

Question 7

Topical NSAID of choice in patient over 75

Answer 7

Ketoprofen

Question 8

If patient is over 75 years old, what is the first line agent for hand osteoarthritis?

Answer 8

Oral NSAIDs, Topical NSAIDs

or

topical capsaicin +/- tramadol

Question 9

If patient is over 75 with hand arthritis what is the 2nd line treatment

Answer 9

Combination: topical NSAID with tramadol

Question 10

Goal of RA treatment

Answer 10

Achieve remission or low disease activity

Question 11

When should disease modifying antirheumatic drugs be started in RA?

Answer 11

within the first 3 months of diagnosis

Question 12

What function do NSAIDs and corticosteroids have on RA disease?

Answer 12

adjunctive therapy for symptom relief.

Question 13

What can be done if one DMARD is not adequate?

Answer 13

1. combination of DMARDS (ex. methotrexate and plaquenil)

2. DMARD + biologic

Question 14

Non biologic DMARDs

Answer 14

• methotrexate*
• leflunomide
• hydroxychloroquine
• sulfasalazine
• minocycline
• Tofacitinib (kinase inhibitor)

Question 15

Anti-TNF drugs

Answer 15

• Entanercept (Enbrel)
• infliximab (Remicade)
• adalimumab (Humira)
• certolizumab (Cimzia)
• golimumab (Simponi)

Question 16

Non-TNF drugs

Answer 16

• abatacept
• tocilizumab (IL-6)
• Rituximab (peripheral B cell depletion)
• Anakinra (IL-1)

Question 17

If triple drug therapy is needed, what does the ACR recommend?

Answer 17

Methotrexate + hydroxychloroquine + sulfasalazine

Question 18

Early vs. established RA

Answer 18

early is <6 months

established is >6 months

Question 19

Methotrexate: Toxicities

Answer 19

Hematologic - thrombocytopenia (CBC)

Pulmonary fibrosis (Xray)

Hepatic - elevated AST, ALT

Stomatitis*

Question 20

Leflunomide

Answer 20

MOA: decreases lymphocyte proliferation

Contraindicated: pregnancy, liver disease

Toxicities: bone marrow toxicity

Question 21

Hydroxychloroquine

Answer 21

-NOT myelosuppressive (like leflunomide)

• Hepatic and renal toxicities
• Ocular** (visual changes decrease in night or peripheral vision)

Question 22

Sulfasalazine

Answer 22

-Prodrug cleaved in colon (2 active metabolites after passing through the liver)

ADEs:

• Elevated ALT, AST
• May turn skin yellow-orange color* (no clinical significance)
• Binds iron supplements decreasing absorption of sulfazalazine**

Question 23

Minocycline

Answer 23

-Tetracycline antibiotic derivative

-

Question 24

Tofacitinib

Answer 24

• Use in moderate to severe disease in pt. who has failed methotrexate
• Tyrosine kinase inhibitor
• No live vaccines if taking this medication**

Question 25

TNF-alpha biologics

Answer 25

infliximab, etanercept, adalimumab

contraindications: CHF
ADE: MS-like illness, exacerbate MS
increased risk of lymphoproliferative cancer

Question 26

Which biologic depletes peripheral b cells

Answer 26

rituximab

Question 27

Infliximab

Answer 27

• Chimeric antibody (human and mouse)

- Must be given with Methotrexate to prevent antibody formation

Question 28

Adalimumab

Answer 28

-human IgG antibody to TNF

Question 29

Anakinra (Kineret)

Answer 29

• IL-1
• MOA: affects T-cell proliferation and activation
• Don’t give live vaccines

Question 30

Tocilizumab

Answer 30

• IL-6

- avoid live vaccines

Question 31

How often can corticosteroids be injected?

Answer 31

every 3 months

MAX of 2-3 a year in same joint