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rheumatology > rheumatology drugs > Flashcards

rheumatology drugs Flashcards

1
Q

what is the hierachy of ra prescription with time

A
  1. methotrexate +steroid
  2. DMARD combination
  3. Anti-TNF
  4. Abatacept, rituximab, tocilizumab, anti TNF2
    plus alongisde nsaid and analgesics, steroid injections either muscular or articular
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2
Q

what management needs to be considered with RA in pregnancy

A
  • immuno most patients go into remission during pregnancy
  • methotrexate and leflunomide discontinue 3 months prior
  • nsaid and cox-2 can only be used up till last trimester
  • steroids may be used but risk highbp, glucose intoler and osteop
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3
Q

what drugs must be avoided in pregnancy with RA 6 and when should they be discontinued

A 
methotrexate 3 months
mycophenylate 3 months
leflunomide 2 years
cyclophosphamide
gold and penicillamine
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4
Q

what drugs must be avoided when breastfeeding with RA 7

A 
methotrexate
leflunomide
cyclophosphamide
ciclosporin
azathioprine
sulfasalzine
hyrodxychloroquine
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5
Q

action of methotrexate

A

inhibits dna synthesis and cell divsion

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6
Q

maintenance dose of methot. also what is the iniital dose and how it increases

A

5-25mg week

-starts 7.5-10mg and increases every 2-4 weeks by 2.5mg

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7
Q

side effects of methot 6

A 
gi upset, nausea and vomiting and malaise seen in first 24-48hrs 
stomatitis
rash
alopecia
hepatoxicity
acute pneumonitis
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8
Q

monitoring requirenments for methot and frequency

A

FBC AND LFT u and e
initially two weekly (ie every 2 weeks) until dose stable for 6 months,
then monthly for 12 months and
then every 3 months

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9
Q

maintenance and starting dose of sulfasalazine

A

2-4 grams daily

500mg initially

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10
Q

side effects of sulfasalazine 6

A 
nausea,
gi upset
rash, 
hepatiits
neutropenia
pancytopenia
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11
Q

what drug must methot be given with (dose and when) and why

A

folic acid (5mg day after) as methot is a dihydrofolate reductase inhibitor

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12
Q

what is CI when on methotrexate and why for each 2

A
  1. sulphonamides (same pathway folic acid)

2. avoid excess alcohol as enhances methotrexate pneumonitis

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13
Q

what should be done if a patient develops methot pneumonitis

A

stop the methot and give high dose steroids instead

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14
Q

what needs to be monitored when on sulfasalazine and how often

A

fbc and lft
Monthly for the first 3 months, then every three months for the next 9 months,
then 6 monthly thereafter.

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15
Q

what should patients be warned about when on sulfasalazine

A

orange staining of urine and contact lenses

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16
Q

what is the dose for hydroxychloroquine

A

200-400mg daily

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17
Q

what are the SE of hydroxychloroquine 6

A

rash, nausea, diarrhoea, headache, corneal depositis, retinopathy

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18
Q

what monitoring and how often does it need to be done for Hydroxychloroquine

A

visual acuity and fundoscopy every 12 months

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19
Q

what dmards can be used in pregnancy 3

A

hydroxychloroquine

sulfasalasine and azathioprine but must be risk assessed first

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20
Q

mechanism of action of sulf and and hydroxy

A

unknown mechanism

Sulfasalazine is a 5ASA

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21
Q

what drugs can cause an abnormal LFT and at what level ALT should drug be stopped and started again

A

methot, sulf, leflunomide, mycophen, azathioprine

if ALT is twice the upper limit ie >100 and only continued when ALT below 50

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22
Q

what drugs can cause a reduce white blood cell count and at what levels of neutrophil and WCC should treatment be stopped

A

methot, sulfasalzine, mycophenylate, leflunomide, azathioprine
<1.5 neutrophils
<3 for WCC

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23
Q

What drugs cause a reduced platelet count and at what level should treatment stop

A

methotrexate, sulfasalazine, mycophenylate, leflunomide, azathioprine
100-150 stop treatment
if <100 then contact rheum

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24
Q

at what level eGFR should should DMARD be reduced by 50%

A

eGFR <50 that was not present when commenced on DMARD

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25
Q

what should be done if macrocytosis level is mcv >105

A

check b12, folate, thyroid function, and treat underlying abnormality

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26
Q

what is the main action of leflunomide

A

blocks t cell division

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27
Q

medication dose of leflunomide

A

10-20mg daily

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28
Q

side effects of leflunomide 6

A 
nausea
gi upset
rash
alopecia
hepatitis
hbp
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29
Q

what test should be done for leflunomide and how often

A

fbc, lft, bp, U&E

twice a week for first 6 months then 2 monthly

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30
Q

mechanism of action D-penicillamine

A

unknown

31
Q

dosage for d-penicillamine

A

250-750 mg daily

32
Q

side effects of D-penicillamine 5

A 
rash
stomatitis
metallic taste
proteinuria 
thrombocytopniea
33
Q

what tests need to be done for D-penicilliamine and how often

A

FBC,urine for protein

initially 1-2 weekly 4-6 weekly

34
Q

mechanism of action of GOLD

A

UNKNOWN but dmard

35
Q

dosage of GOLD and how

A

50mg. monthly intramuscular injection

36
Q

side effects of GOLD 6

A 
rash
stomatitis
alopecia 
proteinuria
thrombocytopenia
myelosuppression
37
Q

tests for GOLD and how often do they need to be done

A

fbc, urine for protein

with every injection

38
Q

action of ciclosporin

A

blocks t cell activation

39
Q

dosage of ciclosporin

A

50-150mg daily

40
Q

side effects of ciclosporin

A

nausea
GI upset
renal impairment
hbp

41
Q

tests for ciclosporin and how often should these tests be done

A

FBC, LFT, U&E

2-4 weekly

42
Q

azathioprine dosage

A

50-150mg

43
Q

side effects of azathioprine

A

abnormal LFT
reduced WCC
reduced platelet count
increased risk of some cancer

44
Q

tests for azathioprine and how often

A

fbc, lft, U&E
weekly for 6 weeks, 2 weekly until dose stable for 6 weeks, monthly until dose stable for 6 months,
then 3 monthly

45
Q

side effects of mycophenylate

A

abnormal LFT
reduced wcc
reduced platelet

46
Q

tests for mycophenylate and how often

A

FBC, lft and u&e
2x weekly until dose stable for 6 weeks
monthly until dose stable for 12 months
3 monthly until dose stable

47
Q

ciclophosphamide use

A

for severe SLE

48
Q

side effects of ciclophosphamide

A

azoospermia
menopause
premature haemorrhagic
cystitis

49
Q

what should ciclophosphamide be given with

A

mensa to bind to the urotoxic metabolites

50
Q

steroid dosage during flare up 3 options

A
  1. high dose oral prednisolone 60mg daily and to reduce gradually stop over a period of 3 months
  2. low dose prednisolone 5-10mg for 6-24 months
  3. give intramuscular injections of methylprednisolone or triamcinolone every 6-8 weeks
51
Q

when are intra-articular steroids indicated

A

one or two problem joints with persistent synovitis

52
Q

significant adverse effects of steroids

A 
o	Hair thinning-
o	Hirsutism in women ie extra hair
o	Acne- 
o	plethora
o	Moon face
o	Peptic ulcer
o	Loss of height and back pain due to compression fracture
o	Hypoglycaemia
o	Menstrual disturbance
o	May have exuberant callus with fractures
o	Osteoporosis
o	Tendency to infections with poor wound healing and inflammatory response
o	Psychosis
o	Cataracts
o	Mild exopthalamos 
o	High bp
o	Centripetral obesity
-stiae and brusing
53
Q

what DAS28 score is required in RA for biological therapy and the citeria

A

> 5.1 in active RA when an adequate trial of 2 other DMARDS including methotrexate has failed

54
Q

risks of being on biological therapy 2

A
  1. immunosuppression so infection risk

2. cancer due to immunosuppression

55
Q

when should biological be stopped 2

A
  1. before surgery
56
Q

which biological therapy needs blood monitoring

A

tocilizumab

needs blood monitoring as can cause abnormal LFT and neutropaenia

57
Q

what cannot be given when on biological therapy

A

live vaccines so give killed vaccines

58
Q

what is the first line BIOLOGICAL therapy for RA

A

ANTI tnf

59
Q

what are anti-tnf drugs

A

etancerpt and end in mab eg infliximab

60
Q

what must infliximab be prescribed with

A

methotrexate to reduce the risk of developing neutralising antibodies

61
Q

adverse reaction of anti tnf

A

serious infection
reactivation of latent tb
increase risk of some malignancies eg basal cell carcinoma of the skin
but reduces vascular disease risk

62
Q

2 ways of action of anti tnf and what drugs go with which

A 
etanercept= decoy receptor for anti tnfa
infliximab= antibodies to TNF
63
Q

what is rituximab action

A

anti-B cell therapy

antibody directed against CD20 receptor on b cells and immature plasma cells

64
Q

nice dose guideline for rituximab

A

1000mg iv repeat every 2 weeks

65
Q

what should be given prior to a rituximab infusion

A

methylprednisolone
chlorpenamine
paracetamol
given 30 min prior to infusion

66
Q

mechanism of action of abatecept

A

inhibits t-cell activation
block activation between CD28 and CD80/86 that is required for full activation of T cells following antigen presentation by dendritic cells or macrophages

67
Q

dosage of abatecept

A

125 mg sc a week

68
Q

action of tocilizumab

A

agent antibody to IL6 receptor by preventing it activating synovial membrane, liver and muscle
similar efficacy to anti tnf and monotherapy/ methotrexate given

69
Q

adverse of tocilizumab

A

leucopenia
hypercholestrolaemia
increased risk infection

70
Q

when is tocilizumab given

A

2nd line to anti-TNF except intolerance to methotrexate in which case 1st line as is more effective

71
Q

action of anakinra

A

decoy receptor for IL1

72
Q

use of anakinra

A

some activity in RA but seldom used

73
Q

action of secukinumab

A

IL17a inhibitor

inhibits release of pro-inflammatory cytokines

74
Q

use for secukinumab

A

psoriatic arthritis and ankolysing spondylitis

rheumatology (9 decks)

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