rheumatology drugs Flashcards
what is the hierachy of ra prescription with time
- methotrexate +steroid
- DMARD combination
- Anti-TNF
- Abatacept, rituximab, tocilizumab, anti TNF2
plus alongisde nsaid and analgesics, steroid injections either muscular or articular
what management needs to be considered with RA in pregnancy
- 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
what drugs must be avoided in pregnancy with RA 6 and when should they be discontinued
methotrexate 3 months mycophenylate 3 months leflunomide 2 years cyclophosphamide gold and penicillamine
what drugs must be avoided when breastfeeding with RA 7
methotrexate leflunomide cyclophosphamide ciclosporin azathioprine sulfasalzine hyrodxychloroquine
action of methotrexate
inhibits dna synthesis and cell divsion
maintenance dose of methot. also what is the iniital dose and how it increases
5-25mg week
-starts 7.5-10mg and increases every 2-4 weeks by 2.5mg
side effects of methot 6
gi upset, nausea and vomiting and malaise seen in first 24-48hrs stomatitis rash alopecia hepatoxicity acute pneumonitis
monitoring requirenments for methot and frequency
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
maintenance and starting dose of sulfasalazine
2-4 grams daily
500mg initially
side effects of sulfasalazine 6
nausea, gi upset rash, hepatiits neutropenia pancytopenia
what drug must methot be given with (dose and when) and why
folic acid (5mg day after) as methot is a dihydrofolate reductase inhibitor
what is CI when on methotrexate and why for each 2
- sulphonamides (same pathway folic acid)
2. avoid excess alcohol as enhances methotrexate pneumonitis
what should be done if a patient develops methot pneumonitis
stop the methot and give high dose steroids instead
what needs to be monitored when on sulfasalazine and how often
fbc and lft
Monthly for the first 3 months, then every three months for the next 9 months,
then 6 monthly thereafter.
what should patients be warned about when on sulfasalazine
orange staining of urine and contact lenses
what is the dose for hydroxychloroquine
200-400mg daily
what are the SE of hydroxychloroquine 6
rash, nausea, diarrhoea, headache, corneal depositis, retinopathy
what monitoring and how often does it need to be done for Hydroxychloroquine
visual acuity and fundoscopy every 12 months
what dmards can be used in pregnancy 3
hydroxychloroquine
sulfasalasine and azathioprine but must be risk assessed first
mechanism of action of sulf and and hydroxy
unknown mechanism
Sulfasalazine is a 5ASA
what drugs can cause an abnormal LFT and at what level ALT should drug be stopped and started again
methot, sulf, leflunomide, mycophen, azathioprine
if ALT is twice the upper limit ie >100 and only continued when ALT below 50
what drugs can cause a reduce white blood cell count and at what levels of neutrophil and WCC should treatment be stopped
methot, sulfasalzine, mycophenylate, leflunomide, azathioprine
<1.5 neutrophils
<3 for WCC
What drugs cause a reduced platelet count and at what level should treatment stop
methotrexate, sulfasalazine, mycophenylate, leflunomide, azathioprine
100-150 stop treatment
if <100 then contact rheum
at what level eGFR should should DMARD be reduced by 50%
eGFR <50 that was not present when commenced on DMARD
what should be done if macrocytosis level is mcv >105
check b12, folate, thyroid function, and treat underlying abnormality
what is the main action of leflunomide
blocks t cell division
medication dose of leflunomide
10-20mg daily
side effects of leflunomide 6
nausea gi upset rash alopecia hepatitis hbp
what test should be done for leflunomide and how often
fbc, lft, bp, U&E
twice a week for first 6 months then 2 monthly
mechanism of action D-penicillamine
unknown
dosage for d-penicillamine
250-750 mg daily
side effects of D-penicillamine 5
rash stomatitis metallic taste proteinuria thrombocytopniea
what tests need to be done for D-penicilliamine and how often
FBC,urine for protein
initially 1-2 weekly 4-6 weekly
mechanism of action of GOLD
UNKNOWN but dmard
dosage of GOLD and how
50mg. monthly intramuscular injection
side effects of GOLD 6
rash stomatitis alopecia proteinuria thrombocytopenia myelosuppression
tests for GOLD and how often do they need to be done
fbc, urine for protein
with every injection
action of ciclosporin
blocks t cell activation
dosage of ciclosporin
50-150mg daily
side effects of ciclosporin
nausea
GI upset
renal impairment
hbp
tests for ciclosporin and how often should these tests be done
FBC, LFT, U&E
2-4 weekly
azathioprine dosage
50-150mg
side effects of azathioprine
abnormal LFT
reduced WCC
reduced platelet count
increased risk of some cancer
tests for azathioprine and how often
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
side effects of mycophenylate
abnormal LFT
reduced wcc
reduced platelet
tests for mycophenylate and how often
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
ciclophosphamide use
for severe SLE
side effects of ciclophosphamide
azoospermia
menopause
premature haemorrhagic
cystitis
what should ciclophosphamide be given with
mensa to bind to the urotoxic metabolites
steroid dosage during flare up 3 options
- high dose oral prednisolone 60mg daily and to reduce gradually stop over a period of 3 months
- low dose prednisolone 5-10mg for 6-24 months
- give intramuscular injections of methylprednisolone or triamcinolone every 6-8 weeks
when are intra-articular steroids indicated
one or two problem joints with persistent synovitis
significant adverse effects of steroids
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
what DAS28 score is required in RA for biological therapy and the citeria
> 5.1 in active RA when an adequate trial of 2 other DMARDS including methotrexate has failed
risks of being on biological therapy 2
- immunosuppression so infection risk
2. cancer due to immunosuppression
when should biological be stopped 2
- before surgery
which biological therapy needs blood monitoring
tocilizumab
needs blood monitoring as can cause abnormal LFT and neutropaenia
what cannot be given when on biological therapy
live vaccines so give killed vaccines
what is the first line BIOLOGICAL therapy for RA
ANTI tnf
what are anti-tnf drugs
etancerpt and end in mab eg infliximab
what must infliximab be prescribed with
methotrexate to reduce the risk of developing neutralising antibodies
adverse reaction of anti tnf
serious infection
reactivation of latent tb
increase risk of some malignancies eg basal cell carcinoma of the skin
but reduces vascular disease risk
2 ways of action of anti tnf and what drugs go with which
etanercept= decoy receptor for anti tnfa infliximab= antibodies to TNF
what is rituximab action
anti-B cell therapy
antibody directed against CD20 receptor on b cells and immature plasma cells
nice dose guideline for rituximab
1000mg iv repeat every 2 weeks
what should be given prior to a rituximab infusion
methylprednisolone
chlorpenamine
paracetamol
given 30 min prior to infusion
mechanism of action of abatecept
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
dosage of abatecept
125 mg sc a week
action of tocilizumab
agent antibody to IL6 receptor by preventing it activating synovial membrane, liver and muscle
similar efficacy to anti tnf and monotherapy/ methotrexate given
adverse of tocilizumab
leucopenia
hypercholestrolaemia
increased risk infection
when is tocilizumab given
2nd line to anti-TNF except intolerance to methotrexate in which case 1st line as is more effective
action of anakinra
decoy receptor for IL1
use of anakinra
some activity in RA but seldom used
action of secukinumab
IL17a inhibitor
inhibits release of pro-inflammatory cytokines
use for secukinumab
psoriatic arthritis and ankolysing spondylitis
