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Pnt Exam 1 > Rhuematoid arthritis > Flashcards

Rhuematoid arthritis Flashcards

1
Q

Rheumatoid Arthritis defintion

A

systemic inflammatory disease characterized by symmetrical joint involvement

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2
Q

Age of onset of RA

A

15-45 years

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3
Q

Most common antigen found in RA pts

A

HLA-DR4

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4
Q

RA is more common in which gender

A

female

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5
Q

symptoms of RA

A 
joint pain or stiffness > 6 weeks
fatigue and weakness
low grade fever, loss of apetite
anemia
muscle pain and afternoon fatigue
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6
Q

Rheumatoid factor to be considered positive

A

> 1: 80; 80% have >1:320

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7
Q

Antibodies against citrullinated antigens (Anti CCP)

A

positive in 80-90% of RA pts.
strongly positive > 60
negative < 20

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8
Q

Labs useful for diagnosing RA

A 
anti CCP 
RF
ESR
C reactive protein (CRP) 
hematologic abnormalities
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9
Q

hematologic abnormalities seen in RA

A

Thrombocytosis and anemia

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10
Q

Score needed to diagnose RA

A

6+ /10

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11
Q

points for involvement of 1 medium to large joint

A

1

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12
Q

points for involvement of 2-10 medium to large joints

A

2

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13
Q

points for involvement of 1-3 small joints (w or w/o involvement of large joints)

A

3

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14
Q

points for involvement of 4-10 small joints (w or w/o involvement of large joints)

A

4

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15
Q

points for involvement of 10+ joints (at least one small joint)

A

5

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16
Q

how many serology tests needed for diagnosis of RA (RF or anti CCP)

A

at least 1

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17
Q

how many acute phase reactants needed for diagnosis of RA (CRP, ESR)

A

at least 1

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18
Q

how many points for a negative RF and negative anti CCP

A

1

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19
Q

how many points for a low positive RF or low positive anti CCP

A

2

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20
Q

how many points for a high positive RF or high positive anti CCP

A

3

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21
Q

how many points for a normal CRP and normal ESR

A

0

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22
Q

how many points for an abnormal CRP or abnormal ESR

A

1

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23
Q

how many points for duration of symptoms < 6 weeks

A

0

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24
Q

how many points for duration of symptoms 6+ weeks

A

1

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25
Q

Functional classification I for RA

A

able to perform daily activites

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26
Q

functional classification II for RA

A

some restriction of performing daily activities

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27
Q

functional classification III for RA

A

Considerable restriction of performing daily activities

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28
Q

Functional classification IV for RA

A

restricted to bed or wheelchair

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29
Q

RA goals of therapy

A 
early diagnosis
reduce progression of joint damage and pain
control disease
alleviation of pain
improve QOL
Maintain joint function
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30
Q

Non pharmacological therapy for RA

A 
rest
PT
assistive devices
weight reduction
short term pain relief
surgery
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31
Q

rest for RA includes

A

relaxation
stress management
coping skills

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32
Q

PT for RA includes

A

Joint flexibility, muscle strength

daily activities

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33
Q

Assistive devices used for RA include

A

proper footwear

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34
Q

Short term pain relief for RA includes

A

wax baths

TENS

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35
Q

Surgery for RA includes

A 
persistent pain due to joint damage
progressive deformity or prevention of deformity
persistent localized synovitis
tendon rupture
stress fracture
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36
Q

symptom control for RA includes what medications

A

NSAIDS, Corticosteroids, opioids (last line)

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37
Q

Advantages for use of corticosteroids in RA

A

quick relief properties, low cost, antiinflammatory action

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38
Q

Disadvantages of corticosteroids in RA

A

do not modify disease process

associated with long term AEs

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39
Q

DMARD definition

A

disease modifying antirheumatic drugs

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40
Q

nonbiologi DMARDS

A 
methotrexate
leflunomide
hydroxycholoquine
sulfsalazine
gold salts
D-penicillamine
azathioprine
cyclophosphamide
cyclosporine
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41
Q

signs of RA

A 
symmetrical
tenderness and warmth, swelling over joints
joint damage +/- deformities
Rheumatoid nodules (elbows, forearms, hands)
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42
Q

normal CRP

A

0-0.5 mg/dL

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43
Q

TNF inhibitors include

A 
Adalimumab
Certolizumab pegol
etanercept
golimumab
infliximab
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44
Q

adalimumab brand name

A

humira

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45
Q

certolizumab pegol brand name

A

cimzia

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46
Q

etanercept brand name

A

enbrel

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47
Q

golimumab brand name

A

simponi

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48
Q

infliximab brand name

A

remicade

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49
Q

abatacept brand name

A

orencia

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50
Q

anakinra brand name

A

kineret

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51
Q

canakinumab brand name

A

ilaris

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52
Q

rituximab brand name

A

rituxan

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53
Q

tocilizumab brand name

A

actemra

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54
Q

tofacitinib brand name

A

xeljanz

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55
Q

non-biologic DMARD of choice

A

methotrexate

56
Q

methotrexate MOA

A

inhibits purine synthesis

57
Q

response to methotrexate takes

A

2-3 weeks

58
Q

dose of methotrexate

A

7.5 mg QW PO

59
Q

max dose of methotrexate

A

30 mg/week

60
Q

methotrexate available forms

A

PO
IM
subQ

61
Q

AEs of methotrexate

A 
elevated LFTs
N/V
stomatitis
malaise
anorexia
bone marrow suppression
folic acid deficiency 
hypersensitivity pneumonoitis
62
Q

Monitoring for methotrexate

A

CBC w/ platelets
AST
albumin
SCr

63
Q

Avoid methotrexate in who

A

pregnant

64
Q

To avoid methotrexate toxicity give what

A

Folic Acid 1 mg PO QD or 7 mg QW
or
Leucovorin (folinic acid) 2.5-10 mg QW PO

65
Q

CIs to methotrexate

A 
pregnancy/nursing
chronic liver disease
immunodeficiency
pleural or peritoneal effusions
leukopenia or thrombocytopenia
decreased renal function (< 30)
66
Q

Drug interactions with methotrexate

A

Caffiene (>180 mg)
Trimethoprim
NSAIDs, salicylates, probenecid, penicillin, ciprofloxacin

67
Q

Leflunomide brand name

A

Arava

68
Q

Leflunomide MOA

A

inhibits pyrimidine synthesis

69
Q

Leflunomide dosage

A

100 mg PO QD 3 days, 20 mg PO QD

70
Q

Leflunomide AEs

A 
Diarrhea
Alopecia
Nausea
Rash
Hepatotoxicity 
Teratogenicity
71
Q

Leflunomide monitoring

A

LFTs at baseline and monthly until stable

CBC

72
Q

Avoid pregnancy how long after leflunomide

A

4 months

73
Q

Hydroxychloroquine brand name

A

Plaquenil

74
Q

Hydroxychloroquine benefit seen when

A

2-4 months, maybe 3-6 months

75
Q

hydroxycloroquine dose

A

200 mg PO BID

76
Q

hydroxychloroquine AEs

A

agranulocytosis, thrombocytopenia, aplastic anemia
Hemolysis if G6PD deficient
Seizures
Visual changes - exam annually

77
Q

Sulfasalazine brand name

A

Azulfidine

78
Q

Sulfasalazine response seen when

A

after 1-2 months

79
Q

Sulfasalazine dose

A

1000mg 2-3 x daily after meals, drink fluids

80
Q

sulfasalazine AEs

A 
steven's johnson syndrome
hepatitis
agranulocytosis
peripheral neuropathy
decrease in sperm count
HA
depression
rash, pruritus
thrombocytopenia
jaundice
fever
81
Q

Minocycline dose for RA

A

50-200 mg /day in divided doses

82
Q

minocycline AEs

A

drug induced lupus

83
Q

CIs to minocycline

A

young children

pregnant/nursing

84
Q

Azathioprine brand name

A

imuran

85
Q

oral gold brand name

A

auranofin

ridaura

86
Q

injectable gold brand name

A

aurothioglucose

solganal

87
Q

D-penicillamine brand name

A

Cuprimine

88
Q

Black Box warnings for all biologic DMARDS

A

Risk of infections - Tb, fungal

Risk of lymphoma or other cancers

89
Q

CIs to biologic DMARDs

A

moderate to severe congestive heart failure

multiple sclerosis or optic neuritis

90
Q

ADRs to all biologic DMARDS

A 
infections
- give live vaccines prior to start
- PPD prior to start
- pt education and monitoring
Allergic reactions
- local: redness and itching
- systemic: hypotension, fever, chills
91
Q

Adalimumab dose

A

40 mg SubQ

recommended take with methotrexate

92
Q

adalimumab AEs

A 
upper respiratory infection
HA
rash
sinusitis
injection site reaction
93
Q

Certolizumab pegol dosage

A

400 mg SubQ, at 2, 4, weeks, then 400 mg subQ 4 weeks

94
Q

Etanercept response time

A

2 weeks

95
Q

Etanercept dosage

A

50 mg SubQ weekly or 25mg SubQ twice weekly

alone or with MTX

96
Q

Do not take what with etanercept

A

anakinra
sulfasalazine
live vaccines

97
Q

Etanercept AEs

A

mild erythema/itching
Risk of severe infections
CNS demyelinating disorders
Hematologic events (pancytopenia, aplastic anemia)

98
Q

Golimumab dosage

A

50 subQ once monthly with MTX

99
Q

Golimumab drug interactions

A

TNF blockers

cyclosporine, theophylline, warfarin

100
Q

Infliximab dosage form

A

IV infusion in outpatient clinics over 2 hours

premedicate with APAP, corticosteroids, and antihistamines

101
Q

Infliximab AEs

A

risk of infections

fever, chills, urticaria, HA, nausea

102
Q

Infliximab CIs

A

CHF, > 5mg/kg moderate to severe heart failure

103
Q

Infliximab dosage

A

3 mg/kg IC infusion 2,6 weeks then Q 8 weeks with MTX

104
Q

Do not use infliximab with what

A

Abatacept
anakinra
TNF blockers
Tocilizumab

105
Q

Check with infliximab

A

weight

dosage rate

106
Q

Rituximab MOA

A

causes B-lymphocyte depletion

107
Q

Rituximab dosage

A

two 1000mg infusions separated by 2 weeks OR
3mg/kg IC infusion, 2,6 weeks then Q8 weeks
Given with MTX

108
Q

Rituximab should be infused how

A

over 4 hours

premedicate with antihistamines, APAP, corticosteroids

109
Q

Abatacept MOA

A

selectively modulating a co-stimulatory signal required for full T cell activation

110
Q

Do not give Abatacept with what

A

TNF blockers

111
Q

Abatacept dosage

A

10mg/kg IV infusion over 30 minutes, repeat in 2 weeks, 4 week, Q4weeks. or give SubQ QW starting day after IV

112
Q

Tocilizumab Dosage

A

4mg/kg IV over 60 minutes Q4W. increase to 8mg/kg if necessary max 800 mg per infusion
with or w/o MTX

113
Q

Tocilizumab drug interactions

A

biologic DMARDS, decreased warfarin, PPIs, cyclosporine, BCPs, statins

114
Q

Anakinra Indication

A

Active RA 18+ failed 1+ DMARDs including TNF blockers

115
Q

Anakinra MOA

A

Interleukin 1 receptor antagonist

116
Q

Anakinra dosage

A

100 mg subQ QD

117
Q

Anakinra AEs

A

transient injection site reactions

Suppression of immune system, neutropenia, and pneumonia

118
Q

Avoid what with Anakinra

A

TNF blockers

119
Q

Tofacitinib MOA

A

Janus associated kinase inhibitor

120
Q

Tofacitinib dosage

A

5 mg PO BID

121
Q

Monitoring for tofacitinib

A

Infections, WBC

122
Q

Drug interactions for tofacitinib

A

biologic DMARDS
strong immunosuppressants
strong 3A4 inducers

123
Q

Canakinumab MOA

A

Interleukin 1 blocker

124
Q

Canakinumab indication

A

Systemic juvenile Idiopathic Arthritis

125
Q

Canakinumab dosage

A

4mg/kg (max 300 mg) SubQ Q4W

126
Q

Cankinumab AEs

A

Infections
Abdominal pain
injection site reactions

127
Q

Treatment of RA with non bio agents with low disease activity and poor prognosis

A

MTX, leflunomide, sulfasalazine or combination DMARD

128
Q

treatment of RA with non bio agents with low disease activity and no poor prognosis

A

hydroxychloroquine or minocycline

129
Q

treatment of RA with non bio agents with high disease activity and poor prognosis

A

MTX, leflunomide, or combination DMARD

130
Q

treatment of RA with non-bio agents with high disease activity and no poor prognosis

A

MTX, leflunomide, sulfasalazine, or combinatin DMARD

131
Q

Treatment of RA with biologic DMARDs with low disease activity

A
  1. nonbiologic DMARD

2. if poor response then combination non-bio DMARD or anti-TNF

132
Q

Treat of RA with biologic DMARDs with high disease activity and poor prognosis

A

MTX, leflunomide, or combination, or Anti-TNF

2. if poor response anti-TNF, rituximab, or abatacept

133
Q

Treatment of RA with biologic DMARDs with high disease activity and no poor prognosis

A
  1. non-bio dmard

2. if poor response anti-TNF or combination nonbiologic

134
Q

Required Immunizations for RA pts

A

Pneumococcal, influenza, hepatitis, HPV, and herpes zoster

135
Q

Comorbidities with RA

A

CV disease
Infections
Malignancy
Osteoporosis

Pnt Exam 1 (6 decks)

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