Saad - Rheumatoid Arthritis Part 2 Flashcards by amanda kastel

MOA of methotrexate

inhibits DHFR

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what is the DMARD of choice for most patients

is it used alone or in combination with other DMARDS

methotrexate

can be either monotherapy or in combo with other DMARDS

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around how long does it take to see the clinical benefits of MTX

3-6 weeks

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how is methotrexate dosed

why is this a concern

WEEKLY – NOT QD

can very easily not read the directions correctly and OD causing blood toxicity and other toxicity

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what is max dose methotrexate/week for RA

20-25 mg

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is renal dose adjustment required for MTX

yes

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name 5 scenarios in which methotrexate is CONTRAINDICATED

teratogenic - no pts who are pregnant or breastfeeding

alcoholism

alcoholic/chronic liver disease

immunodeficiency

hematologic disorders like leukopenia (INC INFECTION RISK) or thrombocytopenia (platelets) - BLEEDING

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what is methotrexate supplemented with and why

FOLIC ACID
usually greater than 5mg a day
to reduce adverse events from methotrexate

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name some adverse effects of methotrexate

GI – NVD, anorexia, dyspepsia

mucosistis (mouth and GI ulceration)

liver fxn abnormalities

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in a patient CURRENTLY taking methotrexate, what should they be monitored for

CBC, ALT, AST (liver), renal functio

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what is done in pts with an underlying LUNG DISEASE about to start MTX

a chest xray

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what kind of screenings must be done before MTX is intitiated

in high risk pts - hep b and c (do NOT want further liver toxicity from MTX) and tb screeenings

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***important consideration regarding leflunomide and why

it has a very long half life (2 weeks)

therefore, if allergic or experience some toxic effects, it is more of a concern

give cholestyramine if need to wash out bc of toxic effects or a pregnancy the pt wasnt aware of – its teratogenic like MTX

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what is an alternative to MTX in pts who cannot tolerate or dont get benefit from it

leflunomide

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MOA of leflunomide

inhibits pyrimidine synthesis
inhibits T cell response to some stimuli
halts the cell cycle

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around how long to see efficacy after taking leflunomide

1 month

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how does the monitoring when taking leflunomide compare to methotrexate

BASICALLY SAME

ALT/AST, CVC, renal function
should get TB screening, CBC with diff prior to start

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name 3 scenarios in which leflunomide is CONTRAINDICATED

pregnancy
impaired liver fxn (inc hep b/c)
sevre immunocomp pts

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true or false

leflunomide is HIGHLY TERATOGENIC, even after discontinuation

TRUE

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name some AE of leflunomide

GI - NVD, anorexia, cramps
inc liver fxn tests, liver failure

myelosuppression when combined with other treatment

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when educating a patient who is taking leflunomide, name 3 points to mention

stay hydrated
report GI symptoms like NVD or jaundice immediately
report sign of infection

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hydroxychloroquine brand

plaquenil

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explain the mechanism of hydroxychloroquine

has anti inflammatory properties by interfering with macrophages and other APC’s and their antigen processing

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what is the role of hydroxychloroquine in RA

use in mild RA in combination therapy – for those who can’t tolerate MTX

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what is the biggest concern with ppl taking hydroxychloroquine***

there is a LIFETIME MAX DOSE due to ocular side effects must get eye exams bc of ophthalmic toxicities

name some ocular toxicity effects of hydroxychloroquine

blurred vision night blindness retinal damage loss of vission

name some neurologic side effects of hydroxychloroquine

mild -- headache, vertigo, insomnia

dermatologic side effects of hydroxychloroquine

rash alopecia hyperpigementation

what is sulfasalazine

another DMARD that is used if MTX can't be tolerated. it is a prodrug

sulfasalazine has ___ and ____ properties

immunomodulating AND anti-inflammatory properties

what are the 2 metabolites of the prodrug sulfasalazine

5-ASA (aminosalicylic acid) and sulfapyridine

can sulfasalazine be used in pregnant and nursing moms

it does cross placenta and is present in breast milk however, it can be used with caution

name 2 contraindications for sulfasalazine

allergy to sulfonamide or salicylate

what is a main side effect of sulfasalazine

urine and skin discoloration - can turn orange or yellow

name 2 OA/RA drugs that are contraindicated in those with sulfa allergy

celecoxib and sulfasalazine

in the 4 DMARDS discussed (MTX, leflunomide, hydroxychloroquine, and sulfasalazine) when is the most frequent monitoring done?

within 3 months of starting therapy - done 2-4 weeks after that it continually decreases, with it being done every 12 weeks after 6 months of taking

BIOLOGIC DMARDS are associated with an increased risk of what and why?

risk of infection bc of their immunosuppressant effects therefore, TB skin test or IGRA blood test is done to detect and treat latent or active tb should also be screened for Hep B and C - risk of reactivation

true or false biologic agents cannot be used in combination with conventional DMARDS

FALSE - they can

true or false biologics can NOT be given with another biologic

true they have additive immunosuppressant effects - dangerous

if patients dont have success with a biologic, what is the next course of treatment

try a different biologic -- never use 2 at once

what is the mechanism of TNFa inhibitor biologics

block TNFa, a proinflammatory cytokine

when would a biologic TNFa inhibitor be used in an RA patient

when, despite conventional/synthetic DMARD therapy, the disease activity is still mod-high

**contraindication for TNFa inhibitors

those with moderate-severe heart failure new onset or worsened heart failure has been reported

what is a big concern with TNFa inhibitor biologics, besides being contraindicated in heart fialure patients

they can increase the risk of serious infection and MALIGNANCIES like lymphoma or skin cancer also, multiple sclerosis, a demyelinating disroder, has occurred

before starting TNFa inhibitors, patients should be screened for what

TB and hep B and C

DURING TNFa therapy, what should be monitored periodically and why

CBC with differential -- bc they can cause blood disorders like pancytopenia (lower RBC, WBC, platelets) also watch for signs of malignancy and serious infectionse

name the 2 BBW for TNFa antagonists

malignancy, specifically hepatosplenic T cell lymphoma (HSTCL) FATAL INFECTIONS - opportunistic infections like legionella and listeria

true or false JAK inhibitors can be used in combo with a biologic DMARD or JAK inhibitor

FALSE can be used with synthetic/conventional DMARD, but not another biologic OR JAK INHIBITOR. way too potent

explain how JAK inhibitors function

they bind the catalytic portion of JAK and block the messaging pathway of multiple pro-inflam cytokines

can JAK inhibitors be used by themselves (monotherapy)

yes

can JAK inhibitors be used with other JAK inhibitors

black box warnings for JAK inhibitors

serious infections malignancies CLOTS -- DVT, PE, thrombosis

TB testing is recommended prior to treatment with WHAT 3 THINGS

biologics methotrexate leflunomide

if a TB infection occurs while on MTX/leflunomide/biologics - what should be done

temporarily discontinue until infection is cured

are JAK inhibitors biologics

NO kind of like a "targeted" synthetic - not conventional synthetic like MTX

a patient with a history of significant TB exposure or recurrent TB infection may not be a candidate for which drugs

MTX, leflunomide, biologics

if a patient has an active or latent TB infection and is looking to start MTX or leflunomide or biologics, what must be done?

they get antitubercular treatment treatment with biologics can start after ONE MONTH of latent TB treatment with meds and after completing treatment of active TB (as applicable)

ALL PATIENTS receiving DMARDS should get what 4 vaccinations

influenza pneumonia HPV herpes zoster (NOT THE LIVE ONE)

If a patient gets the LIVE herpes zoster vaccine, how long do they have to wait before starting biologics

2 weeks

the hepatitis B vaccine is reccomended to certain patients getting biologic OR nonbiologic DMARDS name these 3 populations

healthcare workers those who use IV drugs those who have mult sex partneers

name 3 live vaccines that can NOT be given to patients on biologics

MMR yellow fever LIVE herpes zoster

4 patient populations with high risk comorbidities

hepb/c congestive heart failure malignancy serious infections

a patient has an active hep B infection and is receiving effective treatment for it what kind of RA therapy should they get what about a patient with chronic hep B who is UNTREATED

same as someone who doesnt have the infection UNTREATED - refer to antiviral therapy before getting immunosuppressants

pt with Hep C infection and receiving effective treatment - what RA therapy should they get?? pt with hep C infection NOT getting antiviral treatment, what should they get

same as someone without condition if not being treated - reccomend DMARD over TNFa antagonist

which RA therapy is CONTRAINDICATED in congestive heart failure patients

TNFa antagonists

if a patient is taking TNFa antagonist and devleops signs of worsening heart failure, what should be done

discontinue therapy and recommend combination DMARDS, non TNF biologics, or tofaticinib

in general, patients with treated or untreated skin cancer or lymphoma disorders, what is recommended which type of treated cancer gets treated the same

DMARDS over biologics solid organ malignancy

patients with previous serious infections should use ___ over ____ and ______ over ______

DMARDS over TNFa antagonists abatacept over TNFa antagonists synthetics preferred over biologics

it is recommended that patients _____________ for at least 6 months prior to tapering down the dose

at target -- low disease activity or remission

true or false it is recommended to abruptly discontinue DMARDS

false - gradual tapering is preferred just reducing the dose is even better

explain what a biosimilar is

a biologic product HIGHLY SIMILAR to a reference product no clinically meaningful differences in efficacy/adverse effects/immunogenicity

what is the treatment for NODULES - an extra-articular manifestation of RA

NONE

what is the treatment for vasculitis - an extra-articular manifestation of RA

aggressive treatment of the inflammatory process

what is the treatment for ocular extra-articular manifestations of RA (keratoconjunctivitis sicca of sjogren's syndrome)

articifical tears

what is xerostomia

dry mouth an extra-articular maifestation of RA

how is xerostomia treated

pilocarpine or cevimeline