Treatment of Rheumatoid Arthritis Exam 1 Flashcards

1
Q

monitoring for rheumatoid arthritis

A
  • Clinical assessment
  • Laboratory
  • Radiographic progression: Sharp and Larsen scores
  • Disease activity score (DAS)
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2
Q

monitoring for rheumatoid arthritis: clinical assessment

A
  • swollen joint count
  • tender joint count
  • duration of morning stiffness
  • patient and physician global assessment
  • health assessment questionnaire (HAQ)
  • pain (visual analog scale)
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3
Q

monitoring for rheumatoid arthritis: labs

A
  • ESR
  • C-reactive protein
  • Hb, platelets
  • x-rays
  • NOT RF
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4
Q

monitoring for rheumatoid arthritis: Disease activity score (DAS)

A
  • DAS 44 ≤2.4 or DAS 28 ≤3.2 considered low disease activity

- DAS 44 <1.6 or DAS 28 <2.6, full remission

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5
Q

monitoring for rheumatoid arthritis: ACR 20

A

> = 20% improvement in tender & swollen joint counts and  20% improvement in 3 of the following 5 disease activity measures: patient’s assessments of pain and physical function, patient’s & physician’s global assessments of disease activity, and acute phase reactant value (ESR or CRP)

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6
Q

What is the treatment of target?

A

low disease activity or remission

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7
Q

treatment in early RA

A
  • Initial DMARD monotherapy (usually MTX if not contraindicated)
  • If RA activity moderate or high, add low-dose glucocorticoid
  • If low disease activity or remission not achieved, try nonbiologic DMARD combination or TNF inhibitor +/- MTX or non-TNF biologic +/- MTX
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8
Q

treatment in established RA (treatment naïve)

A
  • Initial DMARD monotherapy (usually MTX if not contraindicated)
  • If RA activity moderate or high, add low-dose glucocorticoid
  • If low disease activity or remission not achieved, try nonbiologic DMARD combination or TNF inhibitor +/- MTX or non-TNF biologic +/- MTX or tofacitinib +/- MTX
  • If target not achieved, try alternative biologic +/- MTX
  • If low disease activity, continue treatment
  • If remission, consider slowly tapering therapy; do not stop all therapy
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9
Q

treatment of RA: nonbiologics

A
  • Corticosteroids
  • Methotrexate (MTX)
  • Sulfasalazine (SAS, SSZ)
  • Leflunomide (Arava)
  • Hydroxychloroquine (Plaquenil)
  • Minocycline
  • Cyclosporine (CY)
  • Azathioprine (Imuran)
  • Tofacitinib (Xeljanz, Xeljanz XR)
  • Baricitinib (Olumiant)
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10
Q

treatment of RA: biologics

A
  • Etanercept (Enbrel)
  • Infliximab (Remicade)
  • Adalimumab (Humira)
  • Golimumab (Simponi)
  • Certolizumab pegol (Cimzia)
  • Rituximab (Rituxan)
  • Abatacept (Orencia)
  • Tocilizumab (Actemra)
  • Sarilumab (Kevzara)
  • Anakinra (Kineret)
  • Infliximab-dyyb (Inflectra)
  • Infliximab-abda (Renflexis)
  • Etanercept-szzs (Erelzi)
  • Adalimumab-atto (Amjevita)
  • Adalimumab-adbm (Cyltezo)
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11
Q

What is the recommendation for prophylaxis osteoporosis?

A
  • 1000-1200mg/d of calcium
  • 600-800units/d of VitD, weight bearing exercise
  • no smoking, limit alcohol intake
  • if high FRAX score add on bisphosphonate
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12
Q

What is the recommended intake of folic acid to avoid methotrexate ADE’s?

A

folic acid 1 mg qd

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13
Q

Discuss combination therapy in RA.

A
  • Methotrexate is anchor of most combinations & given with chimerics to decrease antibody production
  • In general, biologics should not be combined with other biologics or JAK inhibitors – increased toxicity without much improvement in efficacy; some reports of etanercept-rituximab being useful
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14
Q

Which drugs can be used with MTX?

A
  • Can use Leflunomide (Arava) with MTX but increases risk of hepatotoxicity
  • Can use Sulfasalazine (SAS, SSZ) with MTX but increases folate deficiency
  • Can use Etanercept (Enbrel) with MTX
  • Infliximab (Remicade) approved for use with MTX
  • Can use Adalimumab (Humira) with MTX
  • Golimumab (Simponi) approved for use with MTX in RA
  • Can use Certolizumab pegol (Cimzia) with MTX
  • Rituximab (Rituxan) dosed (in combination with MTX)
  • Can use Sarilumab (Kevzara) with MTX
  • MTX-biologic combination may best limit radiographic progression
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15
Q

Tb screening considerations with biologics and tofacitinib

A
  • Screen for Tb (PPD) before starting biologic or JAK inhibitor
  • Concern about the reactivation of TB
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16
Q

hepatitis screening considerations with biologics and tofacitinib

A

could be reactivated with biologic

17
Q

immunization considerations with biologics and tofacitinib

A
  • Immunize based on age & risk, preferably before starting any DMARD; no live vaccines while on biologic or JAK inhibitor
  • Examples of live vaccine: measles-mumps-rubella, varicella/herpes zoster ((live attenuated (Zostavax)), oral polio, smallpox, oral typhoid, BCG, yellow fever, FluMist, rabies