Treatment of Rheumatoid Arthritis Exam 1 Flashcards
monitoring for rheumatoid arthritis
- Clinical assessment
- Laboratory
- Radiographic progression: Sharp and Larsen scores
- Disease activity score (DAS)
monitoring for rheumatoid arthritis: clinical assessment
- swollen joint count
- tender joint count
- duration of morning stiffness
- patient and physician global assessment
- health assessment questionnaire (HAQ)
- pain (visual analog scale)
monitoring for rheumatoid arthritis: labs
- ESR
- C-reactive protein
- Hb, platelets
- x-rays
- NOT RF
monitoring for rheumatoid arthritis: Disease activity score (DAS)
- DAS 44 ≤2.4 or DAS 28 ≤3.2 considered low disease activity
- DAS 44 <1.6 or DAS 28 <2.6, full remission
monitoring for rheumatoid arthritis: ACR 20
> = 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)
What is the treatment of target?
low disease activity or remission
treatment in early RA
- 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
treatment in established RA (treatment naïve)
- 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
treatment of RA: nonbiologics
- Corticosteroids
- Methotrexate (MTX)
- Sulfasalazine (SAS, SSZ)
- Leflunomide (Arava)
- Hydroxychloroquine (Plaquenil)
- Minocycline
- Cyclosporine (CY)
- Azathioprine (Imuran)
- Tofacitinib (Xeljanz, Xeljanz XR)
- Baricitinib (Olumiant)
treatment of RA: biologics
- 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)
What is the recommendation for prophylaxis osteoporosis?
- 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
What is the recommended intake of folic acid to avoid methotrexate ADE’s?
folic acid 1 mg qd
Discuss combination therapy in RA.
- 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
Which drugs can be used with MTX?
- 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
Tb screening considerations with biologics and tofacitinib
- Screen for Tb (PPD) before starting biologic or JAK inhibitor
- Concern about the reactivation of TB
