Treatment Options for Rheumatoid Arthritis

Question 1

Outline the treatment pathway for rheumatoid arthritis.

Answer 1

Pain relief (analgesics, NSAIDs, COX-2 inhibitors) and then DMARDS (biological or non-biological)

Question 2

What regions are most commonly affected by rheumatoid arthritis?

Answer 2

Small joints of the hands and feet

Question 3

What is the difference in action of biologicals and non-biologicals in DMARDs?

Answer 3

Non-biologicals target the immune cells often by unknown mechanisms whereas biologicals target specific parts of the inflammatory cascade and are specific

Question 4

Name some examples of non-biological DMARDs

Answer 4

Gold, sulfasalazine, methotrexate

Question 5

Name some examples of biological DMARDs

Answer 5

Infliximab, adalimumab, rituximab

Question 6

What is the initial treatment given for rheumatoid arthritis

Answer 6

In newly diagnosed patients they are prescribed methotrexate and at least one other DMARD plus short-term glucocorticoids (steroids)

Question 7

What are the some of the issues associated with non-biological DMARDs?

Answer 7

Take a long time for them to start working

Question 8

What are the potential side-effects of methotrexate?

Answer 8

Liver problems, affect blood count, folic acid antagonist

Question 9

What is sulfasalazine?

Answer 9

This is a form of antibiotic that combined sulfapyridine and salicyclate with an azo bond that is used as a non-biological DMARD in the treatment of rheumatoid arthritis

Question 10

Why can’t methotrexate be given to pregnant women?

Answer 10

It is a folic acid antagonist and therefore increases the risk of neural tube defects

Question 11

How can hydroxychloroquine be used in the treatment of rheumatoid arthritis?

Answer 11

Antimalarial drug which accumulates in lysosomes to increase acidity and decrease protein modifications and block TLR-9 and decrease activation of dendritic cells.

Question 12

How can leflunomide be used to treat rheumatoid arthritis?

Answer 12

Mode of action is poorly understood but though tot inhibit pyrimidine biosynthesis by inhibiting dihydroorotate dehydrogenase to prevent DNA and RNA synthesis.

Question 13

How may azathioprine be used in the treatment of rheumatoid arthritis?

Answer 13

It’s a pro-drug consisting of 6-metcaptopurine and a purine synthesis inhibitor; it interferes with the synthesis of prints required for DNA synthesis. It can be used in combination with prednisolone to reduce the dose of steroid required.

Question 14

How may gold salts be used in the treatment of rheumatoid arthritis?

Answer 14

Mechanism is poorly understood but can have substantial side-effects and take a long time to work.

Question 15

Name three examples of TNFa inhibitors used in the treatment of rheumatoid arthritis

Answer 15

Etanercept, infliximab, adalimumab

Question 16

Name three IL-1 inhibitors used in the treatment of rheumatoid arthritis

Answer 16

Anakinra, canakinumab, rilonacept

Question 17

What targets are used for biological therapy for rheumatoid arthritis?

Answer 17

TNFa, IL-1, IL-6, B cells and T cells.

Question 18

Name an IL-6 inhibitor used in the treatment of rheumatoid arthritis

Answer 18

Tocilizumab

Question 19

Name a B cell inhibitor used in the treatment of rheumatoid arthritis

Answer 19

Rituximab

Question 20

Name a T cell inhibitor used in the treatment of rheumatoid arthritis

Answer 20

Abatacept

Question 21

Outline how etanercept works to treat rheumatoid arthritis

Answer 21

Combination of TNF receptor and Fc portion of human IgG1 which works to prevent TNFa from binding to it’s receptors and providing an inflammatory response

ESSENITALLY: antibody against TNFa

Question 22

Outline how infliximab works to treat rheumatoid arthritis

Answer 22

This is a monoclonal antibody against TNFa

Question 23

Outline how adalimumab works to treat rheumatoid arthritis

Answer 23

Human TNFa monoclonal antibody which can bind TNFa in soluble and insoluble forms to prevent binding to receptor

Question 24

Outline how anakinra works to treat rheumatoid arthritis

Answer 24

This is a recombinant IL-1 receptors which binds to IL-1 also to block the receptor so IL-1 can’t bind to have an effect

Question 25

Outline how canakinumab works to treat rheumatoid arthritis

Answer 25

Human monoclonal antibody which targets IL-1b to bind IL-1 before it gets to the receptor to work

Question 26

Outline how rilonacept works to treat rheumatoid arthritis

Answer 26

Binds to extracellular domain of IL-R1 receptor and the Fc portion of human IgG1 to bind IL-1 before it can act on the receptors.

Question 27

Outline how rituximab works to treat rheumatoid arthritis

Answer 27

Monoclonal antibody against CD20 receptor on B cells to destroy normal and malignant B cells.

Question 28

Outline how abatacept works to treat rheumatoid arthritis

Answer 28

A fusion protein of IgG and CTLA4 which has an affinity for the CD28 receptor on the T cells, which prevents the second signal from being delivered

Question 29

Outline how toclizumab works to treat rheumatoid arthritis

Answer 29

Monoclonal antibody against IL-6

Question 30

What condition, aside from rheumatoid arthritis, is rilonacept used to treat?

Answer 30

Acute gout