Week 3 - Tx of RA

Question 1

What drug should be used in all patients with RA?

Answer 1

DMARDs

Question 2

What joints are affected with RA?

Answer 2

Usually symmetrical polyarthritis, but DIP joints are spared

Question 3

What is the most common reason for a patient with RA to present in the acute/short-term setting?

Answer 3

Viral infection

- ex. parvovirus, hepatitis, rubella

Question 4

What is the clinical appearance of the hand for someone who has moderate to severe RA

Answer 4

Swollen MCPs
Ulnar deviation
Deformities
Nodules on joints

Question 5

What is the optimal tx for RA?

Answer 5

Catch them early
Rapidly escalate tx
Combination DMARDs
Use biologic tx for non-responders

Question 6

What are some extra-articular manifestations of RA?

Answer 6

Nodules
Eye inflam
Lung disease
Dry eyes/mouth
Small vessel vasculitis
Pleuritis
Pericarditis
Neuropathy

Question 7

What is a cause of early mortality in RA?

Answer 7

Cardiovascular disease (may lose 10-30 years of life)

Question 8

What drug classes are used to treat RA?

Answer 8

Analgesics (rarely used), corticosteroids, NSAIDs, DMARDs

Question 9

What are examples of analgesics

Answer 9

Acetaminophen & opiods

Question 10

NSAIDs

- pros and cons for use in RA

Answer 10

anti-inflam;
don't alter disease outcomes;
lots of side effects/drug interactions;
used at the beginning while waiting for DMARDs to take effect; 
naproxen, diclofenac

Question 11

Steroids:

- pros and cons for use in RA

Answer 11

Work really well; fast-acting & effective;
Anti-inflam; reduces systemic effects;
MAJOR side effects

Question 12

What are the 4 commonly used DMARDs for treating RA?

Answer 12

Methotrexate (MTX)
Sulfasalazine (SSZ)
Hydroxychloroquine (HCQ)
Leflunomide

Question 13

What are some side effects of Methotrexate?

Answer 13

Pancytopenias
Hepatitis
Interstitial lung disease
Immunosuppression

Question 14

What are some biologic agents for treating RA?

Answer 14

Anti-TNF

• -> Etanercept - soluble p75 receptor
• -> Infliximab - chimeric monoclonal antibody
• -> Adalimumab - human mab
• -> Golilmumab
• -> Certolizumab

Rituximab
Abatacept

Question 15

How does infliximab work?

Answer 15

Binds TNF tightly and gets rid of it through RE system

Question 16

How does Abatacept work?

Answer 16

CTLA-4 (receptor on T-cells) attached to IgG base.

Binds to CD-80/86 on T-cells and blocks the signal

Question 17

How does Rituximab work?

Answer 17

Anti-CD20

• knocks out B-cells with CD20 on it
• helps with RA
• may get more infections though

Question 18

What is the effect of Tocilizumab?

Answer 18

Reduces inflammation quickly

anti-IL-6

Question 19

What would you use to treat mild RA with elderly onset?

Answer 19

HCQ (Hydroxychloroquine)

Question 20

What would you use for treating Moderate RA?

Answer 20

Start with triple therapy (MTX+SSZ+HCQ) and then decrease drugs once the inflammation and symptoms are under control

Question 21

How long is the window of opportunity from onset of disease to when tx is not as effective.

Answer 21

6 months

Question 22

How should severe RA be treated?

Answer 22

Initially with triple therapy (MTX+SSZ+HCQ), but if MTX not tolerated, switch to Leflunomide or Gold.
If patient doesn’t respond, switch to biological agents (start with anti-TNF)

Question 23

What RA drugs are safe for using in pregnancy?

Answer 23

Sulfasalazine
Gold
Hydroxychloroquine

Question 24

For someone on MTX or Leflunamide who wants to get pregnant, what do you do?

Answer 24

Stop MTX.

Stop Leflunomide, but this also requires cholestyramine washout because Lef stays in system for 2 years.

Question 25

Which RA drugs are teratogenic?

Answer 25

Leflunomide
MTX
Cyclophosphamide