wk 10- rheumatology Flashcards
what is RA
chronic autoimmune, systemic inflammation
what are aims for treatment of RA
- symptomatic relief (pain and stiffness)
- maintain level of function
- prevent damage to bones, joints and organs
TREAT TO target principle
goal is to be in remission or low disease activity with adapted therapy, if its not achieved in 3-6 months then alter therapy to achieve this
how do they monitor RA disease activity
- measuring inflammation through swollen/tender joint counts and or ESR and or CRP levels
- and patient reported outcomes questionaires
- joint damage throughout disease course with medical imaging
for activity level and deciding whether to change treatment
drug classes for RA
- corticosteroids
- calcineurin inhibitors
- monoclonal antibodies
- cytokine modulators
- antiproliferative immunsuppressants
- Disease Modifying Anti Rheurmatic Drugs
what are DMARDs
drugs that stop synovial inflammation and prevent joint damage
length and dosing of DMARDs
response should be seen within 12 weeks but can take up to 6 months
once control is achieved, the dose is reduced to lowest effective
types of DMARD therapy
- conventional synthetic disease modifying ARD
- biological disease modifying ARD
- targeted synthetic DMARDs
example of CSDMARDS
methotrexate
lefluomide
sulfasalazine
hydroxychloroquine
example of BDMARDS
abatacept
adalimumab
certolizumab
etanercept
example of targeted synthetic DMARDs
tofacitinib
treatment for RA
initially is a csDMARDS with or without a corticosteriod
typically
1. methotrexate
2. if MTX not tolerated, then lefluonmide
if remission not achieved with csDMARD then bDMARD or tsDMARD trialled
different severities of RA and initial treatment
mild RA- Hydroxychloroquine with or without sulfasalazine
mild-mod RA- MTX
active RA- combination therapy with the 3 above
pre screening before RA treatment, for what?
- active infection
-tuberculosis
-vaccination status - liver, kidney, bone marrow
-history of malignancy - reproductive health education
- medication review
- monitoring regime every 3-6 months
criteria for qualifying for a biologics (cytokine modulators)
- established severe active RA
- 6 more swollen and tender joints, 4 non hand joints or DAS 28 score 3.2 or more
- failed to get into remission with 2 stndard DMARDs, MTX being one of them
what do corticosteroids do
rapid symptoms control at presentation and control disease through anti inflammatory and DMARD effects
use while waiting for the effects of csDMARD
when to use NSAIDs with RA
before DMARD therapy is commenced to control symptoms but do not reduce joint damage
can also be used during flares of joint pain/swelling
MOA methotrexate
inhibits dihydrofolate reductase
side effects of methotrexate
bone marrow suppression
liver toxicity
immunosuppression
folic acid
hydroxychloroquine side effects/complications
risk of retinopathy with long term use
blood dyscrasias
ototoxicity- hearing/balance issues
major drug interactions with antacids, rosuvastatin, duloxetine, atorvastatin
sulfasalazine side effects
increased photosensitivity
itching
skin rash
vomiting
drug interactions with aspirin, celecoxib, warfarin, lidocaine
leflunomide MOA
inhibits dihydroorotate dehydrogenase
leflunomide side effects
N, V, D
skin rash
alopecia- hair loss
drug interactions with aspirin, celecoxib, etanercept, adalimumab, atorvastaitn
bDMARDs and MOA
- TNF-α: adalimumab, certolizumab, etanercept, golimumab, infliximab (all drugs bind and
neutralise TNF) - IL-1: anakinra (competitive inhibition of IL-1 receptors)
- IL-6: tocilizumab (binds to soluble and membrane-bound IL-6 receptors)
- Target B cells: Rituximab
- Target T Cells: Abatacept
what do bDMARDS target
cytokines
bDMards are associated with and complications that occur are
onychocryptosis
have to cease with nail surgery
increased risk of non serious infections (fungal)
tsDMARDs moa
inhibit JAK1, 2, 3 to inhibit immune response
what is included under spondyloarthropathies
psoriatic
reactive arthritis
ankylosing spondylitis
treatment for anklyosing spondylitis
NSAIDS and exercise to control symptoms
if symptoms not controlled or severe disease, bDMARDs are used
csDMARDs no effect
treatment for reactive arthritis and time course
commonly resolves within 6 months
- NSAIDs mild/mod symptoms
- prednisone severe symptoms
- local corticosteroid injection for isolated peripheral joint
treatment of PsA
- NSAIDS symptoms
- corticosteroids for mono or oligoarticular peripheral arthriitis
- DMARD for polyarthritis or severe cases
csDMARD- avoid hydroxychloroquine causes psorarias flare up
bDMARD- if standard dont work
tsDMARD as another option
OA mangement/treatment
- exercise/weight loss
- paracetamol
- low dose, short acting NSAID as required, consider CSI
- higher dose NSAID
- oral opioid
gout management of an acute attack
reduce inflammation through
1. local CSI
2. NSAID
3. prednisone
4. colchicine
colchicine MOA
inhibits neutrophil motility and disrupts phagocytosis
colchicine side effects
GI
neutropenia
neuropathy
anaemia
bone marrow suppression
interat with some statins
chronic gout management
dissolve tophi
prevent future attacks
urate lowering therapy lifelong
- allopurinol- 1st line
- febuxostat
- probenecid
allopurinol MOA
inhibits xanthine oxidase
side effects of allourinol
headache
upset stomach
pruritic rash
febuxostat MOA
inhibits xanthine oxidase
adverse effects of febuxostat
small risk of CVD events
dont change chronic mangement of gout when
during an attach can make worse
difference between acute and chronic gate mangement
acute- symptom and pain relief
chronic- urate lowering to prevent recurrence
