Wk 26 - Rheumatoid arthritis + Osteoarthritis

Question 1

What are the associated conditions of RA?

Answer 1

• Sjörgrens syndrome
• Vasculitis
• Inc CV risk
• Inc osteoporosis

Question 2

Which supportive treatments are used for RA?

Answer 2

• NSAIDs + COX-2 inhibitors
• Steroids: flare ups

Question 3

What is the DAS-28?

Answer 3

Reviews disease activity score - based on how many swollen/tender joints patient has

Question 4

What are the initial pharmacological treatment for RA?

Answer 4

• Monotherapy
• Oral MXT, leflunomide or sulfasalazine

Question 5

When adding a second DMARD, which 2 can’t be used alongside one another?

Answer 5

MXT + leflunomide

Question 6

How long do DMARDs take to work?

Answer 6

Upto 12 weeks

Question 7

What are the general points when taking DMARDs in regards to vaccination?

Answer 7

• Flu, pneumococcal recommended
• Avoid live (2-4 wks before starting)
• Avoid chicken pox/shingles/measles
• VZ immunoglobulin can be given w/in 7 days

Question 8

Which medication given for RA may have a risk of reactivating latent TB?

Answer 8

Biologics

Question 9

What happens when a patient is on a DMARD + gets ill?

Answer 9

Stop until infection cleared

Question 10

Which DMARDs are CI in pregnancy?

Answer 10

MXT + leflunomide

Question 11

Which therapy is given for pregnant women w/ RA?

Answer 11

Azathioprine or hydroxychloroquine

Question 12

When taking leflunomide, how long must the patient use effective contraception before becoming pregnant?

Answer 12

• Women: during treatment + 2 years after
• Men: 3 months after

Question 13

Which conditions may improve/worsen RA?

Answer 13

• Pregnancy improves
• Lupus worsens

Question 14

What are the advice when taking MXT + NSAIDs?

Answer 14

• NSAIDs reduce renal excretion of MXT
• Avoid inappropriate clinical use: post surgical pain relief, OTC
• Monitor bloods + signs of haem/liver/pulmonary toxicity

Question 15

What are the counselling points for MXT?

Answer 15

• Once weekly
• Folic diff. day
• S/e: sick, upset stomach/di

Question 16

When would you report + tell your doctor when taking MXT?

Answer 16

• Unexplained SOB + dry cough
• Jaundice
• Fever, chills, sore throat
• Mouth ulcers, bleeding gums, bruising
• Never had chickenpox + exposed
• Pregnant

Question 17

What is given for MXT rescue therapy?

Answer 17

• Folinic acid (calcium folinate)
• Counteracts anti-folate activity of MXT, speeds recovery of myelosuppression/mucositis

Question 18

What is given for severe neutropenia when taking MXT?

Answer 18

SC filgrastim

Question 19

What are the counselling points for sulfasalazine?

Answer 19

• Dose: 500mg OD 7/7, 500mg BD 7/7, 1g OM + 500mg ON 7/7, 1g BD
• Turns urine orange, contacts + tears yellow
• S/e: nausea, di, upset stomach
• FBC, LFTs + U+Es first 2 yrs
• Report: unexplained cough, sore throat, rash

Question 20

Which conditions would you not use leflunomide?

Answer 20

Liver impairment + hypoproteinemia

Question 21

When taking leflunomide, other than FBCs, what else needs to be monitored?

Answer 21

BP + weight monitoring

Question 22

What is used for a leflunomide wash out?

Answer 22

• Cholestyramine 8g TDS 11 days

OR

• Activated charcoal 50g QDS 11 days

Question 23

When completing a leflunomide wash out, what must the concentration of active metabolites be?

Answer 23

<20microg/L on 2 occasions 2 wks apart

Question 24

Which DMARD may cause ocular disturbances?

Answer 24

Hydroxychloroquine - Visual acuity tested annually (high risk) or every 5 years

Question 25

Which conditions would you be cautious of initiating hydroxychloroquine?

Answer 25

• Epilepsy
• GI disorders
• Exacerbate psoriasis

Question 26

What are the interactions of hydroxychloroquine?

Answer 26

• Amiodarone
• Moxifloxacin (inc ventricular arrhythmias)
• Digoxin (inc dig)
• Ciclosporin (inc cliclo)

Question 27

What are the benefits of using MXT + biologics together?

Answer 27

• Inc efficacy
• Less likely to develop autoantibodies

Question 28

What are the conditions needed to initiate biologics?

Answer 28

• DAS-28 >3.2
• Trails of 2 DMARDs

Question 29

When would you continue using biologics?

Answer 29

Adequate response at 6 months - DAS-28 of 1.2 or more

Question 30

What are the adverse effects of biologics?

Answer 30

• Reactivate TB, HIV, hep B + C
• Inc lymphoma
• Headache, flushing, GI disturbance
• VTE w/ JAK inhibitors

Question 31

When are biologics CI?

Answer 31

Active TB or severe hepatic failure

Question 32

Would you continue biologics after a surgery?

Answer 32

• No bc delays wound healing
• Omit 1 full dosing interval pre-surgery

Question 33

What are the presentations of RA?

Answer 33

• Occurs any age
• Autoimmune inflammatory
• Dry mouth, eyes, skin involvement
• Rapid onset (wks/months)
• Joints painful, hot + swollen
• Morning stiffness >1hr
• Symmetrical

Question 34

What are the presentations of OA?

Answer 34

• Older age
• Wear + tear of cartilage
• Slow onset
• Joints ache, minimal swelling
• Morning stiffness <1hr
• Affects weight baring joints (spine, knees)

Question 35

What is needed to diagnose OA w/o investigations?

Answer 35

• > 45 yrs
• Activity related joint pain
• No morning stiffness/ <30 mins

Question 36

What is given to alleviate pain from OA?

Answer 36

• Topical NSAIDs
• Oral NSAIDs
• Adjunct: capsaicin, intra-articular steroids