Wk 26 - Rheumatoid arthritis + Osteoarthritis Flashcards
What are the associated conditions of RA?
- Sjörgrens syndrome
- Vasculitis
- Inc CV risk
- Inc osteoporosis
Which supportive treatments are used for RA?
- NSAIDs + COX-2 inhibitors
- Steroids: flare ups
What is the DAS-28?
Reviews disease activity score - based on how many swollen/tender joints patient has
What are the initial pharmacological treatment for RA?
- Monotherapy
- Oral MXT, leflunomide or sulfasalazine
When adding a second DMARD, which 2 can’t be used alongside one another?
MXT + leflunomide
How long do DMARDs take to work?
Upto 12 weeks
What are the general points when taking DMARDs in regards to vaccination?
- Flu, pneumococcal recommended
- Avoid live (2-4 wks before starting)
- Avoid chicken pox/shingles/measles
- VZ immunoglobulin can be given w/in 7 days
Which medication given for RA may have a risk of reactivating latent TB?
Biologics
What happens when a patient is on a DMARD + gets ill?
Stop until infection cleared
Which DMARDs are CI in pregnancy?
MXT + leflunomide
Which therapy is given for pregnant women w/ RA?
Azathioprine or hydroxychloroquine
When taking leflunomide, how long must the patient use effective contraception before becoming pregnant?
- Women: during treatment + 2 years after
- Men: 3 months after
Which conditions may improve/worsen RA?
- Pregnancy improves
- Lupus worsens
What are the advice when taking MXT + NSAIDs?
- NSAIDs reduce renal excretion of MXT
- Avoid inappropriate clinical use: post surgical pain relief, OTC
- Monitor bloods + signs of haem/liver/pulmonary toxicity
What are the counselling points for MXT?
- Once weekly
- Folic diff. day
- S/e: sick, upset stomach/di
When would you report + tell your doctor when taking MXT?
- Unexplained SOB + dry cough
- Jaundice
- Fever, chills, sore throat
- Mouth ulcers, bleeding gums, bruising
- Never had chickenpox + exposed
- Pregnant
What is given for MXT rescue therapy?
- Folinic acid (calcium folinate)
- Counteracts anti-folate activity of MXT, speeds recovery of myelosuppression/mucositis
What is given for severe neutropenia when taking MXT?
SC filgrastim
What are the counselling points for sulfasalazine?
- 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
Which conditions would you not use leflunomide?
Liver impairment + hypoproteinemia
When taking leflunomide, other than FBCs, what else needs to be monitored?
BP + weight monitoring
What is used for a leflunomide wash out?
- Cholestyramine 8g TDS 11 days
OR
- Activated charcoal 50g QDS 11 days
When completing a leflunomide wash out, what must the concentration of active metabolites be?
<20microg/L on 2 occasions 2 wks apart
Which DMARD may cause ocular disturbances?
Hydroxychloroquine - Visual acuity tested annually (high risk) or every 5 years
Which conditions would you be cautious of initiating hydroxychloroquine?
- Epilepsy
- GI disorders
- Exacerbate psoriasis
What are the interactions of hydroxychloroquine?
- Amiodarone
- Moxifloxacin (inc ventricular arrhythmias)
- Digoxin (inc dig)
- Ciclosporin (inc cliclo)
What are the benefits of using MXT + biologics together?
- Inc efficacy
- Less likely to develop autoantibodies
What are the conditions needed to initiate biologics?
- DAS-28 >3.2
- Trails of 2 DMARDs
When would you continue using biologics?
Adequate response at 6 months - DAS-28 of 1.2 or more
What are the adverse effects of biologics?
- Reactivate TB, HIV, hep B + C
- Inc lymphoma
- Headache, flushing, GI disturbance
- VTE w/ JAK inhibitors
When are biologics CI?
Active TB or severe hepatic failure
Would you continue biologics after a surgery?
- No bc delays wound healing
- Omit 1 full dosing interval pre-surgery
What are the presentations of RA?
- Occurs any age
- Autoimmune inflammatory
- Dry mouth, eyes, skin involvement
- Rapid onset (wks/months)
- Joints painful, hot + swollen
- Morning stiffness >1hr
- Symmetrical
What are the presentations of OA?
- Older age
- Wear + tear of cartilage
- Slow onset
- Joints ache, minimal swelling
- Morning stiffness <1hr
- Affects weight baring joints (spine, knees)
What is needed to diagnose OA w/o investigations?
- > 45 yrs
- Activity related joint pain
- No morning stiffness/ <30 mins
What is given to alleviate pain from OA?
- Topical NSAIDs
- Oral NSAIDs
- Adjunct: capsaicin, intra-articular steroids
