Term
| what is rheumatoid arthritis? |
|
Definition
| it is an autoimmune d/s with systemic inflamation, symmetrical joints involvement, an extraarticlar involement |
|
|
Term
| what extraarticular involvment is typical for RA? |
|
Definition
Rheumatoid nodules
Vasculitis
Eyes
Neurological
Cardiopulmonary
Lymphadenopathy
Splenomegaly |
|
|
Term
| what is a specific marker fot RA? |
|
Definition
anticyclic citrulinated peptide (ACP)
if not present - no RA |
|
|
Term
| what are the signs of RA? |
|
Definition
Joint pain/stiffness,Joint deformity (progression, Tenderness
Onset = > 30 mins and lasts all day,
Warmth/swelling in joints,SYMMETRICAL
Rheumatoid nodules, Rheumatoid Factor (60-70%)
Anticyclic citrullinated peptide (ACP),
Increased ESR and CRP (inflammation),
Normocytic, normochromic anemia
Thrombocytosis, Progressive (weeks to months),Cycle,,Prodromal, mental |
|
|
Term
| what markers are not diagnostic, but present in RA? |
|
Definition
| rheumatoid factor, ESR, CRP |
|
|
Term
| what are prodromal signs of RA? |
|
Definition
| Joint Pain, Fatigue, Weakness, Low-grade fever, Loss of appetite |
|
|
Term
| what joints are mostly affected? |
|
Definition
|
|
Term
| How joints nodules in RA are different fron OA? |
|
Definition
| they are soft when palpate |
|
|
Term
| what are complictions of RA? |
|
Definition
| small joints deformities, pain, vasculatis, pulmonary fibrosis, sjogren's syndrome, felty's syndrome |
|
|
Term
| what is sjogren's syndrome? |
|
Definition
| decreased tears production |
|
|
Term
| what is felty's syndrome? |
|
Definition
| splenomegaly and neutropenia |
|
|
Term
| what is a typical age for RA onset? |
|
Definition
|
|
Term
| what is a gender prevalence of RA? |
|
Definition
| W 3x M (in 15-45: W 6x M) |
|
|
Term
True/false
RA des not have a genetic component? |
|
Definition
|
|
Term
| What is pathophysiology of RA? |
|
Definition
| Autoimmune,Inflammation of synovial tissue,Invades cartilage – bone surface,Erosions,Destruction, reumatoid factor, |
|
|
Term
|
Definition
| Inflammation of synovial tissue |
|
|
Term
| what does presense of rheumatoid factor indicate? |
|
Definition
|
|
Term
True/false
Number that patient gets during diagnosis will never change |
|
Definition
False.
RA is a progressive disease, numbers may change |
|
|
Term
| what are RA treament goals? |
|
Definition
Slow progression
Prevent or control joint damage
Prevent loss of function
Decrease pain |
|
|
Term
True/ false
RA can be cured |
|
Definition
|
|
Term
| which factors help to determine therapy? |
|
Definition
how long
how active disease is
prognostic factors |
|
|
Term
| what factors indicate poor prognosis for RA? |
|
Definition
High tender and swollen joint counts, Radiographic erosions,Elevated RF,Elevated anti-CCP antibodies,
Elevated ESR, Elevated CRP,Age
Female,Genetics,Tobacco use
Worsening physical function |
|
|
Term
| what nonpharmacologic options we havefor RA? |
|
Definition
| Education,Physical Therapy,Occupational Therapy,Rest, Weight reduction,Surgery |
|
|
Term
| What is a mainstay treatment for RA? |
|
Definition
DMARDS: non-biologic
biologic |
|
|
Term
| What in RA? adjunctive treatment is used for |
|
Definition
|
|
Term
| When pharmacologic treatment should be started in RA? |
|
Definition
| within 3 months of diagnosis |
|
|
Term
true/false
All DMARDS have same effect |
|
Definition
false
all DMARDs have different effect |
|
|
Term
| what are non-biologic DMARDS? |
|
Definition
methotrexate (rheumatrex)
leflunomide (Arava)
hydroxichloroquine
minicycline
sulfasalazine
gold, azzathioprine, D-penicilamine, cyclosporine, cyclophosphamide |
|
|
Term
| what are biologic DMARDS? |
|
Definition
anti-TNF alfa: etanercept, infliximab, adalimumab
TNF alfa: abatacept, rituximab, anakinra, tocilizumab, |
|
|
Term
| what other agents are used for RA? |
|
Definition
|
|
Term
| what is a golden standard for RA? |
|
Definition
| methotrexate (Rheumatrex)- MTX |
|
|
Term
|
Definition
Inhibits cytokines, purines, stimulates adenosine
ANTI-INFLAMMATION |
|
|
Term
| Why TX is a treatment of choice for RA? |
|
Definition
| It is cheap and effective |
|
|
Term
| How long does it take for MTX to show the effect? |
|
Definition
| 3-6 weeks, continue to improve for up to 12 weeks |
|
|
Term
| In what dosage forms MTX is available? |
|
Definition
|
|
Term
| What is typical for MTX kinetics? |
|
Definition
70% orally bioavailable
Protein bound
Excreted 80% unchanged |
|
|
Term
|
Definition
N/V/D
Thrombocytopenia
Leukopenia
Pulmonary Fibrosis and pneumonitis – rare |
|
|
Term
| With presense of what SE pt should D/C MTX? |
|
Definition
Pulmonary Fibrosis and pneumonitis,
LFT > 2x ULN |
|
|
Term
| When biopsy should be done before starting MTX? |
|
Definition
Alcoholics
Hep B or C
Recurring high LFTs |
|
|
Term
| When biopsi should be done after starting MTX? |
|
Definition
|
|
Term
Folic acid should not be added to the regimen with MTX because it diminish activity of MTX
true/false |
|
Definition
| false. FA does not diminish activity of MTX |
|
|
Term
| what drugs are pregnancy category X? |
|
Definition
|
|
Term
| What drug does not determined pregnancy category? |
|
Definition
|
|
Term
| what drugs can be used in all disease durations and severities? |
|
Definition
MTX, leflunomide,
sulfasalazine |
|
|
Term
|
Definition
7.5 mg PO once wekly
or
2.5 mg PO Q 12 H TIW |
|
|
Term
| What is max weekly PO dose of MTX? |
|
Definition
|
|
Term
| Can MTX be used for longer than 2 years? |
|
Definition
| Yes, but there is safety data only for 2 years. |
|
|
Term
| Can IM/SC decrease GI MTX SE? |
|
Definition
|
|
Term
| What is MOA of leflunomide? |
|
Definition
Inhibits pyrimidine – Decreased lymphocyte proliferation
ANTI-INFLAMMATION |
|
|
Term
| What is an onset of action of leflunomide? |
|
Definition
|
|
Term
| How quickly steady state can be achieved with leflunomide without of loading dose? |
|
Definition
|
|
Term
| What are SEs of leflunimide? |
|
Definition
Dose related
N/V/D
Alopecia
Bone marrow depression |
|
|
Term
| What should be monitored when pt is taking leflunomde? |
|
Definition
CBC monthly x 6 months, then q 6-8 weeks
LFT monthly X 3 months, then quaterly |
|
|
Term
| When leflunomide should be stopped? |
|
Definition
|
|
Term
| What is a C/I for leflunomide? |
|
Definition
|
|
Term
|
Definition
LD 100 mg PO daily x 3 days
MD 20 mg PO QD |
|
|
Term
| Can MD of leflunomide be adjusted? |
|
Definition
|
|
Term
|
Definition
| Yes, if worry about toxicity. |
|
|
Term
|
Definition
| to decrease time to steady state |
|
|
Term
| How to care of leflunomide toxicty? |
|
Definition
1. stop leflunomide
2. start cholestiramine 8 mg PO TID x 11 days
3. check leflunomde level 2 tests 14 days apart
4. add more cholestiramine if needed
can use activated charcoal 50 GM Q6 h x 24 h |
|
|
Term
| How does cholestiramine work? |
|
Definition
| It gets adsorbed to the drug and gets eliminated with feces. |
|
|
Term
| What is an onset of action of hydroxychloroquine? |
|
Definition
|
|
Term
| what is considred a treatment failure for hydroxychloroquine? |
|
Definition
|
|
Term
| What is specil about kinetics of hydroxychloroquine? |
|
Definition
|
|
Term
| What are SE of hydroxychloroquine? |
|
Definition
N/V/D – Take with food
Ocular – Monitor regularly |
|
|
Term
| When hydroxychloroquine can be used? |
|
Definition
No poor prognostic features
Low disease activity
Duration <= 24 months |
|
|
Term
| What is a dose of hydroxychloroquine? |
|
Definition
400-600 mg PO daily
can reduce after clinical response to 200-400 mg PO QD |
|
|
Term
| How does Minocycline work in RA? |
|
Definition
Inhibits collagenase activity in synovial tissue
Inhibits protein synthesis in immune cells |
|
|
Term
|
Definition
|
|
Term
| What are minocyclines SE? |
|
Definition
GI
Thrush
liver damage
Photosensitivity (hyperpigmentation) |
|
|
Term
| Pt should use sunscreen whle taking minocycline? |
|
Definition
| false, sunscreen does not work, pt should avoid being on sun |
|
|
Term
| hat dose of minocyclne can be used in RA? |
|
Definition
|
|
Term
| When minocycline can be used? |
|
Definition
No poor prognostic features
Low disease activity
Duration < 6 months |
|
|
Term
|
Definition
|
|
Term
| What is an active part of sulfasalazine? |
|
Definition
| Sulfapyradine is responsible for effect |
|
|
Term
| what is 5-ASA can be used for? |
|
Definition
| Chron disease, it stays in the gut |
|
|
Term
| when should one expect to see the respond to sulfasalazine? |
|
Definition
|
|
Term
| how shold one take Fe supplement while on sulfasalazine therapy? |
|
Definition
| need to separate by 4 hrs |
|
|
Term
| What are SE of sulfasalazine? |
|
Definition
N/V/D/anorexia
Rash
Urticaria
Serum sickness
Hypersensitivity – contraindication
Yellow-orange skin and urine |
|
|
Term
| What dosage form of sulfasalazine is preffered for RA? |
|
Definition
|
|
Term
| When sulfasalazine can be indicated? |
|
Definition
No poor prognostic features
All disease durations
All disease activities |
|
|
Term
| How to dose sulfasalazine? |
|
Definition
0.5 – 1 gm PO daily x 1 week
Increase daily dose by 500 mg q week until 2 gm TDD (3 gm max)
Can titrate more slowly or divide dose to minimize AE |
|
|
Term
| What is a max dose for sulfasalazine? |
|
Definition
|
|
Term
| what drugs can be used as monotherapy? |
|
Definition
| sulfasalazine, methotrexate, minocycline, hydroxychloroquine, leflunomide |
|
|
Term
| What agents are used for bridging |
|
Definition
|
|
Term
| In What dosage forms CCSs are available for RA? |
|
Definition
| PO, IM, IV, Intraarticular |
|
|
Term
|
Definition
|
|
Term
| When intraarticular injection of CCS can be used? |
|
Definition
It is reserved for bad cases
Small number of joints is involved
Less systemic effects
q 3 months
Not to exceed more than 2-3 times per year per joint |
|
|
Term
| What agents are reserved for treatment failure? |
|
Definition
|
|
Term
Biologic agents can be used with non-biologic
True.false |
|
Definition
| True, usually methotrexate |
|
|
Term
| What should be checked before start biologics? |
|
Definition
|
|
Term
True/false
Biologics are less effective than non-biologics in RA treatment |
|
Definition
| False, they are as effective as non-biologics. |
|
|
Term
| Available in injection form |
|
Definition
| Etanercept (Enbrel), Infliximab (Remicade), Adalimumab (Humira), cortisone, methotrexate |
|
|
Term
| What are indicators for TNF alfa agents? |
|
Definition
1. Early RA + high disease activity + poor prognosis + cost not an issue;
2. Intermediate or long standing RA + failed MTX monotherapy + moderate disease activity + poor prognosis;
3. Intermediate or long standing RA + failed MTX monotherapy + high disease activity;
4. Failed 2 or more non-biologic agents + moderate disease activity |
|
|
Term
| What is MOA of abatacept (Orencia)? |
|
Definition
Binds receptors on antigen-presenting cells
Inhibits T-cells |
|
|
Term
| dosing of abatacept (Orencia) |
|
Definition
Weight based
>100 kg – 1000 mg IV over 30 mins q 2 weeks at weeks 0, 2, and 4, then 1000 mg IV over 30 minutes q 4 weeks starting week 8
60 – 100 kg – 750 mg
<60 kg – 500 mg |
|
|
Term
| when abatacept (Orencia) is recommended? |
|
Definition
| Failure of MTX in combo with other DMARDs or sequential admin of other non-biologic DMARDs + moderate disease activity + poor prognosis |
|
|
Term
| What drugs are chimerics? |
|
Definition
rituximab (Rituxan)
infliximab (Remicade) |
|
|
Term
| what is a cause of prolonged effect of rituximab (Rituxan)? |
|
Definition
| It binds to peripheral B cells permanently and depletes them |
|
|
Term
true/false
intermittent therapy is possible with rituximab (Rituxan) |
|
Definition
|
|
Term
| What are SE of rituximab (Rituxan)? |
|
Definition
| infusion reaction (highest with first infuson), hematologic |
|
|
Term
| How to minimize infusion reaction with rituximab (Rituxan)? |
|
Definition
Methylprednisolone 100 mg 30 minutes prior to infusion
also
Acetaminophen and antihistamines |
|
|
Term
| What monitoring should be done with rituximab (Rituxan)? |
|
Definition
|
|
Term
| what is an indication for rituximab (Rituxan)? |
|
Definition
| Failed MTX in combination or failed sequential non-biologic DMARDs + High disease activity + poor prognosis |
|
|
Term
| dosing for rituximab (Rituxan) |
|
Definition
1000 mg IV day 1 and 15
Administer subsequent courses based on clinical symptoms
Don’t give sooner than q 16 weeks
not set interval |
|
|
Term
| what is a last line TNF alfa agent? |
|
Definition
|
|
Term
| dosing for anakinra (Kineret) |
|
Definition
| 100 mg SC daily (timing is important) |
|
|
Term
| what is a SE of anakinra (Kineret)? |
|
Definition
|
|
Term
true/false
anakinra must be combined with TNF infibitors |
|
Definition
false
anakinra (Kineret) can't be combined with TNF inhibitors |
|
|
Term
| what are indications for tocilizumab (Actemra)? |
|
Definition
Moderate to severe disease activity
Failed TNF inhibitor |
|
|
Term
| what is MOA of tocilizumab (Acterma)? |
|
Definition
|
|
Term
| what are SE of tocilizumab (Actemra)? |
|
Definition
| Can increase LFTs, LDL, HTN, GI perforations |
|
|
Term
| dosing for tocilizumab (Actemra) |
|
Definition
4 mg/kg IV over 1 hour q 4 weeks
Titrate to 8 mg/kg
Do not infuse more than 800 mg at a time |
|
|
Term
| C/I for tocilizumab (Actemra) initiation |
|
Definition
| Absolute neutrophile count <2000, Platelets <100,000 or LFT >1.5x UNL |
|
|
Term
| what agent has weight based dosing? |
|
Definition
|
|
