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
|
|