Term
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Definition
| autoimmune disorder that begins w/ inflammation of synovial lining; pannus occurs; pannus invades cartilage & bone surface --> erosion of bone & cartilage --> destruction of joint; inflammation mediated by TNF, IL-1, & IL-6; release of histamine, kinins, & PGs --> edema, warmth, erythema, & pain in joints |
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Term
| Clinical Signs & Symptoms of RA |
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Definition
| occurs over weaks to months; Prodrome: weakness, low grade fever, loss of appetite, joint pain, fatigue; Joint pain: hands, wrists, feet, swelling (feels soft & spongy), erythematous & warmth, joint deformities (swan neck), symmetic involvement, functional difficulties (grip, pinch, clasp); Fatige, morning stiffness >30 min; nodules at pressure points; vasculitis; Felty's syndrome (splenomegaly, neutropenia |
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Term
| Diagnostic Criteria for RA |
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Definition
| Must have 4 or more of following & be present for >= 6 wks: morning stiffness in joints > 1 hr, soft-tissue swelling of 3 or more joint areas, swelling of hand joints, symmetric arthritis, rheumatoid nodules, Rf positive, radiographic changes w/ soft-tissue swelling |
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Term
| Epidemiology & Risk Factors of RA |
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Definition
| occurs in 1-2% of population; can occur at any age; females more affected than males; 1) genetic; 2) females > males; 3) + RF; 4) environmental factors |
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Term
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Definition
| rest; OT; PT; weight loss; assistive devices; surgery; emotional support |
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Term
| Salicylates, NSAIDs, COX-2 inhibitors |
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Definition
| MoA: anti-inflammatory via inhibition of PGs, COX enzymes; rapid anti-inflammatory & analgesic effects to help alleviate sx, DOES NOT prevent or slow joint destruction; Place in therapy: used for early pain relief, adjunct to DMARDs for symptom relief; Toxicities: GI bleeding, cardiovascular effects; Monitor: CBC, LFTs, SCr, blood in stool |
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Term
| Corticosteroids - triamcinolone acetonide, methylprednisolone acetate, prednisone |
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Definition
| MoA: anti-inflammatory, immunosuppressive, decreases inflammation & pain symptoms; Place in Tx: treats symptoms, initial adjunct tx until DMARD begins working, chronic low doses for pts failing DMARDs, burst tx for acute flares, Avoid long-term use (SEs); Dosing: IM depot --> provides 2-8 wks of symptom control, Intra-articular: repeated every 3 months, MAX of 3/year; PO: use lowest daily dose possible --> 5mg/day or more should receive osteoporosis prevention (bisphosphonates); Monitor: bone density, BG, BP, eye exam; |
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Term
| Short-term ADRs of Corticosteroid Therapy |
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Definition
| insomnia, HTN, hyperglycemia |
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Term
| Long-term ADRs of Corticosteroid Therapy |
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Definition
| osteoporosis, "moon face", buffalo hump, glaucoma, cataracts |
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Term
| disease-modifying anti-rheumatic drugs (DMARDs) - methotrexate, hydroxychloroquine, sulfasalazine, leflunomide |
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Definition
| decreases or prevents joint damage & maintains joint integrity & function; initiation should not be delayed beyond 3 months id established diagnosis of RA; early tx --> decreases mortality in RA pts |
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Term
| methotrexate (Rheumatrex) |
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Definition
| standard DMARD, 1st line for active dx; MoA: inhibits purine biosynthesis, cytokine production, stimulates adenosine release, decreasing inflammation; Onset: 2-4 wks; best LONG TERM outcome; ADRs: stomatitis, nausea, diarrhea, alopecia, hepatoxicity, folic acid deficiency; Dosing: 7.5-15 mg PO weekly, >15 mg/wk given IM or SC; C/Is: pre-existing liver dx, renal impairment (CrCl <30 mL/min), significant lung dx, EtOH abuse; Pregnancy Cat. X; Monitor: CBC, LFTs monthly x 6 months, then every 1-2 months after |
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Term
| Toxicities of methotrexate |
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Definition
| stomatitis, nausea, diarrhea, alopecia, HEPATOTOXICITY, FOLIC ACID DEFICIENCY, myelosuppression, hepatic fibrosis, cirrhosis, pulmonary infiltrates or fibrosis; Monitor: CBC, LFTs monthly x 6 months, then every 1-2 months after; Take 5 mg folic acid per week |
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Term
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Definition
| MoA: inhibits pyrimidine synthesis, decreasing lymphocyte proliferation & modulation of inflammation; Used alone or in combo w/ MTX; Onset: 1-2 months; ADRs: diarrhea, alopecia, rash, hepatotoxicity, teratogenic (Preg. Cat. X), HA; Dosing: 100 mg daily x 3 days (loading dose), then 20 mg PO daily; Monitor: CBC, LFTs monthly x 6 months, may increase INR if on warfarin |
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Term
| Toxicites of leflunomide [Arava] |
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Definition
| diarrhea, alopecia, rash, HEPATOTOXICITY, teratogenic, HA; Potential: risk of immunosuppression, liver toxicity, teratogenic; Monitor: CBC, LFTs monthly x 6 months |
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Term
| hydroxychloroquine (Plaquenil) |
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Definition
| first-line choice for early or mild dx; Onset: 1-2 months; MoA: antimalarial, inhibits T cells & B cells, release IL-1; ADRs: nausea, diarrhea, ocular changes, macular damage; Dose: 200 mg PO BID; Toxicities: retinal toxicity; Adv: safety profile, minimal monitoring, effective in early mild dx; Disadv: not as efficacious |
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Term
| Toxicities of hydroxychloroquine |
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Definition
| retinal toxicity; Monitor: eyes every 12 months (visual fields) |
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Term
| sulfasalazine (Azulfidine) |
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Definition
| first-line choice for early or mild dx; MoA: suppression of pro-inflammatory cytokines; Onset: 1-2 months; ADRs: N/V, diarrhea, abdominal discomfort, rash, discoloration of urine (yellow-orange), avoid if SULFA-ALLERGY; Dose: 1000 mg PO BID; Toxicities: myelosuppression, leukopenia, LFT elevation; Monitor: CBC every 2-4 wks x 3 months then every 3 months after, Increases INR if on warfarin |
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Term
| Toxicities of sulfasalazine (Azulfidine) |
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Definition
| myelosuppression, leukopenia, LFT elevation; Monitor: CBC q2-4 wks x 3 months then every 3 months after, may INCREASE INR if on warfarin |
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Term
| biologic response modifiers (BRMs) |
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Definition
| genetically engineered protein molecules that target & block pro-inflammatory cytokines TNF-alpha & IL-1; cause risk for serious infection; quicker response than other drugs; Place in therapy: 2nd line in mild-moderate dx, first line in moderate-severe (aggressive) dx, start with TNF antagonist first then consider changing classes; Limitations: cost, infection risk |
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Term
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Definition
| inhibit TNF, decreasing inflammation; Onset: 1-4 wks; Black box warning: INFECTION RISK; MUST be screened for tuberculosis (TB) |
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Term
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Definition
| TNF antagonist; SC injection; Dose: 25 mg twice weekly or 50 mg once weekly; Injection sites: front of middle thighs, abdomen, outer area of arms, upper outer areas of buttocks, ROTATE INJECTION SITES; C/I: moderate-severe CHF |
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Term
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Definition
| chimeric anti-TNF antibody; Administer in physician's office; Dose: 3-10 mg/kg IV infusion over 2 hrs at 0, 2, & 6 wks then every 8 wks after; C/I: moderate-severe CHF; can use with MTX |
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Term
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Definition
| anti-TNF-alpha monoclonal antibody; Pt administers SC injection at home; Dose: 40 mg SC every other week; can use single 1 mL prefilled glass syringe or single-use prefilled pen |
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Term
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Definition
| newly approved TNF antagonist; Pt administers SC injection; Dose: 50 mg once monthly in combo with MTX |
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Term
| certolizumab pegol (Cimzla) |
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Definition
| newly approved TNF antagonist; Pt administers injection; Dose: 400 mg initially at wks 2 & 4, then 400 mg every 4 wks after |
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Term
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Definition
| IL-1 antagonist; Pt administers injection; Dose: 100 mg SC daily (100 mg every other day if CrCl <30 mL/min); comes in prefilled glass syringe; Keep in fridge, protect from light |
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Term
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Definition
| anti-CD20 monoclonal antibody; genetically engineered chimeric murine/human monoclonal Ab directed against CD20 Ag found on surface of normal & malignant B cells; Use in combo w/ MTX for pts w/ moderate-severe active RA who have inadequate response to 1 or more TNF antagonists; Dose: 1000 mg IV followed by 2nd 1000 mg IV dose 2 wks later; Black Box Warning: infusion rxns, tumor lysis syndrome, severe mucocutaneous rxn; AVOID LIVE VACCINES during tx |
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Term
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Definition
| selective co-stimulation modulator; targets T cells by binding to CD80 & CD86 receptors on APC & prevents them from binding CD28 on T cell for optimal T cell activation, reduces release of IL-1, TNF, & IL-6; Administer in physician's office; Dose: 500 mg if pt weights <60 kg, 750 mg if pt 60-100 kg, 1000 mg for pt >100 kg IV at 2 & 4 wks after 1st dose & every 4 wks after, IV infuse over 30 min; ADRs: HA, nausea, upper respiratory tract infections; TB screening recommended |
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