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22 Cards in this Set
- Front
- Back
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Describe the clinical presentation of rheumatoid arthritis:
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Variable disease progression
Any joint can be affected, but the finger joints are the most common Wrists, knees, and toes are also commonly involved Morning stiffness, swelling, redness Extrarticular manifestations: subcutaneous nodules of the skin, vasculitis, pulmonary complications, lymphadenopathy, splenomegaly, eye inflammation, pericarditis/myocarditis, atherosclerosis |
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What agents are available for RA?
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Goal: to have the patient on a DMARD within 3 months of diagnosis and slow disease progression
Patients may require short or long-term NSAIDs or corticosteroids (significant long term risks for both) Milder disease: may be able to live acceptably on the old standard DMARD methotrexate or other older agents such as hydroxychloroquine or sulfasalazine Severe disease: New biologic agents such |
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Ibuprofen contraindications:
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ASA/NSAID allergy
ASA/NSAID induced asthma Pregnancy in third trimester CABG peri-operative pain |
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Prednisone short term side effects (<1 month):
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Fluid retention
Stomach upset Emotional instability (euphoria, mood swings, irritability) Increased appetite/weight gain Insomnia |
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Prednisone long-term side effects:
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Adrenal suppression/Cushing's syndrome
Impaired wound healing Hypertension Hyperglycemia Cataracts Osteoporosis Hypokalemia Growth suppression in children Muscle wasting Acne Menstrual irregularities |
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If used long term, consider assessing this:
Treatment with this: Taper corticosteroids if used for longer than: |
Bone density
Bisphosphonates and optimized calcium/vitamin D 2 weeks |
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Methotrexate brand names:
MOA: |
Rheumatrex
Trexall Folate anti-metabolite that inhibits DNA synthesis |
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Methotrexate black box warnings:
***Many apply with higher doses for cancer*** |
Fetal death/abnormalities
Hepatotoxicity Life-threatening pneumonitis Bone marrow suppression Malignant lymphomas Severe/fatal dermatologic reactions Acute renal failure with high doses |
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Hydroxoychloroquine brand name:
Important adverse effects of hydroxychloroquine: |
Plaquenil
Decreased visual acuity, photophobia, blurred vision Corneal deposits, Macular damage NV ***Obtain eye exam within first year of treatment*** |
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Sulfasalazine can also be provided. What are the key points about sulfasalazine?
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5-aminosalicyclic acid derivative
Sulfa allergy Can cause folate deficiency (may want to supplement) Can cause yellow-orange coloration of skin/urine |
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What other agents can be used in mild RA (non-biologics)?
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Minocycline
Leflunomide Tofacitinib |
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What biologics (TNF Inhibitors) are available/brand names?
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Etanercept (Enbrel)
Adalimumab (Humira) Infliximab (Remicade) Certolizumab Golimumab |
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What biologics (non-TNF Inhibitors) are available?
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Rituximab (Rituxan)
Anakinra (Kineret) Abatacept (Orencia) Toclizumab (Actemra) |
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Black box warning for TNF inhibitors:
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Serious infections (some fatal)
Lymphomas and other malignancies Perform TB test prior to starting therapy ***Contraindicated in Sepsis or severe infection*** |
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What vaccines are recommended prior to therapy initiation with TNF inhibitors?
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Influenza (IM)
Pneumococcal Hepatitis B HPV Herpes Zoster ***Do not give herpes zoster or any live vaccine to a patient already on therapy with TNF inhibitor*** |
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Important point about infliximab:
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Infusion reactions occur: hypotension, fever, chills, pruritis (may benefit from pre-treatment with APAP, antihistamine, steroids)
Delayed sensitivity reaction: 3-10 days after administration (fever, sore throat, rash, myalgia, HA, sore throat) |
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Rituximab (Rituxan) black box warnings:
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Severe and fatal infusion reactions - usually on first dose
Progressive Multifocal Leukoencephalopathy (PML) to due JC virus Tumor lysis syndrome leading to acute renal failure Severe and fata mucocutaneous reaction (SJS, TENs) |
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Medications that can cause drug-induced lupus:
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Procainamide
Hydralazine Isoniazid Quinidine Chlorpromazine Methyldopa Minocycline |
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Clinical manifestation of SLE:
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Most common: Fatigue, fever, anorexia, weight loss, muscle aches, arthritis, rash (butterfly), photosensitivity, joint pain and stiffness
Morbidity/Mortality: Renal, hematologic, neurologic manifestations Lupus nephritis develops in over 50% of patients |
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Treatment of SLE:
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Immunosuppressants
Cytotoxic agents +/- anti-inflammatory agents Strategy is to minimize use of corticosteroids and suppress the immune system |
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Agents used in SLE:
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Anti-malarial agents: hydroxychloroquine (safer - preferred), chloroquine
Prednisone Cytotoxic agents: Cyclophosphamide, Azathioprine (Imuran, Azasan)), Mycophenolate mofetil (cellcept) Biologics: Belimumab (Benlysta) |
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Methotrexate frequency for RA/Psoriasis:
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Once weekly
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