RA- Heeter

Rheumatoid Arthritis is…

• chronic or acute

• bilateral or asymmetrical

• local or inflammatory

Rheumatoid Arthritis is

• CHRONIC

• BILATERAL/SYMMETRIC

• INFLAMMATORY

RA is more common in what gender?

female

RA is typically caused by

genetic prediposition combined with a triggering event

2 risk factors for RA

• family history/ genetic predisposition

• low t levels in men

RA causes chronic inflammation of the synovial tissue lining the joint which leads to

• erosion of bone (osteoporosis) and cartilage

Compared to Osteoarthritis, what is different about the joint stiffness that occurs in Rheumatoid Arthritis?

• joint stiffness can last all day in RA, where with OA the joint stiffness typically lasts for 30 min in the morning

Signs and Symptoms of RA:

• fatigue, weakness, fever, loss of appetite

• tender/swollen joints, nodules, symmetrical joint involvement

Lab tests done on a patients with RA will show elevated…

ESRs and CRPs

What joints are primarily affected by RA? How is this different than OA?

small joints. OA usually affects larger joints.

In order to diagnosis RA, what is a mandatory requirement?

• evidence of definite synovitis in at least one joint

Are RA treatments for controlling or curing the disease?

controlling

Nonpharm treatments of RA:

• rest

• therapy

• assistive devices (cane, walker, etc)

• weight loss

• surgery

For low disease activity, what medication is recommended for initial therapy?

Hydroxychloroquine

For moderate-high disease activity, what DMARD is recommended for initial therapy?

Methotrexate

Guidelines prefer not bridging RA therapy with _____________ if possible.

Glucocorticoids

Bridging therapy may be needed for patients with

severe pain and inflammation

What is the only thing that can slow the progression of RA?

DMARDs

DMARDs stand:

Disease-Modifying Antirheumatic Drugs

For therapy with DMARDs, treatment should begin

as soon as possible, ideally within 3 months since symptoms start

How long does it take to see effects of therapy from DMARDs?

weeks to months

How are NSAIDs used in the treatment of RA?

bridging therapy, NOT AS MONOTHERAPY

Methotrexate belongs to what class of DMARDs

csDMARDs

Guidelines recommend methotrexate should be titrated to >___ mg per week.

15

ADRs of methotrexate

• GI

• Hematologic

• pulmonary

• hepatic

• TERATOGENIC

What supplement should be taken with MTX?

folic acid

Contraindications of MTX

• pregnancy

• chronic liver disease

• blood disorders (leukopenia, thrombocytopenia)

• Immunodeficiency

Hydroxychloroquine main ADRs

• RETINOPATHY

Leflunomide ADRs

• Hepatic (elevated LFTs)

• Hematologic (leukopenia, thrombocytopenia)

• Teratogenic

Sulfasalazine is contraindicated in individuals that have a

sulfonamide or salicylate allergy

list the csDMARDs

• Methotrexate

• Hydroxychloroquine

• Leflunomide

• Sulfasalazine

Which is preferred over the other, csDMARDs or bDMARDs?

csDMARDs

bDMARDs are seperated what 2 classes

1. TNFI

2. non-TNFI

Names of the TNFi agents:

• adalimumab

• etanercept

• golimumab

• certolizumab

• infliximab

Name the route all TNFi agents are administered, with the exception of infliximab.

SUB-Q

What is the route of Infliximab?

IV infusion

Name the frequency of administration for each TNFi agent:

• adalimumab

• etanercept

• golimumab

• certolizumab

• infliximab

• adalimumab- 1-2 weeks

• etanercept- weekly

• golimumab- monthly

• certolizumab-monthly

• infliximab- 8 weeks

TNFi agents should not be used in patients with

moderate-severe heart failure

ALL TNFi agents increase the risk of ___________ and _______________.

infection and malignancies

This specific TNFi agent has increased risk of infusion related reactions

infliximab

How do we prevent infusion related reactions?

premedicate w/ antihistamines, APAPs, Glucocorticoids

Name of non-TNFi agents

• Abatacept

• Tocilizumab

• Rituximab

• Sarilumab

Name the route and frequency for each non-TNFi agent:

• Abatacept

• Tocilizumab

• Rituximab

• Sarilumab

• Abatacept- SUB-Q, weekly

• Tocilizumab- SUB-Q; every 1-2 weekly OR IV; every 4 weeks

• Rituximab- IV; every 24 weeks

• Sarilumab- SUB-Q; every 2 weeks

Abatacept should be used with caution if you have

COPD

A non-TNFi is used when

csDMARDs and TNFi agents are ineffective

ALL non-TNFi agents increase the risk of

serious infections and malignancies

All tsDMARDs are what route?

oral

Names of tsDMARDs:

• JAK Inhibitors

• Tofacitinib

• Upadacitinib

• Baricitinib

What JAK Inhibitor/ tsDMARD increases the risk of CV morbidity/mortality?

Tofacitinib

What 2 bDMARDs have been shown to be safe to use throughout the entire pregnancy?

Etanercept and Certolizumab

To help reduce GI side effects of Methotrexate, what supplement should be taken?

FOLIC ACID