NAPLEX - Rheumatoid arthritis McGraw Hill

Which of the following choices describe the appropriate use of glucocorticoids in the management of rheumatoid arthritis? Select all that apply.

A

Bridge therapy

B

Long-term, low dose

C

Short-term, high dose

D

Long-term, high dose

A, B, C

Glucocorticoids may be used as bridge therapy while awaiting the onset of action of disease-modifying antirheumatic drugs (DMARDs) given their rapid onset and ability to reduce pain and inflammation. Long-term, low dose glucocorticoids are recommended if patients fail to achieve disease control on DMARDs. Short-term, high dose glucocorticoids may be required to regain control of symptoms during disease flares.

Which of the following combinations would NOT be appropriate for the management of rheumatoid arthritis? Select all that apply.

A

Leflunomide + methotrexate

B

Methotrexate + golimumab

C

Hydroxychloroquine + sulfasalazine + methotrexate

D

Methotrexate + etanercept + tocilizumab

E

Methotrexate + infliximab + baricitinib

D, E

Biologic disease-modifying antirheumatic drugs (DMARDs) should not be used in combination with one another or with targeted synthetic DMARDs such as the Janus kinase (JAK) inhibitors due to the increased risk of serious infections associated with the use of these agents. In option d, etanercept and tocilizumab are both biologic DMARDs which are not recommended for use in combination. In option e, infliximab is a biologic DMARD and baricitinib is a targeted synthetic DMARD, and they should not be used in combination. Though methotrexate may be used in combination with biologic DMARDs, the biologic DMARDs should not be used in combination.

It is appropriate to use conventional synthetic DMARDs in combination.

It is appropriate to use methotrexate in combination with biologic or targeted synthetic DMARDs. ACR guidelines recommend that biologics be used in combination with methotrexate when possible due to the superior efficacy of the combination over biologic monotherapy.

Triple therapy with conventional synthetic DMARDs is not contraindicated. Though monotherapy with DMARDs is recommended in the guidelines, they note that triple therapy may be preferable in patients who need rapid short-term benefits to resume work activities and are willing to accept the additional risk of adverse effects.

A patient with rheumatoid arthritis is averse to needles. Which of the following medications used in the treatment of rheumatoid arthiritis (RA) are oral formulations? Select all that apply.

A

Otrexup

B

Plaquenil

C

Simponi

D

Keyzara

E

Olumiant

B, E

Plaquenil (hydroxychloroquine) is a conventional synthetic disease-modifying antirheum (csDMARDs) dosed by mouth daily. All of the csDMARDs (methotrexate, leflunomide, and sulfasalazine in addition to hydroxychloroquine) are available as oral formulations. Olumiant (baricitinib) is a Janus kinase (JAK) inhibitor that is also administered by mouth daily. The other JAK inhibitors (tofacitinib, or Xeljanz, and upadacitinib, or Rinvoq) are also administered orally.

Otrexup is a subcutaneous formulation of methotrexate. Though methotrexate is available orally, Otrexup and Rasuvo are subcutaneous formulations.

Answer c is incorrect. Simponi, or golimumab, is a TNF inhibitor. It is available as a self-administered subcutaneous injection (Simponi) or an intravenous (IV) infusion (Simponi Aria).

Answer d is incorrect. Keyzara (sarilumab) is an interleukin (IL)-6 receptor inhibitor that is available as a self-administered subcutaneous injection.

Which of the following are true regarding the storage and administration of Humira?

A

Store at room temperature.

B

Administer via intravenous infusion.

C

Allow to reach room temperature before use.

D

Roll between hands to ensure dissolution of particulate matter.

C

Humira (adalimumab) is available as prefilled syringes or a pen for administration subcutaneously. The products should be allowed to come to room temperature before subcutaneous injection as this may decrease injection pain.

Answer a is incorrect. The product should be stored at 2°C to 8°C (36°F to 46°F). It should not be frozen. It can be kept at room temperature for a maximum of 14 days if necessary.

Answer b is incorrect. Humira (adalimumab) is administered via subcutaneous injection and is not available as an IV infusion. Infliximab and golimumab are tumor necrosis factor (TNF)-inhibitors which are available as intravenous injections.

Answer d is incorrect. Humira (adalimumab) should be discarded if they contain particulate matter, and there is no recommendation to roll or shake the product.

Which of the following are contraindications to receiving methotrexate? Select all that apply.

A

Severe hepatic impairment

B

Creatinine clearance (CrCl) of 50 mL/min

C

Pregnancy

D

Latent tuberculosis infection

A, C

.Methotrexate is contraindicated in patients with chronic liver disease and carries a black box warning for hepatotoxicity. Methotrexate is also teratogenic and should be avoided in women who are pregnant or may become pregnant.

Answer b is incorrect. Methotrexate should be avoided in patients with very poor renal function (CrCl <30 mL/min) due to an increased risk of accumulation and therefore toxicities. Some guidelines recommend administering 50% of the dose for CrCl <50 mL/min. Serum creatinine should be monitored regularly, but a CrCl of 50 mL/min is not a contraindication to use.

Answer d is incorrect.Methotrexate should be avoided in patients with active tuberculosis, but there is not a contraindication to its use in patients with latent infection. Patients with an active bacterial infection, ongoing herpes zoster infection, or life-threatening fungal infection should not take methotrexate.

Which of the following medications is an anti-tumor necrosis factor (TNF) biologic disease-modifying antirheumatic drug (boDMARD)?

A

Tofacitinib

B

Tocilizumab

C

Rituximab

D

Golimumab

D

.Golimumab is an anti-TNF agent. It is a human IgG1 monoclonal antibody specific for human TNF-α.

Answer a is incorrect.Tofacitinib (XELJANZ) is a nonbiologic DMARD that acts through the inhibition of Janus kinase.

Answer b is incorrect.Tocilizumab (ACTEMRA) is a humanized monoclonal antibody that selectively antagonizes interleukin-6 receptors.

Answer c is incorrect.Rituximab does not work by interfering with the actions of TNF-α. This drug is a monoclonal antibody that targets the CD20 antigen on B-lymphocytes.

PW is a 50-year-old man with a past medical history of rheumatoid arthritis and heart failure. He has poor control of his rheumatoid arthritis on methotrexate alone, and his physician would like to add a biologic disease-modifying antirheumatic drug (DMARD) to his regimen. Which of the following would be most appropriate to add to PW's regimen?

A

Enbrel

B

Simponi

C

Remicade

D

Orencia

D

Enbrel (etanercept), Simponi (golimumab), and Remicade (infliximab) are all anti-tumor necrosis factor (TNF) biologic DMARDs. As a class, the TNF inhibitors are associated with new-onset or worsening heart failure due to direct myocardial toxicity or exacerbation of underlying myocardial dysfunction, and it is recommended to use caution in patients with moderate-to-severe heart failure. Non-TNF inhibitor therapy is preferable in these patients.

Answer d is correct. Non-TNF inhibitor therapy is preferred in patients with heart failure as the TNF inhibitors are associated with worsening heart failure and should be used with caution in patients with moderate-to-severe heart failure. Orencia (abatacept) is a non-TNF biologic DMARD that does not carry specific warnings related to heart failure. CD80/86

Which of the following may be useful in the symptomatic management of rheumatoid arthritis but does not reduce overall disease progression?

A

Methotrexate

B

Indomethacin

C

Infliximab

D

Abatacept

B

.Indomethacin is a nonsteroidal anti-inflammatory drug (NSAID) that may be used for control of pain and inflammation while awaiting the onset of disease-modifying antirheumatic drug (DMARD) action or during disease flares; however, it does not slow the progression of joint erosion or overall disease progression.

Answers a, c, and d are incorrect. Methotrexate, infliximab, and abatacept are all DMARDs which by definition are disease-modifying and prevent progressive joint damage and erosion. Methotrexate is a conventional synthetic DMARD (csDMARD) while infliximab and abatacept are targeted biologic DMARDs (boDMARDs) (infliximab being a tumor necrosis factor (TNF) inhibitor and abatacept being a non-TNF inhibitor).

Which of the following are considered hazardous drugs per the 2016 NIOSH List of Antineoplastic and Other Hazardous Drugs in Healthcare Settings? Select all that apply.

A

Methotrexate

B

Leflunomide

C

Tofacitinib

D

Infliximab

A, B, C

.Methotrexate is an antineoplastic agent with the manufacturer's safe-handling guidance. Leflunomide and tofacitinib are non-antineoplastic drugs that meet one or more of the NIOSH criteria for a hazardous drug (leflunomide due to teratogenicity, risk of severe liver injury, and carcinogenicity; tofacitinib due to boxed warning for malignancies). The other Janus kinase (JAK) inhibitors (baricitinib, upadacitinib) were not on the market at the time the 2016 NIOSH List was published.

Answer d is incorrect.Infliximab is not considered a hazardous drug per the 2016 NIOSH List.

DR is a 65-year-old female patient with rheumatoid rthiritis (RA), which is being treated with methotrexate and Cimzia. It is November, and her doctor would like to know if DR can receive the flu vaccine. What would you recommend?

A

DR should receive the Fluzone intramuscular vaccine.

B

DR should receive the Flumist intranasal vaccine.

C

DR should receive prophylactic oseltamivir.

D

DR should not receive any vaccines while taking Cimzia for RA.

A

Patients who are taking disease-modifying antirheumatic drugs (DMARDs) (biologic or nonbiologic) should be vaccinated annually against influenza. Fluzone is an inactivated influenza vaccine, so it is safe to administer in patients taking biologic agents.

Answer b is incorrect. The Flumist intranasal vaccine is a live-attenuated vaccine (LAIV). LAIVs are not recommended in patients on biologic DMARDs, such as Cimzia, due to the risk of infection.

A physician prescribes Arava 100 mg daily for 3 days as a loading dose for her patient who has been newly diagnosed with rheumatoid arthiritis (RA). The correct maintenance dose for this medication would be:

A

Methotrexate 20 mg daily

B

Methotrexate 20 mg weekly

C

Leflunomide 20 mg daily

D

Leflunomide 20 mg weekly

C

.Leflunomide is the generic name for Arava. After a loading dose of 100 mg daily given for 3 days, a standard maintenance dose of 20 mg daily thereafter may be used.

Answers a, b, and d are incorrect.Methotrexate is dosed weekly. Various branded methotrexate products are available, including Trexall, Otrexup (autoinjector), and Rheumatrex.

patient has failed to respond adequately to methotrexate monotherapy after 3 months. Their physician would like to add a tumor necrosis factor (TNF) inhibitor which can be self-administered subcutaneously. Which of the following medications would fulfill these criteria? Select all that apply.

A

Orencia

B

Xeljanz

C

Cimzia

D

Remicade

E

Rituxan

F

Humira

C, F

Cimzia (certolizumab pegol) and Humira (adalimumab) are anti-TNF agents that are both available as self-administered subcutaneous injections. Humira is available as both a pre-filled syringe and a pen. Cimzia is available as a pre-filled syringe, but not a pen. Enbrel (etanercept) and Simponi (golimumab) are also TNF inhibitors available as self-administered subcutaneous injections. Golimumab is also available as an IV infusion (Simponi Aria).

Answer a is incorrect. Orencia (abatacept) is not an anti-TNF agent. It is an immunoglobulin protein agent that inhibits T-lymphocyte activation through the blockage of its stimulation by antigen-presenting cells. It is given as an IV infusion at weeks 0, 2, and 4 and then every 4 weeks thereafter.

Answer b is incorrect. Xeljanz (tofacitinib) is a Janus kinase (JAK) inhibitor, not a TNF inhibitor. It is administered orally.

Answer d is incorrect. Remicade (infliximab) is an anti-TNF agent, but it is not available as a subcutaneous injection. Remicade is available as an IV infusion given at weeks 0, 2, and 6 and then every 8 weeks thereafter.

Answer e is incorrect. Rituxan (rituximab) is not an anti-TNF agent. It is a monoclonal antibody that targets the CD20 antigen on B lymphocytes. It is administered intravenously as two infusions 2 weeks apart.

DB is a 50-year-old patient with rheumatoid arthritis and severe hepatic impairment; current aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are two times the upper limit of normal (ULN). Which of the following would be contraindicated for the treatment of DB's rheumatoid arthritis? Select all that apply.

A

Hydroxychloroquine

B

Leflunomide

C

Etanercept

D

Tocilizumab

E

Tofacitinib

B, D, E

.Leflunomide is contraindicated in chronic liver disease and carries a boxed warning for hepatotoxicity. Tocilizumab (and sarilumab) are contraindicated if AST or ALT > 1.5 × ULN and are associated with hepatotoxicity. Tofacitinib (as well as the other JAK inhibitors, baricitinib and upadacitinib) is contraindicated in severe hepatic impairment (CHECK)

Answer a is incorrect.Hydroxychloroquine does not carry any contraindications within its drug labeling and is typically well-tolerated.

Answer c is incorrect.Etanercept and the other tumor necrosis factor (TNF) inhibitors are not contraindicated in patients with hepatic dysfunction.

Boxed warnings for tofacitinib include which of the following? Select all that apply.

A

Serious infections

B

Malignancies

C

Thrombosis

D

Infusion-related reactions

E

Severe skin reactions

A, B, C

All of the Janus kinase (JAK) inhibitors carry boxed warnings for serious infections (including tuberculosis, invasive fungal infections, and bacterial or viral infections due to opportunistic pathogens), malignancies (including lymphoma and cancer), and thrombosis (including pulmonary embolism, deep vein thrombosis, and arterial thrombosis). The thrombosis warning for tofacitinib clarifies that the risk appears to be increased primarily with 10 mg twice daily (in patients who are ≥ 0 years of age with ≥1 cardiovascular [CV] risk factor), which is not the approved dosing for rheumatoid arthritis. The other JAK inhibitors carry warnings for thrombosis regardless of dose, age, or risk factors.

Answers d and e are incorrect. Tofacitinib is an oral agent and is not associated with infusion-related reactions (rituximab carries a boxed warning for fatal infusion-related reactions). Severe skin reactions are not routinely observed with JAK inhibitors. Methotrexate carries a boxed warning for severe skin reactions.

A loading dose may be prescribed when this medication is initiated for rheumatoid arthritis to achieve steady state more rapidly due to its prolonged half-life.

A

Methotrexate

B

Leflunomide

C

Etanercept

D

Baricitinib

B

.Leflunomide 100 mg by mouth daily for 3 days may be used to achieve steady state more rapidly. Some physicians may not utilize a loading dose due to additional adverse effects such as gastrointestinal (GI) toxicity. The elimination half-life of leflunomide is approximately 14 days, so without a loading dose, it may take approximately 2 months to achieve steady state.

Answers a, c, and d are incorrect.Methotrexate (a conventional synthetic disease-modifying antirheumatic [csDMARD]), etanercept (an anti-tumor necrosis factor [TNF] targeted biologic disease-modifying antirheumatic [boDMARD]), and tofacitinib (a Janus kinase [JAK] inhibitor targeted synthetic disease-modifying antirheumatic [tsDMARD]) require a loading dose. Methotrexate is dosed at 7.5 to 15 mg once weekly with doses gradually increased; etanercept is dosed at 50 mg once weekly or 25 mg twice weekly, and baricitinib is dosed 2 mg by mouth once daily.

Patient JJ, a 50-year-old Caucasian female, presents to her primary care physician with a chief complaint of generalized fatigue and malaise over the past 2 months. She also describes having stiffness in her fingers each morning upon waking lasting at least 1 to 2 hours and notes that her fingers and toes (right and left) sometimes appear to be swollen. The physician orders a basic metabolic panel, complete blood count (CBC), rheumatoid factor, and X-rays of the hands and feet. Which of the following medications are appropriate to consider in the initial medication regimen for JJ based on her disease activity and duration of symptoms?

A

Ibuprofen

B

Prednisone

C

Methotrexate

D

Etanercept

A, B, C

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen possess analgesic and anti-inflammatory effects, which provide RA symptom relief. However, they do not affect the underlying disease process of RA, thus they should not be used as the sole treatment.

Answer b is correct. Corticosteroids such as prednisone possess anti-inflammatory and immunosuppressive effects which improve symptoms in RA. They are recommended for "bridge therapy" to provide symptomatic relief until the full onset of disease-modifying antirheumatic drug (DMARD) therapy or in short bursts for treatment of RA exacerbation. Additionally, long-term, low-dose maintenance therapy may be used in patients refractive to DMARD or NSAID therapy. Long-term and high-dose corticosteroid treatment should be avoided due to the risk of long-term side effects.

Answer c is correct. DMARDs reduce and prevent joint damage and preserve joint function. They should be initiated early, within the first 3 months of the onset of symptoms. DMARDs take weeks to months for full onset of effect, thus NSAIDs and corticosteroids will be needed for symptom relief. Methotrexate is the preferred DMARD.

Answer d is incorrect. DMARD monotherapy (preferably with methotrexate) is recommended first-line. Biologic DMARDs are typically reserved for patients who have moderate to severe RA and who have an inadequate response to one or more DMARDs.

Patient JJ, a 50-year-old Caucasian female, presents to her primary care physician with a chief complaint of generalized fatigue and malaise over the past 2 months. She also describes having stiffness in her fingers each morning upon waking lasting at least 1 to 2 hours and notes that her fingers and toes (right and left) sometimes appear to be swollen. The physician orders a basic metabolic panel, complete blood count (CBC), rheumatoid factor, and X-rays of the hands and feet. JJ was diagnosed with rhematoid arthiritis (RA) with moderate-disease activity and has been exhibiting symptoms for about 2 months. Which of the following nonpharmacologic therapies may be recommended to JJ? Select all that apply.

A

Heat therapy

B

Physical therapy

C

Weight reduction

D

Cold therapy

ALL

Nonpharmacologic therapy such as heat or cold therapy, physical therapy, and weight reduction as well as education, emotional support, rest, occupational therapy, and surgery (for severe cases) can be used to improve symptoms and maintain joint function in RA.

Which of the following is the correct mechanism of action for etanercept (Enbrel)?

A

Monoclonal antibody which targets the CD20 antigen on B-lymphocytes

B

Tumor necrosis factor (TNF)-α inhibitor

C

Immunoglobulin protein which inhibits T-lymphocytes

D

Dihydrofolate reductase inhibitor

B

A patient presents to your pharmacy and asks why folic acid 1 mg PO daily is often recommended along with methotrexate therapy?

A

Folic acid can prevent renal toxicity caused by methotrexate.

B

Folic acid can prevent gastrointestinal toxicity caused by methotrexate.

C

Most people with rheumatoid arthritis have folic acid deficiencies.

D

Folic acid will enhance the efficacy of methotrexate.

B

Folate (the naturally occurring form of folic acid, which is also known as vitamin B9) is necessary for the synthesis and maintenance of new cells. Methotrexate is a folic acid antagonist and will deplete the body's folate stores by inhibiting the enzyme dihydrofolate reductase. Since many fast-dividing cells (such as those that line the gastric mucosa) utilize folate during their replication, a deficiency of folic acid will inhibit their growth and proliferation. For this reason, it is recommended that patients on methotrexate take 1 mg daily of folic acid.

Answer a is incorrect. Although methotrexate may cause renal toxicity, folic acid is not indicated to reduce the nephrotoxic effects of the drug.

Answer c is incorrect. Patients who have rheumatoid arthritis are not also likely to have a folate deficiency.

Answer d is incorrect. While folic acid has not been shown to decrease the efficacy of methotrexate, it will not enhance the efficacy of methotrexate.

Which of the following medications used in the treatment of rheumatoid arthritis is hepatically metabolized by CYP3A4?

A

Methotrexate

B

Sulfasalazine

C

Upadacitinib

D

Sarilumab

C

The Janus kinase (JAK) inhibitors (tofacitinib, baricitinib, and upadacitinib) are all hepatically metabolized by CYP3A4. Tofacitinib is also metabolized by CYP2C19. Upadactinib should not be used in combination with strong 3A4 inhibitors.

Answers a, b, and d are incorrect. Methotrexate is partially metabolized by intestinal flora and also intracellularly metabolized, and sulfasalazine is cleaved by bacteria in the colon and further metabolized by acetylation and hydroxylation. The metabolic pathway of sarilumab has not been described, but as a monoclonal antibody, it is thought to be broken down into peptide fragments in the same mechanism as endogenous immunoglobulin G (IgG).

Which of the following agents is dosed weekly?

A

Methotrexate

B

Leflunomide

C

Hydroxychloroquine

D

Sulfasalazine

A

.Methotrexate is dosed weekly and is available orally and for intramuscular, subcutaneous, and intravenous injection. Weekly dosing of the drug appears to cause less gastrointestinal toxicity (less damage to the mucosa) and fewer side effects than daily dosing. It is important to be vigilant when reviewing methotrexate prescriptions to verify proper dosing frequency. Emphasize to your patients that this medication is taken on a weekly, not daily, basis to minimize the risk of overdose.

All others daily except sulfasalazine is dosed twice daily or three times daily.

Patient JJ, a 50-year-old Caucasian female, presents to her primary care physician with a chief complaint of generalized fatigue and malaise over the past 2 months. She also describes having stiffness in her fingers each morning upon waking lasting at least 1 to 2 hours and notes that her fingers and toes (right and left) sometimes appear to be swollen. The physician orders a basic metabolic panel, complete blood count (CBC), rheumatoid factor, and X-rays of the hands and feet. Which of JJ's complaints could lead the physician to a diagnosis of rheumatoid arthritis (RA)? Select all that apply.

A

Complaints of morning stiffness

B

Swelling in fingers

C

Duration of symptoms

D

Swelling in toes

all

All of the above are consistent with classic signs and symptoms of RA, though only 60% to 70% of RA patients will test positive for rheumatoid factor. Radiological changes such as joint erosions or decalcification are other classic symptoms.

A patient with rheumatoid arthritis is averse to needles. Which of the following medications used in the treatment of rheumatoid arthiritis (RA) are oral formulations? Select all that apply.

A

Otrexup

B

Plaquenil

C

Simponi

D

Keyzara

E

Olumiant

B, E

Plaquenil (hydroxychloroquine) is a conventional synthetic disease-modifying antirheum (csDMARDs) dosed by mouth daily. All of the csDMARDs (methotrexate, leflunomide, and sulfasalazine in addition to hydroxychloroquine) are available as oral formulations. Olumiant (baricitinib) is a Janus kinase (JAK) inhibitor that is also administered by mouth daily. The other JAK inhibitors (tofacitinib, or Xeljanz, and upadacitinib, or Rinvoq) are also administered orally.

Answer a is incorrect. Otrexup is a subcutaneous formulation of methotrexate. Though methotrexate is available orally, Otrexup and Rasuvo are subcutaneous formulations.

Answer c is incorrect. Simponi, or golimumab, is a TNF inhibitor. It is available as a self-administered subcutaneous injection (Simponi) or an intravenous (IV) infusion (Simponi Aria).

Answer d is incorrect. Keyzara (sarilumab) is an interleukin (IL)-6 receptor inhibitor that is available as a self-administered subcutaneous injection.

Which of the following adverse reactions is common to all biological disease-modifying antirheumatic drug (DMARD) agents?

A

Bone marrow suppression

B

Heart failure exacerbation

C

Increased susceptibility to infection

D

Teratogenicity

C

All biological DMARD agents suppress the immune system by affecting various immunological components. Consequently, the body becomes more vulnerable to infection. Patients on biological DMARD therapy should be assessed regularly for any signs of infection. Localized signs may include unhealed or draining skin wounds, pain, swelling, or heat at the site of infection. Systemic infection symptoms include fever, chills, and other cold- or flu-like symptoms.

Answer a is incorrect. Bone marrow suppression is not an expected side effect of biological DMARD agents.

Answer b is incorrect. Anti-tumor necrosis factor (TNF)-α agents are contraindicated in patients with New York Heart Association Class III or IV heart failure, but as a class, biological DMARDs have not been shown to cause or exacerbate heart failure.

Answer d is incorrect. Biological agents were historically assigned pregnancy category B and C by the US Food and Drug Administration. Though such ratings are no longer used for newly approved therapies, category B designation indicated that either animal reproduction studies have failed to demonstrate a risk to the fetus and there are no well-controlled studies in pregnant women or that animal studies have shown adverse effects but they have not been confirmed in controlled studies in pregnant women. Category C assignment meant that animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but the potential benefits may warrant the use of the drug in pregnant women despite the potential risks.

AA is a 34-year-old woman who regularly picks up her Arava and Ortho Tri-Cyclen refills at your pharmacy. Today she arrives to pick up her Arava and states she will no longer need her Ortho Tri-Cyclen as she and her husband have decided to start trying to have a baby. Which of the following would be an appropriate response to this information?

A

Continue Arava at a lower dose when she becomes pregnant, as rheumatoid arthritis (RA) typically improves during pregnancy.

B

Change Arava to methotrexate during pregnancy.

C

Discontinue Arava 2 to 3 weeks before trying to get pregnant.

D

Undergo drug elimination with cholestyramine before trying to get pregnant.

D

Arava (leflunomide) is contraindicated during pregnancy based on data suggesting an increased risk for fetal death and teratogenic effects. Due to its active metabolite and long half-life, patients wishing to become pregnant should undergo the drug elimination procedure with cholestyramine (8 g cholestyramine three times daily for 11 days; plasma levels M1 <0.02 mg/L must be verified on two separate occasions at least 14 days apart).

Arava (leflunomide) must be discontinued approximately 3 months before conception to allow for a drug elimination and washout period.

A 45-year-old patient with rheumatoid arthritis (RA) presents with a prescription for hydroxychloroquine, which is being prescribed in addition to methotrexate for management of her RA. You advise her that she will need to have which of the following performed routinely while on hydroxychloroquine?

A

Ophthalmological screenings

B

Liver function tests (LFTs)

C

Lipid panels

D

Tuberculin skin test

A

.Hydroxychloroquine has been associated with various types of ocular toxicity including blurred vision, diminished visual acuity, abnormal color vision, and retinopathy. It appears that the toxicities are specific to the cornea and the macula of the eye. Retinal damage is dose-related and sometimes irreversible. Patients taking hydroxychloroquine are recommended to have an ophthalmology examination within 1 year following initiation of the drug. High-risk patients (those who take a daily dose >6.5 mg/kg, have renal impairment, have been taking the drug for more than 10 years, or have taken a cumulative dose of 200 g) should have the examination repeated every 6 to 12 months, while low-risk patients may repeat the examination approximately every 5 years.

Though hydroxychloroquine can at times be associated with abnormalities in LFTs, a routine monitoring schedule for LFTs is not recommended in the package insert. Routine monitoring of LFTs is recommended for other disease-modifying antirheumatic drugs (DMARDs) such as methotrexate, leflunomide, the interleukin (IL)-6 receptor inhibitors (tocilizumab, sarilumab), and the Janus kinase (JAK) inhibitors (tofacitinib, baricitinib, upadacitinib).

Answer c is incorrect. Regular lipid panels are not recommended during treatment with hydroxychloroquine.

Answer d is incorrect. Tuberculosis screening is required before initiation of any of the biologic or targeted synthetic DMARDs, but it is not required before initiation of hydroxychloroquine.