Test 4 MSK

Aurothioglucose drug class

Gold compounds

Aurothioglucose formulation

IM injection

Auranofin drug class

Gold compounds

Auranofin formulation

PO

Gold sodium Thiomalate drug class

Gold compounds

Gold sodium Thiomalate drug formulation

IM injection

Side effects of gold compounds

dermatitis, mouth lesions, pulmonary disorders, nephritis

antidote for gold compound for severe toxicity

chelating agents (dimercaprol and penicillamine)

Gold compound DDI

concurrent administration of drugs that also produce blood dyscrasias

• - phenylbutazone

• - Antimalarial

• - immunosuppressive

Chloroquine drug class

antimalarials

hydroxychloroquine drug class

antimalarials

antimalarials main SE

retinal damage

antimalarial monitoring

baseline, then Q6M

Leflunomide drug class

immunosuppressant

Azathioprine drug class

immunosuppressants

Sulfasalazine drug class

immunosuppressants

Cyclophosphamide drug class

Immunosuppressant

Cyclophosphamide place in therapy

for life threatening RA

Methotrexate drug class

immunosuppressant

Methotrexate DDIs

• - NSAIDS

• - Penicillin

• - Probenecid

Methotrexate Monitoring

liver enzymes

What condition can be worsened in use with the drug Infliximab

CHF

Etanercept (enbrel) drug class

TNF

Infliximab (Remicade) drug class

TNF

adalimumab (Humira) drug class

TNF

rituximab drug class

TNF

Anakinra drug class

IL-1 receptor antagonist

Tocilizumab drug class

IL-6 receptor antagonist

Colchicine place in treatment

Relieve the pain of acute gout and is the drug of choice for acute gouty attack

Colchicine MOA

Retard the inflammation process initiated by the deposition of urate crystal

• - does not lower the serum levels of uric acid

Colchicine main side effect

GI disturbance (development of diarrhea)

Probenecid and sulfinpyrazone MOA

Promote the excretion of uric acid by inhibiting the urate anion exchange transporter (URAT1), decreasing the reabsorption of uric acid, decrease plasma uric acid concentration

Probenecid and sulfinpyrazone DDIs

uricosuric effects are antagonized by salicylates

Allopurinol MOA

decrease uric acid formation by inhibiting xanthine oxidase. Prevent or reduce the formation of urate deposits and the incidence of attacks.

Febuxostat MOA

1st nonpurine selective xanthine oxidase inhibitor. Results in fewer side effects relative to allopurinol

Pegloticase MOA

enhancing the degradation of uric acid

• - enhances the excretion of uric acid by converting it into a more excretable metabolite

Infliximab dosing route and schedule

I.V

Etanercept dosing route and schedule

SubQ once or twice weekly

Adalimumab and Certolizumab dosing route and schedule

SubQ every other week

Golimumab dosing route and schedule

SubQ monthly

TNF alpha serious side effect

Malignancy (Hodgkins or non-Hodgkins)

Anifrolumab MOA

Treat SLE. Binds to IFNAR1/2 blocking the effects of IFN alpha and IFN beta to stimulate the inflammatory response

Anifrolumab most common SE

Upper respiratory tract infections

Prolia place in therapy

First in class FDA approved fully human MAb to treat OA

Prolia MOA

binds to RANKL blocking maturation of pre-osteoclasts into osteoclasts, protecting bone from degradation, and helps counter the progression of osteoporosis

Romosozumab MOA

inhibits sclerostin, a regulatory factor in bone metabolism that inhibits Wnt/beta catenin signaling pathway regulating bone growth

Romosozumab warning

potential increase risk of Myocardial infraction, stroke, and CV death

RA description

systemic chronic autoimmune inflammation disease characteristics by small joint swelling, pain, and stiffness

Characteristics of joint swelling, pain, and stiffness

• - Joint pain is typically symmetrical and polyarticular (more than 1 joint)

• - joint swelling with morning stiffness lasting longer than an hour that improves with use throughout day

RA incidence

50-75 years of age where women are three times more likely to have RA as compared to men however the sex differential becomes less with age

What is the goal for treatment of RA

remission or low disease activity

RA pathophysiology

synovium lines the joint capsule and early in the disease, there is microvascular injury and an increase in the number of synovial lining cells

• This process then begins to protrude into the joint cavity

• - Leads to joint destruction and loss of cartilage

RA extra-articular involvement

Rheumatoid nodules, vasculitis, pulmonary complications, ocular manifestations, and cardiac involvement,

Rheumatoid nodules in RA

Most commonly develop on pressure areas including the elbows and finger joints

Vasculitis in RA

Inflammatory cells enter the vessels walls resulting in destruction of vessels and infarction of tissue distal to the area damage

• - present in patients with long standing disease

Pulmonary complications

some rare, life-threatening complications

• - 50% of patients with RA

Cardiac involvement in RA

pericarditis, myocarditis, pericardial effusion, and premature atherosclerosis

Comorbid Conditions of RA

• - CVD

• - Infections

• - Malignancy

• - Osteoporosis

• 
  

Percent of deaths from CVD in patients with RA

40%

CV events occur about 10 years earlier than those without RA

What is considered a key clinical feature of RA

metacarpophalangeal (MCP) joints and proximal interphalangeal joints of the hands are often the first site

Average length of morning stiffness in an RA patient

lasts longer than one hour

What does the examination of the hands/wrist tell us about the RA patients

able to tell if the patient is having early, late, or progressive disease

what level of rheumatoid factor is more sensitive for RA

2 times the ULN

what is useful about rheumatoid factor in RA patients

patients with synovitis and high pre-test probability

• - after 3 years 80% of patients with show a positive lab test

What lab valve is useful in diagnosis of RA

Anti-citrulline containing proteins (CCP) antibodies

• - 3 times ULN

What lab valves are useful for acute phase reactants (inflammation)

• - Erythrocyte sedimentation rate (ESR)

• - C-reactive protein (CRP)

What lab value is associated with active severe RA

Antinuclear antibody (ANA)

What should taken after a diagnosis of RA

radiographic findings for baseline and periodically to check progression of disease

What will happen to the joint space after 2 years of an RA patient

estimation of 80% of patients with RA of less than 2 years will have joint narrowing on plain radiographs and 2/3 will have evidence of erosions

NSAIDs and corticosteroids place in therapy for RA

work quickly and reduce inflammation however they are not appropriate for long term use

Ideal duration of steroids for RA patient to reduce inflammation

< 3 months at the lowest effective dose

Recommended daily dose for prednisone

15 mg/day

DMARD drug class for Hydroxychloroquine

conventional synthetic disease-modifying antirheumatic drugs

Hydroxychloroquine place in therapy for RA

safest but least effective

When is hydroxychloroquine considered a therapeutic failure

After 6 months of use with not effect on RA

Can you use hydroxychloroquine in pregnant patients

yes

Monitoring that must occur for hydroxychloroquine

ophthalmologic exam at baseline and then annually within 5 years of therapy

DMARD drug class for MTX

conventional synthetic disease-modifying antirheumatic drugs

MTX initiation dose

7.5 mg QW

MTX target dose

15 mg QW

MTX max dose

25 mg QW

Main AE for MTX that limits dose

Gastrointestinal

What is a way to try and help with the GI related SEs for MTX

may split weekly dose and take two separate doses on the same day

• - can even split into 3 doses

How often are you supposed to test liver, renal, and CBC function for MTX

Q4-8W

Contraindication for MTX usage

pregnancy, CKD, liver impairment, and heavy alcohol usage

MTX avoidance for men trying to conceive

avoid use at least 3 months before planned conception

MTX avoidance for women trying to conceive

avoid for 1 menstrual cycle before planned conception; avoid in breastfeeding

MTX DDIs

NSAIDs

MTX onset of action

4-6 weeks

Supplement of folic acid for MTX patients

5 mg of folic acid QW

DMARDs drug class of Leflunomide

conventional synthetic disease-modifying antirheumatic drugs

Leflunomide avoidance for men and women trying to conceive

Men or Women who wish to conceive a child need to D/C the leflunomide ad ingest cholestyramine 8 grams TID for 11 days

Is it appropriate to use biologics and MTX together

Yes, they should be used together

What should be screened prior to starting biologics DMARDs

• - TB

• - pre-existing conditions

• - live vaccine will not be used (must receive all before starting these medications)

Should one DMARD biologics be used over another for RA patients

No, they all have similar efficacy

What is a primary response to TNF agents

lack of initial response to an TNF agent typically indicated and are unlikely to response to another TNF agent

What is a secondary response to TNF agents

initial response but loses efficacy over time. Able to switch to different agent in the same class

DMARDs drug class of Etanercept (Enbrel)

bDMARDs

DMARDs drug class of Infliximab (Remicade)

bDMARDs

Can Remicade be used in monotherapy for RA treatment

Only used in conjunction with MTX