Th II Exam 4

INACTIVE thyroid hormone =

T4 thyroxine

ACTIVE thyroid hormone =

T3 triiodothyronine

Thyroid hormones are mostly _________ (99% inactive)

protein bound

HYPOthyroidism lab values →

-T4, +TSH

HYPERthyroidism lab values →

+T4, -TSH

HYPOTHYROIDISM

-T4, +TSH

1. #1 cause in iodine-sufficient areas →

2. #1 cause worldwide →

3. s/s → “COLD FACTS”

1. hashimoto’s

2. iodide deficiency or excess 

3. cold intolerance 

4. overweight

5. low mood

6. dry skin

7. fatigue

8. abnormal heavy menses

9. constipation

10. thinning hair

11. slow HR

DRUG-ASSOCIATED CAUSES OF HYPOTHYROIDISM (ITALC)

*can also cause hyperthyroidism

1. interferons*

2. tyrosine kinase inhib

3. amiodarone*

4. lithium

5. carbamazepine

HYPOTHYROIDISM TREATMENT

1. ________ is the drug of choice

2. Dose → ____ mcg/kg/day, may initiate lower

3. Titrate every ____ until TSH normalizes

4. Use _____ formulation/product each time!!

5. Counseling →

6. Side effects →

7. Drug interxns: DEC absorption → 6

8. INC T4 metabolism (higher concentration) → 4

9. DEC effectiveness → 1

10. May increase the effects of _________

1. levothyroxine (T4)

2. 1.7

3. 6-8w

4. same

5. take 30-60m b4 breakfast OR at bedtime (3h+ after evening meal); empty stomach

6. hyperthyroidism, cardiac

7. cations, orlistat, BAS, PPIs, H2RAs, sucralfate

8. rifampin, phenytoin, phenobarbital, SSRIs

9. beta blockers

10. anticoagulants

LEVOTHYROXINE SPECIAL POPULATIONS

1. -

2. -

3. Dosing ____ mcg/kg/day

4. Doses ____ are associated w +fracture risk in adults >70 yo

1. pre-existing cardiac/older adults 

2. osteopenia/osteoporosis 

3. 1.6

4. >93 mcg/day

HYPOTHYROIDISM: OTHER AGENTS → 3

NOT recommended over levothyroxine!!

1. Cytomel/liothyronine

2. Armour Thyroid

3. Liotrix/Thyrolar

#1 cause of HYPERthyroidism

Graves’ disease

HYPERthyroidism s/sx → “SWEATING”

1. Sweating

2. *weight loss (despite +appetite, CARDINAL SIGN)

3. emotional instability

4. appetite +

5. tremor

6. intolerance to heat, irregular HR+

7. nervousness

8. goiter 

DRUG-ASSOCIATED CAUSES OF THYROTOXICOSIS

longest lasting (month-yrs) to shortest (weeks-months)

1. amiodarone

2. lithium

3. IFNa

4. IL2

5. iodinated contrast

6. radioactive iodine

Subacute Thyroiditis

mod-sev pain in the thyroid that radiates to the ears, jaw, or throat after viral infection

1. Presentation? (malaise, low grade fever, pharyngitis sx, fatigue)

2. ____ for mild pain

3. INTENSE pain, fever, and malaise → ______ 40 mg daily x 1-2w with gradual taper over 2-4w

4. Treatment →

1. prodrome sx

2. NSAIDs

3. prednisone

4. propranolol or nadolol

GRAVES’ DISEASE

1. _____ (bulging eyes)

2. Most common tx →

3. ^ Contraindications →

1. exophthalmos 

2. I131 ablation

3. preg/lactation, thyroid cancer

GRAVES’ DISEASE (cont.)

1. Tx option 2 (offers control, not a cure)

2. DRUG OF CHOICE* →

3. Other drug option →

4. Contraindications → 2

5. Monitoring → BASELINE (4)

6. Monitoring → subsequent

7. Length of therapy: _________ if TSH and TRAb levels are normal 

1. thioamides

2. methimazole → 2nd/3rd tri

3. PTU (propylthiouracil) → 1st tri

4. neutrophil <500, liver >5x ULN

5. CBC, liver, TSH, free T4

6. free T3+T4 q 4-8w, CBC w febrile illness 

7. 12-18m

METHIMAZOLE VS PTU

1. _________ than PTU → may be given DAILY

2. _________ compared to PTU

1. t1/2 longer

2. less hepatotox

PTU → ***BBW for severe _____ injury and acute failure

liver

SUBCLINICAL HYPERTHYROIDISM

asymptomatic with normal T4 and -TSH

Tx: wait _____ and check TSH again

1 yr

PATHOPHYSIOLOGY GOUT

1. ________ is the byproduct of the breakdown of purines

2. Most common cause

3. ^ can crystallize when serum levels are ____ mg/dL

4. Crystalls deposit into ____ and _____ triggering inflammatory response

1. uric acid

2. -urate excretion (kidneys)

3. >6.8

4. joints, cartilage

GOUT CLINICAL PRESENTATION

1. _________

2. labs → 2

3. complications → 3

1. monoarticular arthritis

2. +uric acid, leukocytosis

3. nephrolithiasis, gouty neuropathy, tophi

RISK FACTORS FOR DEVELOPING GOUT

1. Conditions → 6

2. Lifestyle → 4

3. MEDICATIONS → 5

1. alcoholism, DM, CVD, dyslipidemia, hypothyroid, renal 

2. obesity, +animal purine intake, high fructose foods/drinks, alc

3. thiazides, low-mod dose ASA, vit B12, cyclosporine, levodopa 

GOUT PHARM MANAGEMENT

1. Acute tx →

2. May use ____ as adjuvant tx

3. Chronic tx →

4. NOT 1ST LINE tx →

1. NSAIDs, corticosteroids, colchicine IF attack began w/in 36h

2. ice

3. XO inhib (allopuriol, febuxostat), uricosurics (probenecid)

4. biologics

GOUT MEDICATIONS

1. ______ blocks formation of uric acid

2. ______ breaks down uric acid

3. ______ +excretion of uric acid in urine 

4. _____________ -degree of inflammation

1. allopurinol

2. uricase

3. probenecid

4. NSAIDs, colchicine, steroids 

ACUTE GOUT ATTACK

Initiate pharmacologic tx within ____ of acute gout onset for optimal results

Ongoing ULT therapy should NOT be interrupted

24h

WHEN TO USE MONOTHERAPY? → 2

colchicine, NSAIDs, corticosteroids

1. mild-mod pain

2. attack of 1/few small joints/1-2 large joints

NSAIDS/COX-2 inhibitors

AVOID FOR … (7)

1. eGFR <60

2. hyperK

3. GI ulcer

4. poorly controlled HTN

5. mod/sev CHF

6. cirrhosis

7. anticoagulation

ORAL CORTICOSTEROIDS

AVOID FOR … (3)

*MONOTHERAPY NOT REC

1. brittle DM

2. recent surgery w unhealed wound

3. suspected concurrent infxn 

INTRAARTICULAR CORTICOSTEROIDS

AVOID FOR … (4)

1. >2 affected joints

2. small joints in hands/feet

3. lack of timely access to provider 

4. suspected joint infxn 

COLCHICINE (COLCRYS)

1. MOA: inhib inflam response by inhibiting ______ and _______

2. Toxicities: NV, myalgia, _______, _______, ______

3. AVOID FOR … (2)

4. Drug interactions → INCREASE colchicine levels

1. MT polymerization, inflam mediators

2. diarrhea, neuropathy, BMS

3. CrCL<10, kidney/hepatic impair

4. CYP/Pgp inhib

WHEN TO USE COMBINATION TX?

1. For _____ pain or ________ attack

2. Combination therapy →

3. WHY AVOID NSAIDS + ORAL STEROIDS?

1. sev, polyarticular

2. colchicine+NSAIDs, colchicine+oral steroids

3. GI tox

STRONG RECOMMENDATION FOR URATE-LOWERING THERAPY (ULT)

1. ______ subcutaneous tophi

2. ________ damage attributable to gout

3. freq gout flares ______

4. Conditional rec for ULT →

1. 1+

2. radiographic

3. >/= 2 a yr

4. >1 flare but infreq (<2 a yr), 1st flare +CKD or urolithiasis 

CHRONIC GOUT MANAGEMENT (ULT)

1. 1st line =

2. 2nd line =

3. last line =

1. allopurinol > febuxostat

2. probenecid

3. peloticase, rasburicase

ULT TX GOALS

serum urate goal of ______, assess every _____ while titrating

<6 mg/dL, 2-6w

ANTI-INFLAM PROPHYLAXIS THERAPY DURING ULT

1. 1ST LINE option

2. 2ND LINE option

3. Continue concomitant prophylaxis for atleast _____

1. low dose colchicine, low dose NSAIDs + PPI (if indicated)

2. prednisone/prednisolone <10mg/day

3. 3-6m

ALLOPURINOL (ZYLOPRIM)

1. USE CAUTION in patients with ____

2. Monitoring → 4

3. ADEs → 3

4. STOP IF ______ DEVELOPS

5. *Hypersens can occur → __________ testing prior to initiation

1. CVD

2. uric acid, LFTs, SCr, CBC

3. dyspepsia, headache, diarrhea

4. pruritic maculopapular rash

5. HLA-B*5801

FEBUXOSTAT (ULORIC)

1. USE CAUTION in patients with ____

2. Greater efficacy at -uric acid BUT more _____

3. Monitoring →

4. ADEs → 4

1. CVD

2. side effects

3. uric acid, LFTs, CBC → baseline, 2m, 4m, periodically

4. +LFTs, nausea, arthralgia, rash

URICOSURIC AGENTS: PROBENECID

1. ineffective in patients with CrCL _____

2. AVOID IN PATIENTS WITH _______ or _____

3. ADEs → 3

1. <50

2. kidney stones, CKD

3. rash, precipitation of gouty arthritis, nephrolithiasis

BIOLOGIC OPTIONS (NOT 1ST LINE)

1. __________ for acute gout flares in pts who cannot use 1st line/inadequate response → anakinra (KINERET), canakinumab (ILARIS) 

2. __________ chronic hyperuricemia only w failure of other agents/freq flares/non-resolving tophi → peloticase (KYSTEXXA), rasburicase (ELITEK)

1. IL1 inhib

2. uricase 

BBW FOR RASBURICASE →

hypersens

GOUT

1. Disease process → break down of …

2. Host factor →

3. Joints affected  → 

4. _____ inflammation 

5. Morning stiffness?

6. Labs →

1. cartilage, localized uric acid crystal deposits

2. M>W

3. asymmetrical

4. local

5. if during/after recent attack

6. +uric acid and ESR

OSTEOARTHRITIS

1. Diagnosis (3)

2. NO specific ______ for OA

3. Symptoms resolve with …

4. RECURS with …

5. Duration ______

1. sx, hx, radiographic

2. labs

3. motion

4. rest

5. <30m

OSTEOARTHRITIS (OA)

1. Disease process → break down of …

2. Host factor →

3. Joints affected  → 

4. _____ inflammation 

5. Morning stiffness?

6. Labs →

1. cartilage

2. +age

3. symmetrical/asymmetrical 

4. local 

5. NO

6. none specific 

OA NON PHARM TX

1. ________ for ALL

2. ________ and _________ programs for ALL

3. Hand

4. Knee

5. Hip

1. exercise

2. self-efficacy, self-management

3. CMC orthosis

4. weight loss, tai chi, cane, TF knee brace

5. weight loss, tai chi, cane

When to use TOPICAL AGENTS?

1. _________ joints affected

2. Especially ________ OA

3. Hand = _____ recommendation

4. Knee = _____ recommendation

5. Hip = _____ recommendation

1. 1 or few

2. knee and/or hand

3. conditional

4. strong

5. NO

TOPICAL NSAIDS

1. VOLTAREN = diclofenac _____

2. PENNSAID = diclofenac _____

3. FLECTOR PATCH = diclofenac _____

4. ^ which one for ACUTE PAIN indication only?

5. Monitoring → 3

1. 1% gel

2. 1.5 or 2% soln

3. 1.3% patch

4. patch

5. LFTs 4-8w after initiation, CBC, renal fx

TOPICAL: CAPSAICIN

1. CONDITIONALLY RECOMMEND AGAINST _____ OA

2. MOA: induces release of ________ from peripheral sensory neurons; repeated application leads to prevention of re-accumulation 

3. _______ (Qutenza) APPLIED BY HEALTHCARE PROFESSIONAL

1. hand

2. substance P

3. 8% patch

T or F:

Acetaminophen may no longer be considered the 1st line analgesic for the tx of knee and hip OA.

T

WHEN TO USE ORAL NSAIDS?

1. Patients w ________ sx relief or unable to use topical NSAIDs

2. Patients w symptomatic OA in ________ and/or patients with ____ OA

1. inadequate

2. multiple joints, hip

ORAL NSAIDS

diclofenac, naproxen, celecoxib

1. _____ recommendation in hand, knee, hip OA

2. CONTRAINDICATED IN …

3. BBW

4. Consider use of _____ if used for chronic management

1. strong

2. CKD IV or V

3. CV and GI risk

4. PPI

WHEN TO USE TOPICAL > ORAL NSAIDs? → 4

1. CKD IV or V

2. hand or knee OA

3. CVD

4. PUD

____________ considered for multiple joint OA + concomitant comorbidities that may contraindicate oral NSAIDs

beneficial for depression

duloxetine

HERBAL AGENTS

1. __________ → recommended against

2. __________ → recommended against EXCEPT hand (conditional rec)

3. If patient still wants to use, suggest DC if no benefit in _____

1. glucosamine

2. chondroitin sulfate

3. 6m

TRAMADOL (ULTRAM)

1. hand, knee, hip → recommendation?

2. schedule →

3. Warning → 

1. conditional, 2ND LINE

2. IV

3. SS, seizures 

INTRAARTICULAR CORTICOSTEROIDS

1. Indication: OA of …

2. RISKS → 4

1. knee, hip

2. crystal synovitis, post inj flares, cartilage atrophy, joint sepsis

OSTEOPOROSIS RISK FACTORS

1. Women

2. Men

3. Body type

4. Social history

1. 65+, estrogen deficiency

2. 70+, androgen deficiency

3. -BMI, calorie-restricted weight loss

4. smoking, alc, high caffeine

OSTEOPOROSIS DRUG-INDUCED CAUSES → 9

1. antiepileptic/anticonvulsant 

2. immunosupp

3. lithium

4. PPIs

5. systemic coticosteroids

6. SSRIs, TCAs 

7. TZDs 

8. aromatase inhib

9. loop diuretics 

OSTEOPOROSIS PREVENTION: CALCIUM INTAKE

1. Dietary → 8

2. Calcium carbonate (___ elemental)

3. Calcium citrate (___ elemental)

4. Tolerability →

5. Safety →

6. __________ preferred in chronic gastric acid-suppression therapy

7. should be used for patients receiving chronic ____________ therapy

8. should be admin w appropriate _____ supplement

1. dairy, leafy greens, OJ, cereals, fish w bones, almonds, tofu, broccoli

2. 40%

3. 21%

4. constipation, GI

5. may +risk of MI, hypercalc in late stage CKD

6. calc citrate

7. systemic corticosteroid

8. vit D

OSTEOPOROSIS PREVENTION: VIT D INTAKE

1. Dietary → 6

2. vit D2 (_________) available RX

3. vit D3 (_________) available RX and OTC

4. Tolerability →

1. fatty fish, milk, OJ, cereal, egg yolks, mushroom

2. ergocalciferol 

3. cholecalciferol 

4. hypercalc, constipation

OSTEOPOROSIS SCREENING RECOMMENDATION

1. Women _______

2. Postmenopausal women __________

3. Risk factors → 5

1. 65+

2. <65 + 1 or more risk factors

3. hx of fracture/falls, smoking, alc, low body weight, long term corticosteroid use

OSTEOPOROSIS DIAGNOSIS

T-score vs Z-score → how many standard deviations separate the patient’s BMD from …

1. T = same sex young healthy adult

2. Z = matched age, sex, ethnicity 

OSTEOPOROSIS DIAGNOSIS

T-SCORES

1. normal

2. osteopenia

3. osteoporosis

4. sev or established osteoporosis 

1. >/= -1.0

2. -1.0 to -2.5

3. </= -2.5

4. </= -2.5 + hx fracture

OSTEOPOROSIS DIAGNOSIS

Z-SCORES

1. considered within the expected range for patient’s age

2. considered BELOW the expected range

1. >/= -2.0

2. < -2.0

OSTEOPOROSIS: BISPHOSPHONATES

1. COUNSELING: 

2. EXCEPTION →

3. Remain upright for ________

4. EXCEPTION →

5. IV therapy (zoledronic acid) → counsel on adequate _______ before/after infusion

6. Side effects → 3

7. Safety

8. NOT REC FOR CrCL _____

9. All dosage forms and intervals equally effective EXCEPT ______

1. take w 6-8 oz water atleast 30-60m before food/meds

2. Atelvia take after breakfast

3. 30m after admin

4. ibandronate 60m

5. hydration

6. GI, eye inflam, acute phase rxns w infusion

7. osteonecrosis of jaw, atypical femur fractures → >5yr use

8. <30 to 35 → zoledronic acid CI in <35

9. ibandronate 

Ibandronate is effective ONLY for preventing _________ fractures

vertebral

HIGH FRACTURE RISK

1. Consider a drug holiday after _____ of oral bisphos therapy

2. after _____ of IV bisphos therapy

1. 5y

2. 3y

VERY HIGH FRACTURE RISK

1. Consider a drug holiday after _____ of IV zoledronate

2. During holiday, _____ can be used

1. 6y

2. raloxifene 

RALOXIFENE (EVISTA)

1. MOA

2. prevention & tx of osteoporosis in ________

3. -incidence of ________ fractures

4. SAFETY → 6

1. SERM

2. postmenopausal women

3. vertebral

4. +risk DVT, +hot flashes, leg cramps, arthralgias, peripheral edema, +risk fatal stroke (hx CAD)

TERIPARATIDE (FORTEO)

1. MOA

2. FDA approv tx of osteoporosis in _______

3. reduces risk of __________ fractures

4. Dosage form

5. Side effects → 3

6. Safety 

1. PTH recomb

2. M+W

3. vertebral+non

4. SQ → do not exceed 2y, refrigerate

5. leg cramps, nausea, orthostasis 

6. abrupt bone loss when DC, DO NOT USE in +risk osteosarcoma

ABALOPARATIDE (TYMLOS)

1. MOA

2. FDA approv tx of osteoporosis in _______

3. Dosage form

Side effects + safety same as teriparatide

1. PTH analog

2. postmenopausal women 

3. SQ → do not exceed 2y, refrigerate then after 1st dose store at room T up to 30d

PTH AGENTS NOTES

1. _______ efficacy if used concurrently w a bisphos

2. After DC or completion of therapy, antiresorptive therapy must be initiated to preserve BMD benefits →

3. AVOID USE in patients with … (4)

1. diminished

2. bisphos or Prolia/denosumab

3. +ALP, open epiphyses, Paget, prior skeletal radiation

DENOSUMAB (PROLIA)

tx postmenopausal women, +bone mass in men at high risk of fracture

1. MOA

2. side effects → 4

3. safety →

4. _________ IS NOT RECOMMENDED!

1. RANKL inhib

2. hypocal, +risk skin infxn and rash, osteonecrosis of jaw, atypical femur factures

3. bone loss rapid if DC

4. drug holiday

CALCITONIN (MIACALCIN, FORTICAL)

1. MOA

2. FDA approved to tx osteoporosis in women who are ______ postmenopausal when other tx not suitable

3. DOES NOT -RISK OF _________ fractures

4. Dosage form →

5. Safety → ____________ in calcitonin-salmon-treated pts

6. ADEs → 3

7. NOT _______ 

1. PTH antag

2. >/= 5yr

3. non-vertebral

4. nasal spray

5. +risk malignancy

6. rhinitis, epistaxis, allergic 

7. routinely used

ROMOSOZUMAB (EVENITY)

1. MOA

2. Considered a __________ for pts at very high fracture risk

3. BBW →

4. duration of therapy

5. Side effects → 7

1. sclerostin inhib

2. rescue drug

3. +risk MI

4. 12m

5. hypocal, osteonecrosis of jaw, arthralgias, headache, inj site rxns, hypersens, CV

OSTEOPOROSIS PHARM THERAPY RECOMMENDED FOR

1. 10-yr major osteoporotic fracture risk _____

2. OR hip fracture ____

1. >/= 20%

2. >/= 3%

OSTEOPOROSIS HIGH RISK/no prior fractures pharm tx

1. 1st line + duration →

2. Adj tx →

3. alternate →

1. alendronate or risedronate x 5yr, zoledronate x 3yr, denosumab indefinitely

2. calc + vit D

3. ibandronate, raloxifene 

OSTEOPOROSIS VERY HIGH RISK/prior fractures pharm tx

1. Indicators → 5

2. 1st line + duration →

3. Alternate therapy →

1. +age, frailty, glucocorticoids, very low T score, +fall risk

2. abaloparatide or teriparatide x 2y then transx, denosmab until no longer high risk then transx, romosozumab x 1y then transx, zoledronic acid x 6y

3. alendronate, risedronate

1. _____________________ are the key substances in the initiation and continuance of rheumatoid inflammation

2. →

1. pro-inflammatory cytokines

2. TNF, IL1, IL6

RA CLINICAL PRESENTATION

1. Morning stiffness that lasts _________ & may persist all day

2. _______ joint involvement

3. Disease process

4. Host factor

5. Labs

1. >30m

2. symmetrical

3. systemic, autoimmune 

4. smoking

5. +ESR/CRP, RF may be present, anti-CCP

RA SYMPTOM CONTROL → 2 choices

1. NSAIDs → equally effective, celecoxib less GI → consider +PPI

2. </= 10 mg prednisone/day → calc/vit D supp to prevent bone loss 

3 CLASSES OF DMARDS

1. Conventional (c ) → 4

2. Targeted synthetic (ts) → 3

3. Biologic (b)

1. MTX, hydroxychloroquine, sulfasalazine, leflunomide 

2. tofacitinib/Xeljanz, baricitinib/Olumiant, upadacitinib/Rinvoq

3. -mabs 

METHOTREXATE (MTX)

1. 1st line for DMARD naive with ________ disease activity

2. Time to benefit

3. Counseling

4. MOA

5. BBW → 3

6. CONTRAINDICATED IN _________

7. AVOID in CrCL ____

8. Drug interxns → 6

1. mod-high

2. 2-4w

3. ONCE WEEKLY, +folic acid 1 mg/day except day of MTX admin

4. DHFR inhibitor

5. serious infxns, BMS, GI/liver/lung/kidney tox

6. preg

7. <30

8. PPIs, NSAIDs, salicylates, bactrim, acitretin, alcohol

MTX should be stopped _____ prior to attempting to become pregnant, INCLUDING MEN!

3m

MTX MONITORING

1. ______ and ______ function

2. ___________ for first few months

3. -

4. -

5. -

1. renal, liver

2. CBC q 2-4w

3. preg test

4. hep B and C

5. TB screening

HYDROXYCHLOROQUINE (HCW)

1. 1st line for DMARD naive with ______ disease activity

2. Time to benefit

3. MOA

4. Common ADEs → 2

5. Rare ADEs → 2

1. low

2. 8-12w → give 6m trial of benefit

3. inhib polymorphonuclear leukocytes

4. GI, itchy skin rash

5. vision, tinnitus

HYDROXYCHLOROQUINE MONITORING

1. Complete _____________ (repeat annually for high risk patients)

2. ^ High risk = 3

3. other → 3

4. AVOID IN _______

5. Drug interxns →

1. eye exam w/in 1yr of tx

2. liver disease, retinal disease, age 60+

3. CBC, LFTs, SCr

4. preg

5. may +digoxin levels

SULFASALAZINE (SSZ)

1. Indication

2. Time to benefit

3. Common ADEs → 2

4. Most serious ADEs → 5

5. Monitoring →

6. Caution in patients with _________

7. Drug interxns →

1. 2nd line for low-disease

2. 1-3m

3. GI, rash

4. liver tox, sev skin rash, -blood counts, -sperm counts, kidney stones

5. CBC, LFTs (avoid if >2x ULN), SCr

6. G6PD def

7. -digoxin, give folate 1mg/day

LEFLUNOMIDE (LEF)

1. Indication

2. Time to benefit

3. Monitoring → 4

4. Contraindications 

5. Check LFTs …

6. Initiate _______ if LFTs >3x ULN + monitor weekly until normal

7. Drug interxns

1. 2nd line for low-disease

2. 4-12w

3. CBC, LFTs, SCr, Hep B/C testing in high risk

4. preg, sev hepatic impair >2x ULN

5. monthly x 6m then q 6-8w

6. cholestyramine 

7. inhib diclofenac and ibuprofen metabolism, smokers have +clearance

All JAK inhibitors (tsDMARDs) are _________ (dosage form)

oral tabs

tsDMARDs (JAK inhibitors) Safety

1. Inc risk of _________

2. ___________

3. ___________

BMS, hepatotox, caution in kidney disease, +lipids

4. MONITORING →

5. _______ requires dose adjustments for DRUG INTERXNS

6. Dose reduction for mod-sev _______

7. MAY BE USED AS ____________ for RA

1. serious infxns

2. malignancies

3. thrombosis

4. baseline CBC, LFTs, Hgb, lipids within 1-2m; CBC, LFTs, Hgb q 3m

5. tofacitinib (Xeljanz)

6. renal impair

7. monotherapy or combo w cDMARD

Anti-TNF DMARDS

1. ______ choice for bDMARDs

2. _____________ with other bDMARDs

3. Agents → 5

4. Time to benefit

5. ADEs → inj/infusion rxns, +risk serious infxn, _____, _____, _______

6. Monitoring →

1. 1st line

2. should not be used in comb

3. Enbrel/etanercept, Remicade/infliximab, Humira/adalimumab, Simponi/golimumab, Cimzia/certolizumab 

4. few days to months

5. URTI, headache, worsening HF

6. CBC, LFTs, SCr

Which anti TNF inhibitor is a fusion protein?

A. Enbrel/etanercept

B. Remicade/infliximab

C. Humira/adalimumab

D. Simponi/golimumab

E. Cimzia/certolizumab 

A

Which anti TNF inhibitor is a PEGylated recombinant Fab?

A. Enbrel/etanercept

B. Remicade/infliximab

C. Humira/adalimumab

D. Simponi/golimumab

E. Cimzia/certolizumab 

E

ANTI-TNF bDMARDs SAFETY

1. Associated with reactivation of _____ → test for latent before/during therapy

2. Increase risk of invasive _____________

3. Increase risk of __________

4. Linked to new or worsening __________

1. TB

2. bacterial/fungal infxns

3. malignancies

4. HF

Which are preferred for overlapping inflammatory bowel disease? (Select all)

A. Enbrel/etanercept

B. Remicade/infliximab

C. Humira/adalimumab

D. Simponi/golimumab

E. Cimzia/certolizumab 

B, C, E

Which are preferred for preconception, pregnancy, and breastfeeding? (Select all)

A. Enbrel/etanercept

B. Remicade/infliximab

C. Humira/adalimumab

D. Simponi/golimumab

E. Cimzia/certolizumab 

A, E

NON-TNF BIOLOGICS → 4

1. Orencia/abatacept

2. Rituxan/rituximab

3. Actemra/tocilizumab

4. Kevzara/sarilumab

1. T-cell inhibitor bDMARD =

2. Indication

3. Safety →

4. ADRs → 5

1. Orencia/abatacept

2. alt to MTX w mod-high disease

3. COPD, +risk infxn

4. infxns, pneumonia, cellulitis, UTIs, bronchitis

1. Anti-CD20 bDMARD =

2. Indication → 

3. Monitoring → 5

4. PRE-MEDICATE WITH …

5. BBW → deaths due to infusion rxn, ________, sev mucocutaneous rxns

6. ADEs → 6

1. Rituxan/rituximab 

2. inadequate response to MTX & anti-TNF

3. CBC+platelets, TB screening, infusion rxn, cardiac, high risk screen HBV/HCV

4. glucocorticoid, acetaminophen, antihistamine

5. tumor lysis syndrome

6. HTN, nausea, arthralgia, pyrexia, pruritus, hep B reactivation

1. IL6 INHIBITOR bDMARDs =

2. Monitoring → LFTs, CBC+platelets, TB screening, s/s infxn, ________

3. ADEs → 4

4. AVOID USE IN … 3

1. Acetemra/tocilizumab, Kevzara/sarilumab

2. Lipid panel

3. URTI, hypersens, dyslipidemia, neutropenia/TC

4. ANC<2000, platelets <100k, ALT or AST >1.5x ULN