Rheumtoid Arthritis Pharm
Terms
undefined, object
copy deck
- What is the clinical presentation of RH?
-
-Joint pain and stiffness of more than 6 weeks duration
-Fatigue, weakness, low-grade fever, and loss of appetite
-Muscle pain and afternoon fatique may also be present
-Joint deformity is generally seen late in the dz - Sign of RA?
-
-Tenderness and warmth and swelling over affected joints usu involving hands and feet
-Distribution of joint involvement is symmetrical
-RH nodules may be present - Labs for RH dx?
-
-fairly detect in 60-70%
-Elevated ESR and C-reactive protein are markers for inflammation
-Normocytic normochromic anemia is most common, as is thrombocytosis - Other tests?
-
-Joint fluid aspiration may show increased WBC counts w/o infection and crystals
-Joint X-rays mas show osteoporosis, joint space narrowing, or erosions. - TX goals for RH?
-
Prevent or control joint damage
prevent loss of fxn
decrease pain - For dx if RH need 4 of the following?
-
-morning stiffness >1hour
-arthritis and soft tissue swelling of >3 of 14 joints/joint groups
-Symmetric arthritis
-subQ nodules in specific places
-Radiological changes suggestive of joint errosion - RH Tx options?
-
1) Opiods
2) Acetaminophen
3) NSAIDS
4) DMARDs
5) Cytokine inhibitors - Best efficacy to toxicity ratios of DMARDs?
-
Methrotrexate
Hydrochloroquine - ASA and NSAIDs work by?
- inhibiting prostoglandin synthesis by blocking cycliixygenase, the enzyme that converts arachondic acid to prostaglandins
- Prostoglandins?
-
-potent mediators of pain
-prod in response to injury and inflammatory conditions - Acetominophen inhibits?
-
Prostoglandin production in the CNS resulting in fever reduction and analgesia
-exact mechanism is not well known - ASA?
- -The most widely prescribed analgesic/antipyretic/antiinflammatory
- -ADVSE RXN with ASA?
-
-GI tract
N&V
Gastric ulceration, GI hemorrhage and blood loss
hives, rash, angioedema
liver dysfxn, mental confusion, hdche, sweating, hyperventilation, and lassitude. - Warnings with ASA?
-
-Allergic/anaphylatic rxns with asthma, nasal polyps, gastric, duodenal ulcers.
-Children with high BP, HD, Thyroid dz.
-Inhibits platelet aggregation, prolongs bleeding time
-Interacts with Wafafin, may result in serious bleeding. - Non-Salicylates?
-
-inhibit prostaglandin synthesis
-Reversibly inhibit cyclooxgenease
-May inhibit Leukotriene synthesis - What is one of the safest Non-Steroidals?
- -Naproxen
- ADVSE RXNS to NSAIDS
-
-GI
-Renal
-CNS
-Hypersensitivity
*see notes pg 6 for specifics - Indomethacin?
-
-About 20-30 times more potent than aspirin
-More advse effects
-Not used for analgesic prop.
-Uriconsuric
-20% pts DC due to ADRs - Indications for Indomethacin?
-
-RA
-Osteoarthritis
-Ankylosing spondylitis
-Acute Gouty arthritis
-acute bursitis
-acute tendinitis - Hydroxychloroquine?
-
MOA: (DMARD-antimalarial)
Inhibits locomotion of neutrophils and chemotaxis of eosinophils; impairs complement-dependant antigen-antibody rxns
-More commonly used in early and less aggresive mild dz.
ADRS:
GI
RASH
Retinopathy(eye exam Q 9-12 months)
Headache, irritability, tinnitus - Methrotrexate?
-
MOA:(DMARD)
-inhibits reductase, neutrophil adhesion, migration and distrupts fxn of interleukin-1(inflamm. cytokines).
-TX of active RA
-given once per week
ADRS: Liver toxicity
GI toxicity, HEME (fatal BM supression), pneumonitis, lymphoproliferative malignancy - What is the DOC for aggresive RA?
- Methrotrexate
- What else is good with RA?
-
-Auranofin (gold compound)
-Injectable gold
-d-penicillinase
-Azathioprine
not on list.
See notes pg 9 - Sulfasalazine?
-
MOA: (DMARD-anti-inflammatory)
-involves anti-inflammatory and immunomodulatory effects but exact mechanism is not known*
-FDA approved for RA adults/kids
-no improv for 2-3 months
-Cross allergy to sulfas
-combo with MTX, hydrochloroquine, cyclosporine and others common
ADX:
N/V, HDCHE, Fever, Hemolysis,male infertility, hep,orange-yellow urine, SJS - Leflunomide (Arava)
-
MOA: (DMARD)
-Bibds ot TNF providing competetive inhibition of the binding of TNF molecules to the TNF cell-surface receptior sites.
-Entanercept renders the bound TNF bilogically inactive resulting in reduced inflammatory activity.
-Modulates expression or adhesion molecules responses that are induced or regulated by TNF, inculuding expression or adhesion molecules resp for leukocyte migration, serum levels of cytokinesw, and serum levels of matrix.
see notes - What is a DMARD again?
- Disease modifying antirheumatic agent
- Infliximab?
-
MOA: (Biologic Response Modifier Anti-TNF)
-A monoclonal antibodyu IgG that binds to TNF providing competetive inhibition of the binding of TNF molecules to the TNF receptor sites=reduced inflammatory activity and antiproliferative activity.
-Specific for - What mus Ifliximab be given with?
- MTX!
- What is Infliximab good for?
-
-use in Chron's disease and mod-severe RA DZ.
*most common reason pts DC tx is due to infusion reactions and infxn
ADRS:
-Infusion rxns (chills, fever, uticaria, and pruritis)
-CXT pain
-HTN, Dyspnea, Prod of auto antibodies, Lupus-like syndrome, UTI, URI, Lymphoma and other neoplasia - What is Anakinra indicated for?
-
-pts 18yo or older who have failed on or more DMARDS
not on list, pg 14 - What drugs are for RA only?
-
-Hydroxychloroquine
-Methothrexate
-Leflunomide
-Sulfasalazine
-Infliximab
-Entanercept
-Cyclosporine - What drugs for Gout only?
-
-Allopurinol
-Colchicine
-Probenecid - Wyat drugs used for RA, OA, AS, G?
-
-Indomethacin
-Ibuprofen
-Naproxen
-Acetomenophin - Cyclosporine (Gengra)?
-
MOA: (Biologic response modifier anti-TNF)
-Immunomodulatory agents
-blocks prod and release of cytokines
-inhibits synthesis of factors that stim growth of T-cells - More stuff on Cyclosporine:
-
-demonstates reduction in radiographic progression of dz
-similar effect to Methrotrexate, inj Gold
-Not approved for RA
-Used for refractory dz of severe nature, good when comb with MTX
ADR: Nephrotoxicity
Hyperlipidemia
Cholethisias
-Osteoporisis
-Transient liver dsfxyn
-Poss bone marrow supression - What drug is good for supression of immune response in organ transplants and autoimmune disorders?
- Cyclosporine!
- What combo is recommended by the RH thing?
-
MTX and Leflunomide
see notes for combo tx pg 15 - Tx for mild RA?
-
-NSAIDS for inflammation, acetominophen (for pain)
-Add a DMARD: Hydroxychloroquine or Sulfasalazine
-Intraarticular injxns of corticosteroids - Moderate RA tx?
-
-NSAIDS(start with max doese)
-Analgesics PRN
-DSMARDS usu in combo with MTX
-Intraauricular corticosteroid injxn - Tx for Sever RA?
-
-NSAIDS at full anti-inflammatory responsed
-DSMARDS-MTX(increasing dose)-monitor liver, bone marrow, and lung toxicity.
-Anticytokine tz (entanercept)
-Anakinra mono tx
-add oral prednisone
-Inraauricular corticosteroid injxns