Rheumatoid Arthritis

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Author:
capnhue
ID:
136664
Filename:
Rheumatoid Arthritis
Updated:
2012-03-01 16:19:14
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Regis University
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Description:
Rheumatoid Arthritis
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  1. Interleukin-1 (IL-1)
    • promotes the activation of monocytes and macrophages
    • Stimulates the release of cartilage matrix metalloproteinases from fibroblasts and chondrocytes
    • metalloproteinases mediate the destruction of articular cartilage
  2. Interleukin-4 (IL-4)
    • Produced by CD4+ type 2 helper cells and helps drive the differentiation and growth of B cells
    • Inhibits the activation of type 1 helper T cells and decreses the production of IL-1 and TNF-α
  3. Interleukin-6 (IL-6)
    • produced by T cells, macrophages, monocytes, and synovial fibroblasts
    • induces profliferation of synovial fibroblasts
  4. Interleukin-10 (IL-10)
    • anti-inflammatory cyokine produced by macrophages, monocytes, and both T and B cells
    • dampens the inflammatory response by inhibiting production of IL-1 and TNF-α as well as proliferation of T cells
  5. 4 Major Criteras for RA
    • Joint involvement: (0-5 pts)
    • assess the number and location of joints involved
    • Serology: (0-3 pts)
    • RF (rheumatoid factor) and ACPA (anticyclic citrullinated peptide antibody)
    • Acute-phase reactants positive: (0-1 pts)
    • ESR (erythrocyte sedimentation rate) and CRP (C-reactive protein)
    • Duration of symptoms: (0-1 pts)
    • less than or more than 6 week duration
  6. Clinical presentatin of RA
    • Symptoms: RA
    • joint pain and stiffness >6 weeks duration
    • experience fatigue, weakness low-grade fever, loss of appetite
    • muscle pain and afternoon fatigue
    • joint deformity seen late in disease
    • Signs: RA
    • tenderness w/warmth and swelling over affected joints involving hands and feet
    • distribution of joint involvement is symmetrical
    • rheumatoid nodules may be present
  7. Summary of Biologic Agents
    • NOT first line therapy for RA
    • use w/ methotrexate
    • variable response
    • TB testing prior to use
    • No live vaccines
  8. Release of TNF from T cells results
    • increase vascular permeability
    • release of nitric oxide
    • vasodilation
    • increased platelet activation and adhesion
    • local activation of vascular endothelium
    • increased expression of adhesion molecules on endothelial blood vessels
  9. Methotrexate
    • blocks purine & pyrimidine biosynthesis
    • inhibits production of spermine & spermidine
    • lowers intracellular glutathione conc
    • inhibit AICAR enzyme leading to release of AMP/ or adenosine a potent anti-inflammatory mediator
  10. Methotrexate drug-drug interactions
    • probenecid
    • NSAIDs
    • penicillin G
    • *drugs inhibt methotrexate elimination
  11. Avoid Methotrexate if:
    • chronic liver disease (cirrhsosis)
    • immunodeficiency
    • leukopenia
    • thrombocytopenia
    • preexisting blood disorders
    • CrCl <40
    • pregnant
  12. Avoid Leflunomide if:
    • preexisting liver disease
    • pregnant
    • *leflunomide toxicity occurs: treat with cholestyramine
  13. Hydrochloroquine adverse effect
    • benign corneal deposits
    • blurred vision
    • scotomas (absent vision)
    • night blindness
    • *due eye exam prior to use
    • *6 months to take effect
  14. Sulfasalazine adverse effects
    • GI: nausea, vomiting, diarrhea, anorexia
    • *sula or aspirin allergy: AVOID
  15. Congestive heart failure AVOID:
    • infliximab
    • etanercept
    • * Ejection Fraction (EF) < 40: AVOID etanercept & infliximab
  16. Dosing regimen Infliximab
    • 1 week
    • 2 week
    • 6 week
    • then every 8 weeks thereafter
  17. Etanacept adverse reactions
    local injection-site reactions
  18. Infliximab adverse reactions
    • fever
    • chills
    • pruritus
    • rash
    • anaphylactic (very uncommon)
    • * treat w: apap, diphenydramine, corticosteroid
  19. Corticosteroid treatment in RA
    • used in severe RA pts who initiate DMARD therapy for bridging purposes
    • low dose is used for long term treatment of RA
    • high doses are used to control flares of RA
  20. Pregnancy RA
    • treat w: sulfazalaine, hydroxychloroquine
    • AVOID: methotrexate, leflunomide

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