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What is most commonly used DMARD
DMARD stands for
disease modifying antirheumatic drug
How long is methotrexate effective in
What is cornerstone of tx for RA
early diagnosis and aggressive treatment
MOA of DMARDS
exact is unknown but do have antinflammatory effects that slow progression of RA and preserve the joint
MOA of hydroxychloroquine
mimics the parent compound chloroquine.
Antiinflammatory properties by inhibiting conversion of arachidonic acid to prostaglandin F2
Is anti-inflammatory and reaches high concentrations in serous fluids and connective tissue
anti-inflammatory and immunosuppressive properties.
Impairs DNA synthesis.
Inhibitory on cytokines especially interleukin 1 and arachidonic acid
antiproliferative effect on synovial cells.
cytokines (TNF and IL) are released during inflammation. These agents have been cloned and given to immunodeficient patients for RA.
Some are given for MS
Cytokine blockers MOA
two cytokines are targeted TNF and IL-1
Cytokine blokcers bind to TNF and inhibit its interaction with cell surface receptors.
Anakinra blocks IL-1 by inhibiting binding to its receptor
Abatacept inhibits T-cell binding
Leflunomide blocks synthesis of pyrimidine needed for T-cell proliferation
inhibit production of interleukins
immunosuppressive and antiinflammatory
interfere with enzymes that contribute to tissue inflammation
First line tx for RA
COX 2 selective NSAID should be used with this.
If DMARDs do not provide pain relief then add?
Low dose oral glucocorticosteroids (predinisone) should only be given _____?
May need to add calcium supplement to decrease risk of osteoporosis
What can be used for intense flare ups of RA and OA, but can only be repeated 3 times per year
Add opioids only if
inadequate pain relief with other drugs first
DMARDs are only prescribed by
Hydroxychlorquine should be used in caution with patients with
These drugs can cause _______?
- renal or hepatic impairment
- or history of ETOH abuse
Irreversible retinal damage, patients should be advised to wear sunglasses due to photosensitivity
Pts who are candidates for immunomodulator therapy should be screened for
What is used to monitor disease activity over time
ESR and C-reactive protein
DMARDS monitoring should include
CBC with diff, and platelets for blood dyscrasias, metabolic panel for renal and hepatic function and UA
Monitoring of hydrochloroquine
blood cell counts and ophthalmic exam baseline and at 3 months
Assess muscle strength and knee and ankle reflexes
monitoring of sulfasalaxine
- CBC with diff and LFTS before starting and every two weeks for 3 months
- Renal function periodically
monitoring of methotrexate
cbc, albumin, creatinine, and LFTs at baseline and monthly for 6 months. and 1-2 months thereafter.
Also alkaline phosphatase, chest x-ray, and hepatitis b and c in high risk patients.
- tb test before beginning tx
- assess for infection
- monitor for signs and symptoms of infection
- monitor CBC and LFTs
more susceptible to adverse effects because of decreased renal and hepatic fx.
Use methotrexate with caution
extreme caution has caused death in this population
Pregnancy and Lactation
B- sulfasalazine, TNF inhibitors, IL-1 receptor antagonist.
C- hydroxychloroquine (lactation prob safe), abacept
X- methotrexate, leflunomide
Methotrexate black box warning
NSAIDS, sulfonamides, tetracycline, chloramphenicol, phenytoin, and cyclosporine may interfere with elimination of this drug.
- toxic effects, potentially serious at all dosages.
- Deaths have occurred from this medication
Vitamins containing folic acid may ______ response of methotrexate but can give to reduce toxicity without compromising therapeutic effect