Therapeutics - RA 5
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Why does the American college of rheumatology not recommend Tocilizumab?
Not updated their recommendations since 2012
What is the MOA of Anakinra?
Should Anikinra be combined with a TNF-alpha inhibitor, why or why not?
No, causes increased infection rates
When is is recommended to use Anakinra?
Only if you have failed on TNF-alpha inhibitors
What is the dosage form of Anakinra?
What is the onset of symptom relief for Anakinra?
What are the AE for Anakinra?
- Injection site reactions
How should Anakinra be administered?
At room temperature
What is the dose for Anakinra?
100 mg SQ QD
What are the dosage forms available for Anakinra?
What is the dose for Tofacitinib?
- 5 mg PO BID
- Renal impairment (Child-Pugh > or = to 7) OR potent 3A4 inhibitor OR moderate 3A4 inhibitor and potent 2C19 inhibitor: 5 mg PO QD
What are the adverse effects of Tofacitinib?
- Infection (Black box)
- Elevated lipids
Why should you get a CBC when on Tfacitinib?
To monitor for Neutropenia and Anemia
Does Tofacitinib need to be adjusted for renal impairment?
Yes, give 5 mg PO QD (normally BID)
What RA drugs need to be adjusted for renal impairment?
What RA drugs are CI in renal impairment?
What RA drugs are CI or cautioned in liver impairment?
- CI: Leflunomide
- Cautioned: Sulfasalazine, Rituximab
What RA drugs are teratogens?
- Abatacept is category C
What is the MOA of Abatacept?
Inhibits T cell interaction and activation by modulating Co-stimulation
What is the role of Corticosteroids in RA therapy?
- Bridging therapy – Symptom relief before onset of DMARD
- Control of acute disease flares or difficult to control disease
How long does it take to receive symptom relief with corticosteroids?
What is the role of a high dose of corticosteroid in RA?
Used to control acute disease
What is the role of a continuous low dose of corticosteroids in RA?
Used to control difficult to control disease
What is the MOA of corticosteroids in relieving symptoms of RA?
Interfere with antigen presentation and inhibit prostaglandin and leukotriene synthesis
By what route are corticosteroids administered for RA relief?
Oral or intra-articular, IM or IV
What is a low dose of corticosteroids for RA?
< or = to 7.5 mg of prednisone
Under what conditions would you use IV corticosteroids for RA?
Very severe symptoms
What forms of Corticosteroids are available for the treatment of RA?
IM, Intra-articular and IV
How often can you repeat Intra-articular corticosteroid injections in RA, and why?
- Max: Q 3 months
- Risk of accelerated joint destruction and tendon atrophy with more injections than 2-3 a year
Which route of corticosteroid administration is a good choice for a non-adherent patient and why?
- Long-acting and provides physiologic taper
Which route of corticosteroid administration is a good choice if you want to reduce systemic side effects?
When are intra-articular corticosteroid injections a good choice?
When a small number of joints are affected
What are the AE of corticosteroid injections?
- HPA suppression
- HTN/fluid retention
- Electrolyte disturbances
- Skin atrophy
- Fungal infections
Should NSAIDs be used as a monotherapy in RA?
Do NSAIDs alter disease progression in RA?
What is the role of NSAIDs in RA?
- Used for symptomatic relief while Biologics are kicking in
- Analgesia/anti-inflammatory, reduce stiffness
What are the AE of NSAIDs in the treatment of RA?
- Peptic ulceration and bleeding
- Renal insufficiency
- CV effects
According to the American College of Rheumatology, therapeutic recommendations ahould be based onwhat factors?
- Disease duration
- Disease activity (low, mod, high)
- Prognosis (good/poor)
What triple therapy has been shown to be efficacious for RA?
What pharmacologic therapies are considered adjunctive for the treatment of RA?
Corticosteroids and NSAIDs
What dual therapies are available for RA?
- Methotrexate + leflunomide
- Methotrexate + hydroxychloroquine
- Methotrexate + sulfasalazine
- Methotrexate + TNF alpha inhibitor
- Sulfasalazine + hydroxychloroquine
If a patient has a poor prognosis and an inadequate response to an oral DMARD, what treatment would you susggest?
DMARD + Biologic
What treatment plan should be used for a patient with High disease activity and a poor prognosis?
- Anti-TNF ± MTX
- Combination DMARD therapy
What treatment plan should be used for a patient with High disease activity and a good prognosis?
- DMARD monotherapy
- HCQ + MTX
What treatment plan should be used for a patient with Low disease activity?
What treatment plan should be used for a patient with Moderate disease activity and a good prognosis?
What treatment plan should be used for a patient with Moderate disease activity and a poor prognosis?
Combination DMARD therapy (double & triple therapy)
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