Term
| What are the normal lab values for hemogloblin? |
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Definition
Male - 14-18
Female - 12-16 |
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Term
| What are the normal lab values for hematocrit? |
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Definition
- Male - 40-52%
- Female - 37-47% |
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Term
| What is the normal range for platelets? |
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Definition
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Term
| What is the normal range for WBC? |
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Definition
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Term
| What are the normal lab values for RBCs? |
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Definition
- Male - 4.8 - 6.0 x10^6
- Female - 4.1 - 5.5 x 10^6 |
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Term
| What are normal CHEM7 values? |
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Definition
SCr – 0.5 – 1.5
Na – 134 – 146
K – 3.5 – 5.1
CO2 – 24-31
BUN – 8-25
GLU – 60-110 |
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Term
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Definition
Chronic joint inflammation and pain. Affects joints symmetrically
Low grade fever, dry eyes
Fatigue and weakness |
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Term
| What are some local results of RA? |
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Definition
- Hand - deformity and reduced grip?
- Shoulder - decr RoM
- Knee - instability
- Foot - problems walking & with shoes
- Jaw - difficulty chewing |
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Term
| What are specific deformities associated with RA? |
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Definition
- Hammertoe - pain while walking
- Baker's cyst - behind the knee, can rupture
- Hand: boutonnier's thumb, ulnar deviation, swan-neck deformity in fingers |
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Term
| What are extra-articular manifestations of RA? |
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Definition
If not being treated:
- Rheumatoid nodules
- Vasculitis - finger turns black due to BV damage
- pulmonary - nodules and scarring
- Ocular - dry eye, Tx w/ cyclosporine
- Cardiac - chronic inflammation, MTX lowers.
- Felty's syndromme - enlarged spleen/neutropenia - incr risk of infection. |
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Term
| What are goals of therapy in RA? |
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Definition
- reduce inflammation?
- protect joints
- reduce extra-articular symptoms
- Slow/halt progression
- improve/maintain QoL |
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Term
| How is an RA damaged joint different than a normal joint? |
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Definition
| less volume, opaque/turbid due to WBC presence, low viscosity, elevated leukocytes. |
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Term
| What indicates a poor prognosis in RA? |
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Definition
- Delay in diagnosis
- Waiting until radiographic damage is present
- Presence of extra-articular disease
- Toxic rxns to therapy |
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Term
| What is the only way to fix a low Hct/HGb? |
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Definition
a DMARD. Iron will not help.
Other lab findings besides anemia: Thrombocytosis, elevated ESR (30 for women, 20 for men), elevated C-reactive protein, +RF |
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Term
| What are criteria for diagnosing RA? |
|
Definition
4 of 7:
- Morning stiffness
- Arthritis of 3+ joints
- Arthritis of hand joints
- Bilateral involvement
- Rheumatoid nodules
- + RF --> Positive for all of these = aggressive treatment
- Radiographic changes |
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Term
| Why does it have to be known if a patient has TB, Hep B or C? |
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Definition
| Many RA drugs cannot be given to these patients |
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Term
| What is the goal for beginning of therapy? |
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Definition
| Begin DMARD, biologic, or combo with 3 months. In high disease activity or poor prognosis, start a biologic with or without MTX. |
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Term
| What DMARDs are recommended in RA? |
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Definition
| MTX, leflonamide/Arava, Hydroxychloroquine/Plaquenil, and Sulfasalazine |
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Term
| What biologics are TNF inhibitors? |
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Definition
- Infliximab/Remicade
- Adalimumab/Humira
- Etanercept/Enbrel
- Golimumab/Simponi
- Certolizumab/Cimzia |
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Term
| Which biologic agents are not TNF inhibitors? |
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Definition
- Abatacept/Orencia - T cell activation inhibitor
- Rituximab/Rituxan - B cell depletion
- Tocilizumab/Actemra - Il-6 inhibitor |
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Term
| What is the algorhythm for RA tx? |
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Definition
- begin MTX in a naive patient, check in 3 months. Can use combo in moderate to severe disease.
- Can switch methods |
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Term
| When can corticosteroids be used? |
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Definition
| As bridge therapy, but not without a steroid or a biologic. |
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Term
| What vaccinations do RA patients need? |
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Definition
Pneumonia, influenza, Zostavax, Papilloma, Hep B
Vaccinate BEFORE biologic use, not during. |
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Term
| What is the ASPIRE trial? |
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Definition
| Combo therapy > Humira or MTX alone, and Humira > MTX |
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Term
| What is the purpose of NSAID therapy in RA? |
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Definition
Decreased pain and swelling
Does NOT slow progression - must combine with biological or DMARD |
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Term
| What does the term monotherapy mean? |
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Definition
| Monotherapy refers to a drug that retards disease progression, not Prednisone or NSAIDs. Do not use 2 biologics together! But you can use 2 DMARDs together. |
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Term
| What information is important about MTX? |
|
Definition
- Most widely used DMARD, benefits in 1-2 months.
- Initiate in all patients unless contraindicated.
- Renally eliminated. Dosed 7.5-15 mg QW orally or IM
- Increases survivability by decreasing cardiac symptoms
- ADRs - GI, thrombocytopenia, rare pulmonary fibrosis
- May required folic acid supplementation |
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Term
| What are the hepatic effects of MTX? |
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Definition
| In 15% of patients, elevated liver enzymes. Must monitor. In patients with liver problems, must have a liver biopsy. Did albumin lower? D/c drug. |
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Term
| What monitoring is required with MTX? |
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Definition
CBC, SCR, AST/ALT, Albumin. Screen for Hep B/C
Report: GI symptoms, cough, jaundice, symptoms of bone marrow suppression. Toxicity occurs more often at cancer doses.
Contraindications: Chronic liver or renal disease, leuko or thrombocytopenia, pleural effusion
PREGNANCY CATEGORY X, makes infertile. |
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Term
| What are contraindications for biologics? |
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Definition
| Severe CHF, active TB, active infection, liver damage or failure, |
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Term
| What is important about Enbrel? |
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Definition
Etanercept/Enbrel - a TNF inhibitor as monotherapy or w/ MTX. Response in 1-2 weeks. 50 mg SQ QW. Store in the fridge.
Caution: worsening CHF or infection. Can use in pregnancy |
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Term
| What is important about Remicade? |
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Definition
Infliximab/Remicade - a TNF inhibitor for severe to moderate RA.
Must be combined with MTX. Doses 3 mg/kg IV q8weeks - see benefit to a few days to 4 months
- Causes infection, recurrent TB and Hep B, worsening CHF
- Serious infusion reaction: slow rate, tx with APAP, steroids, and benadryl |
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Term
| What is important to know about Humira? |
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Definition
Adalimumab/Humira is a TNF inhibitor for moderate to severe RA alone or in combo with MTX. Initial response in 1-7 days! Peak response in 3 months, and can be used in pregnancy. 40 mg SQ QoW, may use QW when not on MTX
- DO NOT USE WITH ANAKINRA
- Screen with PPD, store in fridge, may self administer after dr witnesses |
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Term
| What is important to know about Simponi? |
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Definition
-Golimumab/Simponi is indicated for moderate to severe RA WITH MTX.
- 50 mg SQ QM in thigh or abdomen. Can cause infection |
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Term
| What is important to know about Cimzia? |
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Definition
Certolizuman pegol/Cimzia is a TNF antagonist indicated for moderate to severe RA. Can be used alone or with MTX
- 200 mg SQ QoW or 400 mg SQ q4w. Can cause infection |
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Term
| What is important to know about Orencia? |
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Definition
Abatacept/Orencia is a T-cell activation inhibitor for use in patients w/ an inadequate response to DMARDs or TNF antagonists. Use alone or with MTX. Do not use w/ another biologic!!
- dosed IV infusion QM based on body weight (500 if <60kg, 750 if 60-100kg)
- SE: infections, rare malignancies, HA, nausea, infusion RXN. May worsen COPD. |
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Term
| What is important to know about Rituxan? |
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Definition
Rituximab/Rituxan is a B cell agent. Indicated in combo with MTX that had an inadequate response to TNF antagonists.
- MUST have pre-meds: APAP, benadryl, steroid - prevents injection site rxn.
- SEVERE reactions, high infection risk. Do not use in pregnancy |
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Term
| What is important to know about Actemra? |
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Definition
Tocilizumab/Actemra is an IL-6 receptor antagonist for use in RA who have failed TNF antagonists, use alone or with MTX.
- IV infusion q4weeks
- Only drug that causes elevation in lipid levels. Can also cause URIs. MONITOR! |
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Term
| What are the 3 uses of steroids in RA? |
|
Definition
- Bridge therapy with taper
- Continuous low dose
- Short term bursts with taper
- must have baseline monitoring plus continuous bone density scans
- Steroid shots in a joint up to 3x/year |
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