Term
| What is rheumatoid arthritis? |
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Definition
| - Systemic disease characterized by symmetrical inflammation of the joints (synovium), it is a chronic condition |
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Term
| What is the pathophysiology and clinical signs of rheumatoid arthritis? What are key cytokines involved in this process? |
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Definition
Patho --> autoimmune disease, attacks synovial and other connective tissues. 60-70% of patients have detectable rheumatoid factor (RF) levels.
Key Cytokines --> Proinflammatory (TNF, Il-1, Il-6), they activate osteoclasts which leads to resorption of the bone
Symptoms --> Morning stiffness for > 6 weeks, fatigue, weakness, low-grade fever, loss of appetite and fatigue
Signs --> tenderness and warmth and swelling over affected joints, symmetrical |
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Term
| What is the difference in joints affected, joint distribution, and presence of inflammation between RA and OA? |
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Definition
Joints Affected:
RA - small joints
OA - large joints
Joint Distribution:
RA - symmetrical
OA - symmetrical, asymmetrical
Presence of inflammation:
RA - local and systemic inflammation
OA - none or mild, local inflammatino |
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Term
| What are the laboratory findings for rheumatoid arthritis? |
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Definition
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Laboratory Test
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Characteristic Result
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Erythrocyte Sedimentation Rate (ESR)
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Elevated
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C-Reactive Protein (CRP)
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Elevated
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Rheumatoid Factor (RF)
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Present (~70%)
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Antinuclear Antibody (ANA)
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Present (~25%)
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Anticyclic Citrullinated Peptide Antibody (Anti-CCP)
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Present (50-85%)
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Hgb/Hct
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Decreased
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Platelets
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Elevated during active disease
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Immunoglobulins
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IgG, IgA, IgM increased; IgD normal or low
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Synovial fluid
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Inflammatory
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Term
| What is the difference between RA and OA in regards to disease process, host factors, joints affected, presence of inflammation, morning stiffness, laboratory |
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Definition
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Rheumatoid Arthritis
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Osteoarthritis
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Disease Process
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Autoimmune (immune system attacks joint), systemic disease
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Breakdown of cartilage (not autoimmune), localized
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Host Factors
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Genetic, gender, smoking status, environmental exposure
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Genetic, trauma, biomechanical, metabolic, age
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Joints Affected
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Symmetrical, small joints-
Hands, wrists and feet
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Symmet., asym. large joints-
Neck, spine, knees, shoulders
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Presence of inflammation
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Chronic local and systemic inflammation
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None or mild, local inflammation
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Morning Stiffness
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Yes
(lasting >60mins)
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No
(Stiffness lasting <30mins)
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Laboratory
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Elevated ESR, RF present, leukocytosis in synovial fluid
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None specific, mild leukocytosis in synovial fluid
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Term
| What is the American College of Rheumatology criteria for a diagnosis of RA? |
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Definition
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1. Morning stiffness ≥ 6 weeks
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2. Inflammation in 3 or more joints ≥ 6 weeks
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3. Inflammation of wrist or finger joints ≥ 6 weeks
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4. Bilateral joint inflammation ≥ 6 weeks
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5. Rheumatoid nodules
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6. Elevated serum rheumatoid factor
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7. Bone destruction seen on radiograph
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Term
| What are some factors associated with poor prognosis in RA? |
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Definition
- Early age of disease onset
- Elevated ESR
- High titer of RF
- Swelling in more than 20 joints
- Presence of extra-articular manifestations
**Patients with this should be considered for more aggressive therapy** |
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Term
| What are some non-pharmacologic therapies for RA? |
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Definition
- Rest vs. Exercise (rest relieves stress but exercise improves mobility, must balance)
- Weight reduction to alleviate joint stress
- Occupational and physical therapy
- Surgery (severe disease) |
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Term
| What are the key concepts of RA pharmacological therapy? |
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Definition
- DMARD's must be initiated within three months of diagnosis to reduce joint erosion
- Most clinicians favor "Step down" method to slow or reverse damange ASAP
- MTX is DMARD of choice
- DMARD's present risk of infection
- Bridge to DMARD therapy using corticosteroids
- Always consider prophylaxis for osteoporosis |
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Term
| When would you use NSAIDS for RA therapy? |
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Definition
- No impact on disease progression
- Used for symptomatic relief only
- Used a bridge therapy for pain until DMARDS take effect
- Not the best option |
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Term
| When would you use prednisone and methylprednisone therapy in RA? |
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Definition
- Bridging therapy to control pain and inflammation before DMARD's take effect
- Use continuous low dose therapy to control disease, with high dose bursts for flare-ups.
- Limitations are risk of infeciton and other side effects |
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Term
| What is significant regarding methotrexate? |
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Definition
- 1st line of DMARD therapy
- Down-regulates inflammatory pathways
- Analog of folic acid, so interferes with enzyme functions, must supplement with folic acid as a result
- Category X, don't use with alcohol or with an Scr < 2.0
- Monitor pulmonary function; if sign of Acute Interstitial Pneumonitis, D/C MTX immediately |
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Term
| What is significant regardign MTX dosing? |
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Definition
- At 7.5mg/week, oral = parenteral
- At >7.5mg/week, oral absorption drops by 30% more than parenteral
pMTX Plasma Levels
nSub-therapeutic <20nmol/L - Patient may not be metabolizing MTX effectively. Is the patient taking it correctly, should the patient be switched to parenteral
nIntermediate 20-60nmol/L - patient may need more exposure to MTX. Is time on therapy sufficient? Could dose be adjusted?
nTherapeutic >60nmol/L - patient is metabolizing MTX effectively. Non-responder-Could another DMARD be added? |
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Term
| What if there is an inadequate response to MTX therapy |
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Definition
Poor prognosis - Switch to or add TNF antagonist
Without poor prognosis - Combine with another convential DMARD (Sulfasalazine, hydroxychloroquine, or leflunomide)
Failure after combo - Consider biologic DMARD |
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Term
| Name the biologic DMARDs that fall under the drug classes: TNF Antagonists, IL-1 Receptor antagonist, IL-6 Receptor Antagonist, Costimulation Modulator, B-cell Modulator |
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Definition
pTNF-∝ Antagonists
nInfliximab (Remicade)
nEtanercept (Enbrel)
nAdalimumab (Humira)
n*Golimumab (Simponi)
n*Certolizumab pegol (Cimzia)
pIL-1 Receptor Antagonist
nAnakinra (Kineret)
pIL-6 Receptor Antagonist
n*Tocilizumab (Actemra)
pCostimulation Modulator
nAbatacept (Orencia)
pB-cell Modulator
nRituximab (Rituxan)
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Term
| When would you use Abatacept? |
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Definition
- Inadequate response with MTX/MTX combo/other DMARD's
- Moderate disease activity or higher
- Poor prognosis |
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Term
| When would you use Rituximab? |
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Definition
- Inadequate response to MTX/MTX Combo/non-biological DMARDS
- high disease
- Poor prognosis |
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Term
| What are the limitations to biological DMARDs? |
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Definition
- Risk associated with therapeutic immunosuppression
Increased:
- Risk of opportunistic infections
- Risk of serious infections
- Risk of lymphomas |
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Term
| How would you counsel on, and monitor, DMARD therapy? |
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Definition
SC Administration: Etanercept (Enbrel), Adalimumab (Humira), Golimumab (Simponi), Certolizumb pegol (Cimzia)
Key counseling points:
- Know when to hold a dose --> infection
- Have sharps container ready
- Take pen out of refrigerator ~15 prior
- Never inject into broken skin
MTX, Sulfasalazine, Leflunomide: first three months monitor labs q 2-4 weeks. After that do q 8-12 weeks
Biologics: Monitor for signs of infection, tell patient's to contact physician if they get an infection
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Term
| Which RA options are unsafe during pregnancy? Which are safe? |
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Definition
pRA medications CI during pregnancy
nLeflunomide- Category X
nMethotrexate- Category X
nCyclophosphamide
nPenicillamine
pSafe options:
nGlucocorticoids- Category B
nHydroxychloroquine- Category B
nSulfasalazine- Category B
nBiologics- Category B but LIMITED human data |
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Term
| Overall, what are the key concepts of Rheumatoid Arthritis therapy? |
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Definition
- RA is a systemic autoimmune disease causing symmetrical joint inflammation, and may involve other organs
- Morning stiffness lasting >1 hour is indicative of RA
- Know how to differentiate between RA and OA
- Identify and treat comorbidities associated with RA
- Always consider prophylaxis for osteoporosis
- Use corticosteroids and NSAIDS as a bridge to DMARD therapy, symptomatic relief initially |
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