If patients have ____ antigen, they are almost 4x as likely to have RA
rheumatoid factor (present in 2/3 of patients)
If a patient has this antibody, they are considered seropositive for RA
2-3 weeks (6 months for max effect)
What is the onset time of methotrexate?
GI, hematologic, pulmonary, hepatic, teratogenic, folic acid deficiency
What supplementation might be required while on MTX?
kidneys 80% unchanged
How is methotrexate eliminated?
What is the DMARD of choice?
oral, IM, SC, parenterally
MTX can be administered how?
Inhibits cytokine production and purine biosynthesis (may stimulate adenosine release)
FALSE (it's reversible)
TRUE/FALSE - MTX GI involvement is irreversible
leflunomide (oral DMARD)
Inhibits pyrimidine synthesis which decreases lymphocyte proliferation and modulation of inflammation
leflunomide (onset within 1 month with loading dose, longer without)
DMARD with a loading dose
alopecia, hepatitis, GI distress, teratogenic
TRUE/FALSE - leflunomide can be used in pregnancy
ALT, CBC with platelets (baseline and every 1-2mos)
What needs to be monitored with leflunomide
Because this DMARD will take months to leave the body, cholestyramine is sometimes used to help eliminate it
hydroxychloroquine (report visual problems immediately)
DMARD that requires an eye exam
GI, ocular, dermatologic, neurologic (headache)
Toxicities of hydroxychloroquine
radiographic outcomes, improvement in symptoms
Hydroxychloroquine does not improve ____, but you can see _____
Onset of hydroxychloroquine
Active metabolite of sulfasalazine
2months (stop if no effect after 4)
Onset time for sulfasalazine
CBC with PLTs (baseline, then weekly, then monthly)
What needs to be monitored with sulfasalazine?
DMARD that can turn skin dark yellow/orange
sulfasalazine (unlike hydroxychloroquine)
____ improves radiographic outcomes
antibiotics and iron
Absorption of sulfasalazine decreases with _____
Absorption of ____ decreases with antibiotics and iron
MTX + leflunomide or HCQ or sulfasalazine or sulfasalazine+HCQ
Combination DMARD therapy (oral) might include ____
disease is difficult to control (use lowest dose possible)
When is chronic corticosteroid use indicated in RA?
bridging to DMARD, high dose bursts (to suppress flare ups), chronic use (in hard to control disease)
What are the roles of corticosteroids in RA therapy?
When are IV corticosteroids indicated in RA?
non-adherent patient (2-6 weeks of relief)
When are intramuscular corticosteroids indicated in RA?
small number of joints affected (want less systemic effects, no more than 3 per joint per year)
When are intraarticular injections indicated in RA?
calcium, vitamin D, bisphosphonate
What supplements can be taken with chronic corticosteroid use?
HPA suppression, Cushings, osteoporosis, glaucoma, cataracts, gastritis, electrolytes, glucose intolerance, HTN
What are the side effects associated with corticosteroids usage?
NSAID toxicities that require monitoring
TRUE/FALSE - NSAIDs are never used for RA monotherapy
TRUE (only relieve symptoms)
TRUE/FALSE - NSAIDs don't alter the course of RA
First line agents for RA therapy