Scheduled maintenance: Wednesday, February 8 from 10PM to 11PM PST

Only $35.99/year

20_Bones

Terms in this set (426)

Pharmacists in an Ambulatory Care or Community Pharmacy setting are faced with needing to make
informed decisions for patients in a relatively short period of time (to avoid delays and backups).
1. Most clinicians will allow 60 seconds to search for an answer to a question before allowing the question
to go unanswered.
2. Clinicians will develop one to two patient care questions for every two to three patient encounters but
will only be able to answer 10%-20% of these questions.
3. Pharmacists should have an information network in place that provides them with quick access to highquality
resources to quickly summarize information to answer patient care questions at the point-of-care.
4. Extensive searches of databases such as the National Library of Medicine (PubMed) and reading fulltext
journal articles are important but not feasible at the point-of-care.

what are Evaluating Point-of-Care Resources?

Professional treatment guidelines
Hunting tools
Foraging tools

what are Professional treatment guidelines?

a. Usefulness determined by:
i. Relevance: The applicability of the information in the guideline. The guideline should address
the applicable population, outcomes that are important to the clinician and the patient, and
information that influences how a condition is managed.
ii. Validity: The quality of the information based on the justification of recommendations (strength
of recommendations) and the quality of the evidence to support these recommendations (level of evidence).
iii. Work: The speed and ease at which information is accessed for use at the point-of-care
b. If a resource/guideline fails to meet an acceptable level for any of these three categories (practitioner
dependent), then consider the resource/guideline as NOT good for use at the point-of-care.

what are Hunting tools?

a. Online or print resources that allow providers to easily search and access information at the pointof-care
b. Usefulness determined by:
i. Relevance: The database or print tool addresses patient conditions that are common in the
pharmacist's area of practice (e.g., family medicine office, anticoagulation clinic, diabetes
clinic, community pharmacy).
ii. Validity: The database or tool describes the process for updating its information: to what extent
it searched for new information and the frequency at which it is updated. It also provides a key
for determining the quality of the evidence and strength of recommendations it provides.
iii. Work: The database or tool can be used quickly on a computer or through portable electronic
device while caring for a patient.
iv. If a tool fails to meet an acceptable level for any of these three categories (practitioner
dependent), then consider the guideline as NOT good for use at the point-of-care.
c. Example hunting tools include the following:
i. EBSCOhost DynaMed
ii. UpToDate
iii. Essential Evidence Plus
iv. The NNT

what are Foraging tools?

a. Online or print resources that act as an early alert system of useful information for practitioners, that may change their practice.
b. Usefulness is determined by:
i. Relevance: The early alert system addresses patient conditions that are common in the
pharmacist's area of practice (e.g., internal medicine clinic, hypertension management, health
screenings, community pharmacy programs).
ii. Validity: The early alert system describes the process for searching and acquiring its information:
to what extent it searched for new information and the frequency at which it is updated. It also
provides a key for determining the quality of the evidence it provides.
iii. Work: The early alert system uses a notification and access system that providers can easily
review and access to search for historical alerts.
iv. If a tool fails to meet an acceptable level for any of these three categories (practitioner
dependent), then consider the guideline as NOT good for use at the point-of-care.
c. Example foraging tools include the following:
i. BMJ Evidence Updates
ii. NTK (Need to Know) Institute
iii. Pharmacist's Letter

what are worksheets?

Worksheets for evaluating the usefulness of point-of-care tools are available at http://medicine.tufts.edu/
Education/Academic-Departments/Clinical-Departments/Family-Medicine/Center-for-InformationMastery

what are osteoporosis guidelines?

1. 2011 U.S. Preventive Services Task Force (USPSTF)
2. 2014 National Osteoporosis Foundation (NOF)
3. 2010 American College of Rheumatology (ACR) (glucocorticoid-induced osteoporosis) - being updated
for release in 2017
4. National Institute for Health and Care Excellence (NICE) clinical pathway (last major update September
2016)

Factors Associated with Decreased BMD and/or Osteoporotic Fractures

table

Factors Associated with Decreased BMD and/or Osteoporotic Fractures

...

Fracture Prevention Counseling (all individuals older than 50 years)

table

what are National Osteoporosis Foundation (2014) screening recommendations?

Women:
BMD testing
> 65 years
Postmenopausal (age 50-69 years) with
clinical risk factors
Vertebral imaging
Age > 70 years if BMD at any location is
greater than −1 SD
Age 65-69 years if BMD at any location is
greater than −1.5 SD
Postmenopausal woman: Age > 50 years
with risk factors (low BMI, previous lowtrauma
fracture, high-risk medication use,
height loss)
Men:
BMD testing
> 70 years
Age 50-69 years with clinical risk factors
Vertebral imaging
Age > 80 years if BMD at any location is
greater than −1 SD
Age 70-79 if BMD at any location is greater
than −1.5 SD
Men: Age > 50 years with risk factors (low
BMI, previous low-trauma fracture, highrisk
medication use, height loss)

what are U.S. Preventive Services
Task Force (2011) recommendations?

Women:
≥65 years without known
fractures or secondary
causes of osteoporosis
Age 50-65 years with 10-year
major osteoporotic risk
(FRAX) > 9.3%

Men: no recommendations

what are American Association of
Clinical Endocrinologists (2010) recommendaions?

Women:
≥65 years
≤65 years at an increased risk of
fracture, based on risk factors

Men: no recommendations

what are Fracture Risk Assessment Tools ?

WHO FRAX
ClinRisk QFracture
Peripheral
(Calcaneal) DXA

what is WHO FRAX?

Available online at www.sheffield.ac.uk/FRAX
Developed to assess a 10-year probability for hip or other major osteoporotic fracture
For screening, results may be used to identify patients who require diagnostic evaluation
with a DXA scan, but it is not a definitive tool for deciding to treat a patient
For treatment, results may be used to determine whether patients with osteopenia require
pharmacologic treatment (see Figure 1)
Consider treatment with antiresorptive agent when 10-year risk of any major osteoporotic
fracture is > 20% or his fracture > 3%

what is ClinRisk QFracture?

Available at http://qfracture.org
Developed by ClinRisk Ltd. to assess the 10-year risk of developing an osteoporosisrelated
fracture in patients from the United Kingdom
Consider diagnostic evaluation with a DXA scan in the following situations:
Women's 10-year risk calculated to be ≥8.75%
Men's 10-year risk calculated to be ≥2.11%

what is Peripheral
(Calcaneal) DXA?

Useful tool found in many community screenings
This method of screening/assessment is useful for identifying individuals with a low BMD, but it should not be used as a diagnostic tool to quantify the severity of bone loss
Pharmacies using this form of outpatient DXA should develop a policy and/or protocol
for referral of patients to a physician if the test results are abnormal and require additional
investigation

what is diagnostic criteria?

Dual-energy x-ray absorptiometry
Quantitative ultrasonography (QUS)
Quantitative computed tomography

what is Dual-energy x-ray absorptiometry?

a. Definitions
i. T-score: Reports how many standard deviations (SDs) separate a patient's BMD compared with
the BMD of a young, healthy adult of the same sex
ii. Z-score: Reports how many SDs separate a patient's BMD compared with the BMD of another
patient matched for age, sex, and ethnicity
b. Measures the lumbar spine (1-4) and femoral neck of nondominant hipc. T-scores are based on the mean BMD for a healthy young man or woman.
i. "Normal": 0-1 SDs below the mean value
ii. Osteopenia: 1-2.5 SDs below the mean value
iii. Osteoporosis: Greater than 2.5 SDs below the mean value
d. The lumbar spine T-score is reported as the average of L1-L4. Consider a diagnosis of osteoporosis if two individual lumbar spine measurements are greater than 2.5 SDs below the mean, regardless of the lumbar spine average.
e. If a patient's Z-scores are greater than 2 SDs below the mean, the result is usually indicative of
accelerated bone loss unrelated to menopause and/or aging.

what is Quantitative ultrasonography (QUS)?

a. Does not measure BMD, but assesses fracture risk by using speed of sound and broadband ultrasound attenuation
b. Not associated with radiation exposure
c. QUS may be as good of a predictor of fracture as DXA, but more evidence is needed to fully
support. NOF still recommends as an alternative.
d. T-scores are not comparable to those from DXA and should not be compared or used interchangeably

what is Quantitative computed tomography?

Able to predict fracture risk, but with greater radiation exposure than DXA

what is Additional Tests to Consider When Evaluating for Secondary Causes of Osteoporosis?

what is Osteoporosis evaluation and treatment algorithm.?

what are Nonpharmacologic Interventions?

what is STEPS Analysis?

Safety
Tolerability
Efficacy
Preference (Pearls)
SIMPLICITY

what is Safety component in calcium STEPS analysis?

May increase in risk of myocardial infarction
Nephrolithiasis risk slightly increased with calcium carbonate
Hypercalcemia in patients with later-stage chronic kidney disease

what is Tolerability in calcium STEPS analysis?

Constipation
GI discomfort

what is Efficacy in calcium STEPS analysis?

Improves and/or sustains bone mineral density
With or without vitamin D, evidence that calcium supplementation reduces fracture risk is not
robust; some isolated studies show benefit, but systematic reviews and meta-analyses do not
agree whether there is a significant impact

what is Preference
(Pearls) in calcium STEPS analysis??

Calcium citrate preferred in following instances:
Chronic gastric acid-suppressive therapy
Intolerance of calcium carbonate formulations
Should be used (at a minimum) in patients receiving chronic systemic corticosteroid therapy
Should be administered with an appropriate dose of vitamin D

what is simplicity in calcium STEPS analysis?

Various formulations available to meet the needs of patients:
Tablets (varying sizes)
Chewable tablets
Soft chews and "gummy" formulations

what is pharmacologic interventions of osteoporosis?

Calcium supplementation
Vitamin D
Bisphosphonates
RANKL antagonist
Estrogen replacement therapy
Estrogen Receptor Agonist/Antagonist (ERA/A)
Parathyroid hormone
Calcitonin (Miacalcin, Fortical)

what does Calcium supplementation include?

Available formulations (be aware of whether calcium supplement labels list
calcium content as elemental or compound)
a. Calcium carbonate (40% elemental)
b. Calcium citrate (21% elemental)

what are Vitamin D: Available formulations?

a. Vitamin D2 (ergocalciferol)
b. Vitamin D3 (cholecalciferol)

what is Safety in Vitamin D STEPS?

Annual dosing alternatives (500,000 units) may result in higher rates of falls and fractures in
older patients

what is Tolerabilty in Vitamin D STEPS?

Hypercalcemia
Constipation

what is efficacy in Vitamin D STEPS?

Increases BMD
May reduce risk of falls in elderly population with low serum vitamin D concentrations

what is Preference
(Pearls) in vitamin D STEPS?

Unclear whether vitamin D without calcium is effective for improvement in bone mineral
density or fracture prevention
In elderly patients with low vitamin D concentrations, daily administration of vitamin D may be
associated with a reduced fall risk (800 units/day)
NOF recommends replacement strategy of 50,000 units weekly for 8 to 12 weeks and/or a serum
25-OH Vitamin D concentration of about 30 ng/ml; After that, maintain serum concentrations
using 1,500 to 2,000 mg each day

what is Simplicity in vitamin D STEPS?

Co-formulated with calcium supplements (200-400 units per dose)
Administered daily as 400- to 1000-unit tablets/capsules
Option for quarterly dosing (100,000 units every 3 months) is available

what are available agents of bisphosphonates?

a. Alendronate (Fosamax; Fosamax Plus D; Binosto [effervescent])
b. Ibandronate (Boniva)
c. Risedronate (Actonel, Atelvia [delayed release])
d. Zoledronic acid (Reclast)

What is brand of Alendronate?

(Fosamax; Fosamax Plus D; Binosto [effervescent])

what is brand of Ibandronate ?

(Boniva)

what is brand of Risedronate ?

(Actonel, Atelvia [delayed release])

what is brand of Zoledronic acid ?

(Reclast)

what is Safety in Bisphosphonates STEPS?

Major concerns, but of low prevalence (risk will increase with longer duration of use):
Osteonecrosis of the jaw (medication-related osteonecrosis of the jaw [MRONJ])
Subtrochanteric fracture
Major concerns, proved to NOT be of risk:
Esophageal cancer
Atrial fibrillation
Cautious use in patients with impaired renal function (CrCl < 30 mL/minute for risedronate and
ibandronate or < 35 mL/minute for alendronate and zoledronic acid) or low serum calcium
concentration
In patients with hypocalcemia, resolve low calcium values before starting therapy

what is Tolerability in Bisphosphonates STEPS?

Abdominal pain
Acute-phase reaction (zoledronic acid and ibandronate infusions)
Arthralgias
Dyspepsia
Cautious use in patients with severe esophageal reflux disease, Barrett esophagus, or esophageal
strictures
Scleritis and/or uveitis

what is Efficacy in Bisphosphonates STEPS?

All bisphosphonates have evidence to support use for preventing vertebral fractures
Alendronate, risedronate, and zoledronic acid have proved efficacious for preventing non-vertebral
and hip fractures
Used in patients taking chronic systemic corticosteroids to prevent BMD loss and subsequent
fracture (see Rheumatoid Arthritis, Figure 5 and Figure 6, for assistance when deciding to use a
bisphosphonate for corticosteroid-induced BMD loss)

what is Preference
(Pearls) in Bisphosphonates STEPS?

Most oral doses should be taken with 6-8 oz of water at least 30-60 minutes before food, drink,
or other medications (risedronate delayed release should be taken with 4 oz of water right after breakfast)
Patients should remain upright for at least 30 minutes after being administered an oral dose (60
minutes with ibandronate) (Domain 1, Task 6, Knowledge 5)
If a patient is unable to tolerate one bisphosphonate, discontinue the agent until the adverse effect
resolves, and offer the patient the option to try another available bisphosphonate
Questionable efficacy beyond 5 years; may warrant reevaluation and possible discontinuance of therapy

what is Simplicity Bisphosphonates STEPS?

Once-daily, once-weekly, and once-monthly tablets; quarterly and yearly infusions
Alendronate: Prevention (5 mg/day or 35 mg/week) and treatment (10 mg daily or 70 mg weekly)
Risedronate: Prevention and treatment (5 mg daily, 35 mg weekly, or 150 mg monthly)
Ibandronate: Prevention (150 mg monthly) and treatment (150 mg monthly OR 3 mg intravenously every 3 months)
Zoledronic acid: Prevention (5 mg intravenously every 2 years) and treatment (5 mg intravenously every year)
All dosage forms and intervals are equally effective, so consider the patient's prescription drug coverage (or lack of) when choosing a medication

what are RANKL antagonist ?

Denosumab (Prolia)

what is low fraction risk?

no evidence of osteoporosis

what is duration Before
Discontinuance/Holiday of low fraction risk?

Therapy not indicated

what is Mild fraction risk?

T-score between -1 and -2.5 SD with risk factors for fracture;

what is duration Before
Discontinuance/Holiday of mild fraction risk?

not recommended

what is moderate fraction risk?

T-score less than -2.5 SD with risk factors for fracture;

what is duration Before
Discontinuance/Holiday of moderate fraction risk?

Between 5 and 10 years

when can one restart therapy after discontinuation of moderate fraction risk?

2 to 3 years

what is high fraction risk?

T-score less than -2.5 SD with history of fracture

what is duration Before
Discontinuance/Holiday of moderate fraction risk?

10 years

when can one restart therapy after discontinuation of moderate fraction risk?

1 to 2 years; may consider using non-bisphosphonate
during holiday (e.g. teriparatide, denosumab)

what is brand of Denosumab ?

(Prolia)

what is Safety in RANKL Antagonist STEPS?

Cellulitis was the most common serious adverse event in clinical trials
Osteonecrosis of the jaw
Infections

what is Tolerability in RANKL Antagonist STEPS?

Eczema
Flatulence

what is Efficacy in RANKL Antagonist STEPS?

Decreased incidence of vertebral, non-vertebral, and hip fractures in patients with osteoporosis
Increases bone mineral density in the hip and lumbar spine
Comparable in efficacy to the bisphosphonates, but with much less frequent dosing

what is Preference
(Pearls) in RANKL Antagonist STEPS?

NICE in the United Kingdom recommends denosumab for patients at risk of an osteoporotic
fracture and unable to adhere to the dosing recommendations or tolerate an oral bisphosphonate
Must be administered by a health professional, either in a physician's office practice or by a
pharmacist

what is Simplicity in RANKL Antagonist STEPS?

Subcutaneous injection every 6 months

what is NICE Recommendations for T-Score at Which to Recommend Denosumab as an Alternative to
Bisphosphonates ?

table

what is Safety in Estrogen Replacement STEPS?

Based on information from the WHI trial, the risk of adverse events with hormone replacement
therapy exceeds the fracture prevention benefits
Hormone replacement therapy is more likely to be associated with the following:
Coronary heart disease (estrogen/progesterone only) Stroke Invasive breast cancer (estrogen/progesterone only)
Venous thromboembolic event

what is Tolerability in Estrogen Replacement STEPS?

Breast discomfort
GI symptoms
Headache disorders
Vaginal bleeding
Venous thromboembolism

what is Efficacy in Estrogen Replacement STEPS?

Reduced risk of vertebral fractures
Reduced risk of non-vertebral fractures

what is Preference
(Pearls) in Estrogen Replacement STEPS?

Results from the WHI trial showed the benefit of fracture prevention to be similar to or less than
the patient's risk of heart disease, stroke, venous embolism, and breast cancer
Acts in conjunction with a bisphosphonate to increase BMD more than either agent alone

what is Simplicity in Estrogen Replacement STEPS?

Once-daily oral dosing
Transdermal patch is approved for the prevention of postmenopausal osteoporosis

what is Estrogen Receptor Agonist/Antagonist (ERA/A)?

Raloxifene (Evista)

what is brand of Raloxifene ?

(Evista)

what is Safety in Estrogen Receptor Agonist/Antagonist STEPS?

Increased risk of fatal stroke in women with a history of coronary heart disease
Increased risk of venous thromboembolism

what is Tolerabilty of Estrogen Receptor Agonist/Antagonist STEPS?

Arthralgias
Hot flashes/flushes
Peripheral edema
Sweating

what is Efficacy of Estrogen Receptor Agonist/Antagonist STEPS?

Increased BMD
Reduced incidence of clinical vertebral fractures, but not non-vertebral fractures

what is Preference
(Pearls) Receptor Agonist/Antagonist STEPS?

The rates of preventing clinical vertebral fractures are similar to rates of venous
thromboembolisms
Evidence to support its use to prevent invasive breast cancer (5-year risk > 3%)

what is Simplicity of Estrogen Receptor Agonist/Antagonist STEPS?

Fixed-dose, once-daily dosing

what is Parathyroid hormone?

Teriparatide (biosynthetic parathyroid hormone 1-34) (Forteo)

what is Safety in Parathyroid Hormone STEPS?

Avoid use in patients with the following:
Alkaline phosphatase elevation (unexplained)
Open epiphyses
Paget disease
Prior skeletal radiation
Associated with osteosarcoma (in rats) after about 24 months of therapy (3-60 times the human dose)

what is Tolerability in Parathyroid Hormone STEPS?

Influenzalike symptoms
Hypercalcemia
Injection site pain and/or rash
Urolithiasis

what is Efficacy in Parathyroid Hormone STEPS?

Increases vertebral and total hip BMD
Decreased incidence of new or worsening vertebral and non-vertebral fractures
Prevents BMD loss and vertebral fractures in patients receiving chronic systemic
corticosteroid therapy

what is Preference (Pearls) in Parathyroid Hormone STEPS?

Diminished efficacy if used concurrently with a bisphosphonate
After discontinuing teriparatide, adding a bisphosphonate preserves BMD benefits
Dropout and discontinuance rates in clinical studies are almost double those of alendronate

what is Simplicity in Parathyroid Hormone STEPS?

Once-daily injection
Available as a prefilled (3 mL) pen

what are NICE Recommendations for When to Use Teriparatide as an Alternative to Bisphosphonates for Secondary Prevention of Fragility Fractures?

what is brand of Teriparatide?

(Forteo)

what is brand of Calcitonin ?

(Miacalcin, Fortical)

what is Safety in Calcitonin STEPS?

Anaphylactoid and anaphylaxis reactions associated with injection

what is Tolerability in Calcitonin STEPS?

Injection
GI symptoms
Injection site reaction
Flushing

Nasal spray
Rhinitis
Nasal congestion
Mucosal irritation

what is Efficacy in Calcitonin STEPS?

Reduced incidence of recurrent vertebral fractures
Beneficial effects on BMD in patients treated with steroid-induced disease

what is Preference (Pearls) in Calcitonin STEPS?

Inferior to alendronate for preventing BMD loss
May help relieve bone pain associated with fractures but is not an indication to choose as the
primary treatment
FDA (2013) stated that the lack of effectiveness combined with the increased risk of cancer (oral
calcitonin) raises concerns about the overall utility of calcitonin

what is Simplicity in Calcitonin STEPS?

Nasal administration in only ONE nostril per day, alternating nostrils each day

what is Follow up of osteoporosis?

Dual-energy x-ray absorptiometry
Medication adherence
Patient resources

what does Dual-energy x-ray absorptiometry follow up include

a. Recheck at around 24 months to evaluate for changes: Do not consider treatment failure if initial, solitary evaluation shows net bone loss.
b. In patients NOT receiving drug therapy, may recheck DXA findings every 5 years, unless the patient has developed risk factors for osteoporotic fracture

what does Medication adherence follow up include?

a. Review adherence at least every 6 months.
b. As many as one-half of patients being treated with a bisphosphonate will self-discontinue therapy within the first 6 months, so pharmacists should continually assess for medication adherence.

what does Patient resources follow up include?

a. Various handouts available from the American Family Physician website
b. National Library of Medicine MedlinePlus has patient-oriented educational materials at no cost to provider or patient.
c. National Osteoporosis Awareness and Prevention Campaign examination room booklets and posters

what is Cost-effectiveness Evaluation?

1. The World Health Organization (WHO) defines cost-effectiveness at three levels.
a. Highly cost-effective: Less than the gross domestic product (GDP) per capita of a WHO region
b. Cost-effective: Between one and three times the GDP per capita of a WHO region
c. Not cost-effective: Greater than three times the GDP per capita of a WHO region
2. For the region of North America (Amro A), the GDP per capita per WHO is $39,950.
a. Highly cost-effective: Less than $39,950
b. Cost-effective: $39,950 to $119, 849
c. Not cost-effective: Greater than $119,849
3. The available evidence for cost-effectiveness of antiresorptive and other agents for osteoporosis is as
follows:
a. Bisphosphonates (about $11,600/quality-adjusted life-year [QALY])
b. RANKL inhibitors (about $31,600/QALY, but possibly less with more recent reviews)
c. Estrogen-receptor agonist/antagonist (about $26,100/QALY for breast cancer prevention, about $164,200/QALY for fracture prevention)
d. Biosynthetic parathyroid hormone (about $264,500/QALY)

what is Physician Quality Reporting System 2015 Quality Measures ?

(physician-reported quality of care to the
Centers for Medicare & Medicaid Services)

2016 Physician Quality Reporting System Quality Measures

what is dose of Calcium plus vitamin D in osteoporosis?

500 mg of elemental calcium PLUS vitamin D 400
international units twice daily

what is dose of alendronate in osteoporosis?

5-10 mg by mouth once daily
35-70 mg by mouth once weekly

what is dose of risedranate in osteoporosis?

5 mg by mouth once daily
35 mg by mouth once weekly
150 mg by mouth once monthly

what is dose of Ibandronate in osteoporosis?

150 mg by mouth once monthly
3 mg intravenously every 3 months

what is dose of Zoledronic acid in osteoporosis?

5 mg intravenously every 1-2 years

what is dose of Denosumab in osteoporosis?

60 mg subcutaneously every 6 months

what is dose of Raloxifene in osteoporosis?

60 mg by mouth once daily

what is dose of Teriparatide in osteoporosis?

20 mcg subcutaneously once daily

what is dose of Calcitonin in osteoporosis?

100 units intramuscularly every other day
200 units sprayed into one nostril each day

what are clinical guidelines of rheumatoid arthritis?

1. 2010 rheumatoid arthritis (RA) classification criteria: An ACR/European League Against Rheumatism
(EULAR) collaborative initiative
2. The EULAR 2013 recommendations for the management of RA with synthetic and biologic diseasemodifying
drugs
3. 2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis

what is Patient Symptom Presentation of rheumatoid arthritis?

1. Diffuse pain (myalgias, arthralgias, arthritis)
2. Variable time to symptom onset
3. Morning joint stiffness (gelling) lasting more than 1 hour
4. Affected joints are swollen and inflamed.
a. Large joints: shoulders, elbows, hips, knees, ankles
b. Small joints: wrists and hands/fingers (proximal interphalangeal and metacarpo(tarso)phalangeal
joints)

what are Other Contributing Factors of rheumatoid arthritis?

1. Family history of other inflammatory disorders such as the following:
a. Autoimmune thyroid disease
b. Multiple sclerosis
c. Myasthenia gravis
d. Rheumatoid arthritis
e. Systemic lupus erythematosus
2. Smoking is associated with increased disease activity.

what is Evaluation and Diagnosis: 2010 ACR/EULAR Classification Criteria for RA?

1. Test patients who have at least one joint with clinical synovitis not otherwise explained by another
disease (e.g., systemic lupus erythematosus [SLE], gout, psoriatic arthritis).
2. Although this tool (Table 20) is not intended to be diagnostic, a score of at least 6 of 10 points classifies patients as having definite RA. (Note: Use the highest score from each category.)
3. Classification criteria score of at least 6 may also be a good guide for identifying individuals with the highest probability of persistent or erosive disease who would benefit from enrolling in clinical trials or DMARD intervention.

what is 2010 ACR/EULAR Classification Criteria for Rheumatoid Arthritis?

table

what is Testing to Consider for Diagnosis and Treatment Decisions in RA?

table

what is Disease Prognosis of ra?

table

what does one need to do Before Initiating Pharmacologic Therapy?

1. Address the entire scope of patient needs with respect to RA.
a. Discuss potential functional limitations and strategies to overcome and/or compensate.
b. Involve other health professionals to care for and educate the patient.
i. Physical therapy
ii. Occupational therapy
iii. Social workers and counseling/cognitive services
2. Educate the patient regarding physical conditioning.
a. Energy conservation
b. Joint protection
c. Range-of-motion exercises
d. Strengthening exercises
3. Tuberculosis screening
4. Immunizations

what is Vaccinations to Consider in Patients Receiving Rheumatoid Arthritis Immunosuppressive Therapy ?

table

what are 2015 ACR recommendations for the treatment of RA in patients with disease duration of less than 6 months?

fig

what are 2015 ACR recommendations for the treatment of RA in patients with disease duration of greater than 6 months?

fig

what is EULAR-recommended use of nonbiologic and biologic DMARDs.?

fig

what are American College of Rheumatology (2015 update) guideline recommendations?

a. Symptomatic pain control achieved with the following:
i. Nonsteroidal anti-inflammatory drugs
ii. Low-dose systemic steroids (ACR defines as 10 mg of prednisone per day or less)
iii. Local steroid injections (not more often than every 3 months)
b. DMARDs (preference to methotrexate) should be initiated within the first 3 months of diagnosis
as monotherapy or combination therapy, depending on the patient's prognosis and disease activity.
c. ACR recommendations consider a patient's ability to pay for therapy as self or through a third party.

what are European League Against Rheumatism (2013 update)?

a. Initiate synthetic DMARDs early - as soon as the patient's condition is diagnosed
(see Figure 4 for EULAR's recommended treatment algorithm).
i. Methotrexate is preferred as first-line over all available classes for all levels of disease severity.
ii. Consider leflunomide or sulfasalazine when methotrexate is contraindicated or not tolerated by
the patient.
iii. Initiate DMARD with a systemic corticosteroid.
(a) Begin to taper the corticosteroid to the lowest effective dose with target of discontinuing
at or before 6 months.
(b) If the patient is unable to discontinue systemic corticosteroids, modify DMARDs to better
control symptoms.
(c) In some severe cases, providers may choose to use two nonbiologic DMARDs when
initiating therapy (6 months).
b. Consider changing synthetic and biologic DMARDs if patient has an inadequate response to therapy.
c. Remission may be defined as tender or swollen joints count, C-reactive protein concentration, and patient global assessment score of < 1. It may also be a simplified DAS of < 3.3.
d. In patients who show evidence of persistent remission, consider the following:
i. Tapering the dose of corticosteroids
ii. Tapering biologic DMARDs
iii. Decreasing the dose of synthetic DMARDS to the lowest efficacious dose

what is supportive care meds for rgeumatoid arthritis?

NSAIDs - systematic and /or topical
corticosteroids

what os Safety in NSAIDs STEPS?

In patients at risk of or with existing cardiovascular disease, NSAIDs may increase the risk of a fatal or nonfatal event
All NSAIDs carry the risk of causing changes in renal function
Patients at greater risk of GI toxicity include the following:
Elderly patients
Patients with a history of GI bleed
Patients concurrently using anticoagulants, antiplatelet drugs, and/or systemic corticosteroids

what is Tolerability in NSAIDs STEPS?

Dyspepsia
Prolonged bleeding
Dermatologic reactions

what is Efficacy in NSAIDs STEPS?

Available NSAIDs are equally effective, but individuals' responses to agents will vary
NSAIDs will reduce joint pain and swelling to some degree, but they will not modify the
destruction or progression of RA

what is Preference (Pearls) in NSAIDs STEPS?

Celecoxib has fewer GI adverse events than other NSAIDs; however, it is no more effective at
reducing pain and inflammation
Adding misoprostol to an NSAID will decrease the risk of GI ulceration
Adding a proton pump inhibitor to an NSAID will decrease nonulcerative symptoms
If a patient does not achieve response to NSAID therapy (after an appropriate 14- to 28-day trial),
providers should consider trying other NSAIDs before concluding therapeutic failure

what is simplicity in NSAIDs STEPS?

Widely available prescription and over-the-counter agents
Once-daily formulations allow continuous analgesia

What is Safety in Corticosteroid STEPS?

Increased risk of osteoporosis and fracture
Risk of symptoms of a psychiatric disturbance with increasing doses of corticosteroids
< 40 mg of prednisone per day (1%-2% incidence)
> 40 mg of prednisone per day (5% incidence)
> 80 mg of prednisone per day (20% incidence)

what is Tolerability in Corticosteroid STEPS?

Cataracts
Dyslipidemia (high dose)
Glaucoma
Hirsutism
Hyperglycemia

Hypertension (high dose)
Hypothalamic-pituitary-adrenal axis suppression
Osteoporosis
Pancreatitis (high dose)
Weight gain

what is Efficacy in Corticosteroid STEPS?

Short-term (weeks), low-dose (< 10 mg of prednisone daily) corticosteroids are effective for
symptoms flare
Early initiation of corticosteroids and continuance at a low dose reduce joint destruction and
increase likelihood of clinical remission
Higher corticosteroid doses may be warranted to treat symptoms of severe or advanced disease
(e.g., presence of vasculitis)
Intra-articular injections may be beneficial, but limit injections in joint to no more often than
every 3-4 months

what is Preference (Pearls) in Corticosteroid STEPS?

Start calcium and vitamin D supplementation in all patients taking corticosteroid therapy
See Figure 5 and Figure 6 for recommendations for using bisphosphonates in patients receiving
chronic corticosteroid therapy

what is Simplicity in Corticosteroid STEPS?

Once-daily fixed dose appears to be effective for symptom control and possibly slowing disease
progression

what is Preventing corticosteroid-induced BMD loss in postmenopausal women and men older than 50 years.?

fig

what is Preventing corticosteroid-induced BMD loss in premenopausal women and men younger than 50 years?

fig

what are synthetic DMARDs?

Methotrexare
leflunomide
sulfasalazine

what is Safety in Methotrexate STEPS?

Contraindicated in pregnancy and breastfeeding; pregnancy should be avoided for at least 3
months with men and at least one ovulatory cycle for women after discontinuing methotrexate
Significantly diminishes ability to generate an immune response
Increased incidence of the following:
Any malignancy
Lung cancer
Melanoma
Non-Hodgkin lymphoma
Avoid in patients with the following:
CrCl < 30 mL/minute
Platelet count < 50,000/mm3
White blood cell count < 3 x 103
cells/mm3
Liver transaminase concentrations > 2 times the upper limit of normal
Avoid concurrent use of NSAIDs in patients before or while actively using high-dose methotrexate

what is Tolerability in Methotrexate STEPS?

Abdominal cramping
Anorexia
Bone marrow suppression
Hypersensitivity pneumonitis
Increased aminotransferases
Infections
Nausea
Stomatitis

what is Efficacy in Methotrexate STEPS?

Intense treatment strategy and dose may result in an increased chance of disease remission but
also an increased likelihood of having an adverse event or discontinuing therapy
Proposed benefit of decreased risk of cardiovascular mortality

what is Preference (Pearls) in Methotrexate STEPS?

Considered first choice for therapy in both ACR and EULAR recommendations
Adding a folic acid supplement decreases adverse events (1 mg daily or 5 - 10 mg weekly)
Emerging evidence that coadministration of omega-3 fatty acids with triple DMARD therapy
(methotrexate, sulfasalazine, and hydroxychloroquine) significantly reduced disease progression
Consider changing to subcutaneous methotrexate in patients with an inadequate response to oral
therapy (secondary to increased bioavailability of the injectable formulation) and/or unable to
use biologic DMARDs because of cost or other factors

what is Simplicity in Methotrexate STEPS?

Dosed as one oral dose or one subcutaneous injection weekly (5-20 mg)

what is generic of sulfasalazine?

azulfidine

what is Safety in Leflunomide (Arava) STEPS?

Stevens-Johnson syndrome and toxic epidermal necrolysis
May decrease defenses against malignancy
Women who wish to become pregnant or men who wish to father children should
discontinue leflunomide use and use cholestyramine to achieve plasma (leflunomide) active metabolite concentrations < 0.02 mg/L
Patients with preexisting liver disease or aspartate aminotransferase/alanine
aminotransferase values > 2 times the upper limit of normal should not receive leflunomide

What is Tolerability in Leflunomide (Arava) STEPS?

Alopecia
Debilitating diarrhea
Rash
Severe hepatotoxicity

What is Efficacy in Leflunomide (Arava) STEPS?

Available evidence shows leflunomide is comparable to methotrexate therapy
May be added to methotrexate therapy to further improve symptoms, but at risk of hepatic toxicity

what is Preference (Pearls) in Leflunomide (Arava) STEPS?

An alternative for patients unable to tolerate or who do not achieve response to methotrexate
therapy

what is Simplicity in Leflunomide (Arava) STEPS?

100 mg by mouth daily for 3 days (loading dose) and then 20 mg by mouth once daily
Dosage may be reduced (10 mg daily) for patients unable to tolerate full dose
Loading dose can be omitted for patients at high risk of hepatic or hematologic toxicities

what is generic of arava?

leflunomide

what is Safety in Sulfasalazine STEPS?

"Probably" safe for use in pregnancy; has not demonstrated abnormal/adverse fetal outcomes
Avoid use in patients with the following:
Platelet count < 50,000/mm3
Liver transaminase concentrations > 2 times the upper limit of normal
Acute hepatitis B/C
Chronic hepatitis B, not receiving therapy
Chronic hepatitis B, Child-Pugh class C
Chronic hepatitis C, Child-Pugh class B or C

what is Tolerability in Sulfasalazine STEPS?

GI effects (may be lessened with enteric-coated tablets)
A lupus-like syndrome has been reported in patients taking sulfasalazine

what is Efficacy in Sulfasalazine STEPS?

Available data suggest that sulfasalazine is effective at modifying rheumatic disease activity, but data are less supportive of its effects on radiologic progression

what is Preference (Perals) in Sulfasalazine STEPS?

May be an alternative for women who are (or planning to become) pregnant

what is Simplicity in Sulfasalazine STEPS?

Twice- to thrice-daily dosing
May require 2-4 tablets per dose

what are Other considerations in tx of rheumathoid arthritis?

Routine monitoring of CBC, hepatic transaminases, and serum creatinine when
starting or adjusting DMARD therapy (methotrexate, leflunomide, sulfasalazine)
a. Every 2-4 weeks for the first 3 months
b. Every 8-12 weeks until month 6
c. Every 12 weeks thereafter

what are Additional agents to consider in tx of rheumathoid arthritis?

a. Low disease activity and no poor prognostic factors
i. Hydroxychloroquine
ii. Minocycline (diagnosis less than 6 months)
b. The following medications are not recommended by the ACR because of their infrequent use and
lack of new evidence since the last iteration of the guideline.
i. Azathioprine
ii. Cyclophosphamide
iii. Cyclosporine
iv. D-penicillamine
v. Gold salts

what are Biologic DMARDs?

TNF inhibitors
T-cell inhibitor - Abatacept (Orencia)
Anti-CD20 - Rituximab (Rituxan)
Interleukin-6 Antagonist - Tocilizumab (Actemra)
Anakinra (Kineret)

what are TNF inhibitors?

a. Adalimumab (Humira)
b. Certolizumab pegol (Cimzia)
c. Etanercept (Enbrel)
d. Golimumab (Simponi)
e. Infliximab (Remicade)

what is brand of Adalimumab ?

(Humira)

what is brand of Etanercept ?

(Enbrel)

what is brand of Golimumab ?

(Simponi)

what is brand of Certolizumab pegol ?

(Cimzia)

what is brand of Infliximab ?

(Remicade)

what is Safety in TNF Inhibitors STEPS?

Increased risk of serious bacterial and/or fungal infections
Associated with reactivation of tuberculosis
May increase risk of malignancy, including melanoma, leukemia, and lymphoma
Linked with new or worsening heart failure and possibly death in patients with heart failure

what is Tolerability in TNF Inhibitors STEPS?

Headache
Abdominal pain
Injection site reactions
Upper respiratory tract infection
Infusion reactions (infliximab)

what is Efficacy in TNF Inhibitors STEPS?

First-line choice for biologic DMARDs on the basis of their ability to improve physical function
and delay radiographic changes
Superior to synthetic DMARDs with respect to radiographic outcomes
Combination with methotrexate yields better outcomes than using TNF inhibitors alone

what is Preference (Pearls) in TNF Inhibitors STEPS?

The ACR generally recommends biologic DMARDs after insufficient response to synthetic
DMARDs
The EULAR recommends biologic DMARDs after insufficient response to methotrexate or other
synthetic DMARDs
All patients receiving biologic DMARDs should be tested for (and treated for) TB before starting
RA therapy (see Figure 7 for TB screening recommendations)
Treatment is expensive for patients without insurance or suboptimal coverage
Infliximab should only be used in combination with methotrexate

what is Simplicity in TNF Inhibitors STEPS?

Doses may be given subcutaneously weekly (etanercept), every other week (adalimumab),
or every 4 weeks (golimumab)
Certolizumab is dosed subcutaneously every other week when initiating therapy and may be
extended to every 4 weeks for maintenance therapy
Infliximab is dosed intravenously every 8 weeks after completing induction therapy at 0, 2, and 6
weeks; interval may be decreased to every 4 weeks if necessary

what is T-cell inhibitor ?

Abatacept (Orencia)

what is brand of Abatacept ?

(Orencia)

what is Safety in Abatacept STEPS?

In patients with COPD, abatacept has been linked with more adverse pulmonary effects
Increased risk of developing serious infections

what is Efficacy in Abatacept STEPS?

Should not be used in combination with other biologic DMARDs
Effective for improving RA symptoms but should not be introduced until failure of at least one
TNF inhibitor
Combination with methotrexate results in higher rates of remission than methotrexate monotherapy

what is Tolerability in Abatacept STEPS?

Acute infusion reactions
Upper respiratory tract infections

what is Preference (Pearls) in Abatacept STEPS?

The ACR recommendations suggest abatacept as an option for patients with moderate to severe
disease who have not achieved remission with a nonbiologic DMARD

what is brand of Rituximab ?

(Rituxan)

what is Simplicity in Abatacept STEPS?

IV regimen: After initial infusion, administer again at 2 weeks and then at 4 weeks; then begin
administering every 4 weeks
Subcutaneous regimen: Initial IV infusion; then subcutaneous injection within 24 hours; and then
weekly thereafter

what is Anti-CD20 ?

Rituximab (Rituxan)

what is Safety in Rituximab STEPS?

Acute renal failure
Cardiac arrhythmias
Linked to fatal infusion-related adverse reactions
Mucocutaneous reactions
Progressive multifocal leukoencephalopathy
Tumor lysis syndrome

what is Tolerability in Rituximab STEPS?

Arthralgias
Hematologic effects may include lymphopenia, neutropenia, leukopenia, thrombocytopenia, and anemia
Hyperphosphatemia
Hypertension
Hyperuricemia

what is Preference (Pearls) in Rituximab STEPS?

Avoid use in patients who have not had an adequate trial with a TNF inhibitor
Avoid administering live vaccines 3 months before or during treatment with rituximab

what is Efficacy in Rituximab STEPS?

Has shown efficacy as monotherapy or as add-on therapy to methotrexate

what is Simplicity in Rituximab STEPS?

A two-dose therapeutic course (separated by 14 days) every 24 weeks (may be readministered every 16 weeks, if needed)
Consider using acetaminophen and antihistamine before infusion

what is Safety in Tocilizumab STEPS?

Serious bacterial, fungal, and viral infections reported with use
All patients should receive monitoring for tuberculosis before and after starting
tocilizumab therapy
GI perforation reported with concomitant use of tocilizumab and NSAIDs, corticosteroids, and/or
methotrexate
Avoid use in patients with the following:
Absolute neutrophil count < 2000/mm3
Platelet count < 100,000/mm3
Aminotransferase concentrations > 1.5 times the upper limit of normal

what is Interleukin-6 Antagonist ?

Tocilizumab (Actemra)

what is brand of Tocilizumab ?

(Actemra)

what is Efficacy in Tocilizumab STEPS?

Effective treatment option for patients not achieving response, or with inadequate response, to methotrexate therapy
Used in combination with methotrexate therapy

what is Tolerability in Tocilizumab STEPS?

Dyslipidemias reported
Hypersensitivity reactions starting with the second to fourth infusion
Neutropenia or thrombocytopenia
Transaminase elevations
Upper respiratory tract infections

what is Preference (Pearls) in Tocilizumab STEPS?

FDA approved for patients with an inadequate response to one or more TNF inhibitors

what is Simplicity in Tocilizumab STEPS?

Intravenous infusion every 4 weeks

what is brand of Anakinra ?

(Kineret)

what is Janus-Associated Kinase Inhibitor ?

(Xeljanz)

what is Safety in Anakinra STEPS?

Increased risk of neutropenia when combined with TNF inhibitors
High doses are associated with an increased risk of serious infection

what is Tolerability in Anakinra STEPS?

Diarrhea
Influenzalike reaction
Injection site reactions

what is Efficacy in Anakinra STEPS?

Effective for decreasing RA symptoms, but not as effective as TNF inhibitors

what is Preference (Pearls) in Anakinra STEPS?

Do not administer live vaccines to patients receiving anakinra
Not included in the ACR recommendations because of limited data available in the literature and not recommended in the EULAR guidelines because of lesser clinical efficacy in trials

what is Simplicity in Anakinra STEPS?

Once-daily subcutaneous injection

what is brand of Tofacitinib ?

(Xeljanz)

what is Tolerabilty in Tofacitinib STEPS?

Increased risk of infection
Diarrhea
Headache
Upper respiratory tract infections

what is Safety in Tofacitinib STEPS?

Bone marrow suppression
Gastrointestinal perforation in those with a history or at risk
Hepatotoxicity
Malignancy
Tuberculosis

what is Efficacy in Tofacitinib STEPS?

Effective to reduce symptoms of RA
Most studies evaluate efficacy by using ACR20 (20% improvement in RA symptoms), but others
use ACR50 (50%) or ACR70 (70%) to assess symptom improvement

what is Preference (Pearls) in Tofacitinib STEPS?

Included in 2015 ACR update as an option for patients with established disease (> 6 months) with continued disease activity despite treatment with methotrexate and/or a TNF inhibitor or nonTNF biologic agent
EULAR recommends using tofacitinib after other biologic treatments fail to control the disease

what are other patient resources for rheumathoid arthritis?

a. Patient handouts from American Family Physician
b. Online information from the Arthritis Foundation (www.arthritis.org)
c. Online information from the ACR

what is Simplicity in Tofacitinib STEPS?

Oral therapy, dosed twice daily
Price (per month) is comparable to that of most biologic DMARDs

what are Other Considerations with Biologic DMARDs?

fig
2. Biologic DMARDs are quite expensive. Medication assistance programs (www.needymeds.com) are available for those who qualify on the basis of financial need. (Domain 2, Task 6, Knowledge 2)
3. Many pharmacy insurance providers require authorization paperwork before paying for biologic DMARD therapy. (Domain 2, Task 6, Knowledge 3) (Domain 4, Task 6, Knowledge 6)
a. Step therapy: Documentation of unsuccessful treatment with one or several available conventional DMARDs
b. Prior authorization: Documentation of symptom severity or contraindications requiring advancement of therapy beyond recommended first-line agents
c. Authorization is usually temporary (12 months) and requires reevaluation to continue coverage.
d. Specialty pharmacies may ship meds to the patient's physician's office or directly to the patient. With the latter, the patient must store and take the medicine to his or her physician for administration.
e. Pharmacies (specialty or otherwise) may wait for full payment by insurance before releasing the
medicine to the patients, thereby delaying therapy or making administration scheduling difficult.
4. Support groups are available, but patients who have used support groups have not shown significant improvements in disease or outcomes.
a. Local group meetings
b. Online chat or message boards
c. Social networking groups

what are 2016 Physician Quality Reporting System Quality Measures ?

table

what is dosing of Methotrexate in rheumathoid arthitis?

5-20 mg by mouth once weekly

what is dosing of Sulfasalazine in rheumathoid arthritis?

1-3 g by mouth once or twice daily

what is dosing of Leflunomide in rheumathoid arthritis?

10-20 mg by mouth once daily

what is dosing of Tofacitinib in rheumathoid arthritis?

5 mg by mouth twice daily

What is dosing of Minocycline in RA?

100 mg by mouth twice daily

what is dosing of Hydroxychloroquine in RA?

200-600 mg by mouth once daily

what is dosing of Adalimumab in RA?

40 mg subcutaneously every other week

what is dosing of Etanercept in RA?

50 mg subcutaneously once weekly or 25 mg twice weekly

what is dosing of Certolizumab in RA?

200-400 mg subcutaneously every other week (or every 4 weeks)

what is dosing of Golimumab in RA?

2 mg/kg intravenously at weeks 0 and 4;
then every 8 weeks thereafter 50 mg subcutaneously once month

what is dosing in Infliximab in RA ?

3 mg/kg intravenously at weeks 0, 2, and 6,
and then every 8 weeks thereafter

what is dosing in Abatacept in RA ?

Initial weight-based infusion, then intravenously at weeks 2 and 4, and then every 4 weeks thereafter
125 mg subcutaneously within 24 hours of infusion, and then 125 mg subcutaneously every week thereafter

what is dosing of Anakinra in RA?

100 mg subcutaneously once daily

what is dosing in Rituximab in RA?

1000 mg intravenously at days 1 and 15, and then repeated every 24 weeks

what is dosing of Tocilizumab in RA?

4-8 mg/kg intravenously every 4 weeks

what are clinical guidelines of PSORIATIC ARTHRITIS?

1. 2009 Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA)
2. 2008 American Academy of Dermatology guidelines on management of psoriasis and psoriatic arthritis

whats are risk factors of PSORIATIC ARTHRITIS?

1. Presence of psoriasis, specifically at sites such as the scalp, nails, and/or gluteus and perineum
2. Environmental exposures - Trauma (Koebner effect) or infectious origin
3. Genetic predisposition - First-degree relative with disease increases risk.

what are subtypes of PSORIATIC ARTHRITIS?

a. Arthritis mutilans - Progressive disease with "telescoping digits"
b. Distal interphalangeal disease (DIP arthritis) - Classic symptoms presentation
c. Oligoarticular - Asymmetric arthritis, typically with dactylitis (sausage digits)
d. Polyarticular - Symmetric arthritis
e. Spondyloarthropathy - Symptoms predominantly in vertebrae, hip, and shoulder

what are History and physical findings of psoriatic ARTHRITIS?

a. Articular pain, discomfort, and/or malformation
b. Ocular inflammation
c. Psoriatic lesions on body
d. Skin and fingernail symptoms (e.g., fingernail begins to separate from nail bed)

what is Diagnostic Evaluation ?

CASPAR (ClASsification criteria for Psoriatic ARthritis) criteria are both highly sensitive and specific
for the diagnosis of psoriatic arthritis.

what are Disease Complications of PSORIATIC ARTHRITIS?

1. Rarely as severe as RA and not usually as debilitating (still painful and debilitating)
2. May result in premature cardiovascular damage or pulmonary fibrosis

what is AAD Recommendations for Classification of psoriatic arthritis?

mild
moderate
severe

what are requirements of Diagnostic Evaluation ?

Requires a score of at least 3 (of possible 6) points plus established articular inflammation
a. Current (2 points) or personal/family history of (1 point) psoriasis
b. Dactylitis (1 point)
c. Juxta-articular new bone formation (1 point)
d. Negative RF finding (1 point)
e. Nail dystrophy (1 point)

what are Negative prognostic indicators of Diagnostic Evaluation ?

a. More than five actively inflamed joints
b. Increased acute phase reactants
c. Evidence of progressive radiographic changes
d. Previous treatment with glucocorticoids
e. Functional decline (or loss thereof)
f. Deteriorated quality of life

what are GRAPPA treatment guidelines for psoriatic arthritis?

fig

what are Treatment Recommendations of psoriatic arthritis?

1. Treatment is based on agents for psoriasis and type of arthritis.
2. Initial therapy is determined by level of severity (mild, moderate, or severe).

what is Impact on Quality of Life of mild psoriatic arthritis?

Minimal

what is Impact on Quality of Life of moderate psoriatic arthritis?

Affects daily tasks of living and physical/mental functions
Lack of response to NSAID

what is tx of choice for mild psoriatic arthritis?

NSAID

what is Impact on Quality of Life of severe psoriatic arthritis?

Cannot perform major daily tasks without pain or dysfunction
Large impact on physical/mental functions
Lack of response to either DMARD or TNF blockers as monotherapy

what is tx of choice for moderate psoriatic arthritis?

DMARD
Anti-TNF

what is tx of choice for severe psoriatic arthritis?

DMARD plus anti-TNF
or other biologic therapy

what is tx of psoriatic arthritis?

NSAIDs
Synthetic DMARDs
Biologic DMARDs
Alefacept (Amevive)
Apremilast (Otezla)
Interleukin Inhibitors
Surgery may be necessary for patients whose condition does not respond sufficiently to pharmacotherapy
or who have progressive loss of joint function.
Psoralen ultraviolet A/ultraviolet B therapy may be helpful for patients with both (extensive) skin and articular disease.

what is Efficacy and Preference/Pearls for NSAIDs in Psoriatic Arthritis?

table

what is Efficacy and Preference/Pearls for Synthetic DMARDs in Psoriatic Arthritis?

table

what is Efficacy and Preference/Pearls for Biologic DMARDs in Psoriatic Arthritis?

table

what is brand of Alefacept ?

(Amevive)

what is Safety in Alefacept STEPS?

HIV-infected patients should avoid because this medication actively reduces CD4+ counts
Increased risk of malignancy
Liver failure
Lymphopenia and infectious complications including the following:
Abscesses
Cellulitis
Pneumonia
Toxic shock syndrome
Herpes infection

what is Preference (Pearls) in Alefacept STEPS?

In clinical trials, alefacept was superior to placebo when added to methotrexate only in the
ACR20 criteria and not the ACR50 or ACR70 criteria
Predominantly indicated for psoriatic skin disease as opposed to peripheral arthritis symptoms

what is Tolerability in Alefacept STEPS?

Injection site reaction
Shivering
Myalgias

what is Efficacy in Alefacept STEPS?

Effective as an add-on for patients with psoriatic arthritis with continued symptoms while treated
with methotrexate

what is Simplicity in Alefacept STEPS?

Once-weekly intramuscular injection

what is generic of Apremilast ?

(Otezla)

what is Safety in Apremilast STEPS?

Depression and suicidal ideations

what is Tolerability in Apremilast STEPS?

Unintentional weight loss
Nausea
Diarrhea

what is Preference (Pearls) in Apremilast STEPS?

Dose reduction required in patients with CrCl less than 30 mL/minute
Dose titration required to help patients with gastrointestinal tolerance
In clinical research, improvements over placebo were noted when using both the ACR20 and
ACR50 response criteria

what is Efficacy in Apremilast STEPS?

As monotherapy, demonstrated improvements in patients' arthritic symptoms and quality of life

what is Simplicity in Apremilast STEPS?

Oral medicine dosed once (renally impaired) to twice daily

what is brand of Ustekinumab ?

(IL-12 & IL-23; Stelara)

what are Interleukin Inhibitors?

a. Secukinumab (IL-17A; Cosentyx)
b. Ustekinumab (IL-12 & IL-23; Stelara)

what is brand of Secukinumab ?

(IL-17A; Cosentyx)

what is Safety in Interleukin Inhibitor STEPS?

Risk of severe infection such as sepsis, tuberculosis, or opportunistic infections
Hypersensitivity reactions
Malignancy
(Rare) neurotoxicity (with ustekinumab)
Many (potentially) significant drug-drug interactions

what is Efficacy in Interleukin Inhibitor STEPS?

Has demonstrated efficacy in patients with psoriatic arthritis

what is Tolerability in Interleukin Inhibitor STEPS?

what is Preference (Pearls) in Interleukin Inhibitor STEPS?

Provide all necessary immunizations before starting therapy
If necessary, may administer inactivated vaccines during therapy, but avoid all live vaccines
Ustekinumab may be used in combination with methotrexate, though safety and efficacy do not
appear to change with use of methotrexate
In clinical research, improvements vs. placebo are noted in the ACR20 and ACR50 response
criteria

what is Patient Information in psoriatic arthritis?

Only a few resources are dedicated specifically to psoriatic arthritis because most
originate from "arthritis" advocacy and information groups. (Domain 5, Task 2, Knowledge 5)
1. The Arthritis Foundation (www.arthritistoday.org)
2. The American College of Rheumatology (www.rheumatology.org)
3. The Mayo Clinic (www.mayoclinic.com)

what is Simplicity in Interleukin Inhibitor STEPS?

Secukinumab: Subcutaneous every week for 4 weeks; every 4 weeks thereafter
Ustekinumab: Intravenous every 12 weeks; first two doses are administered 4 weeks apart

what is dosing of Methotrexate in psoriatic arthritis?

5-20 mg by mouth once weekly

what is dosing of Leflunomide in psoriatic arthritis?

10-20 mg by mouth once daily

what is dosing of Sulfasalazine in psoriatic arthritis?

2-3 g by mouth once or twice daily

what is dosing of Infliximab in psoriaitc arthritis?

5 mg/kg IV at weeks 0, 2, and 6; then every 8 weeks thereafter

what is dosing of Adalimumab in psoriatic arthritis?

40 mg subcutaneously every other week

what is dosing of Golimumab in psoriatic arthritis?

50 mg subcutaneously once monthly

what is dosing of Etanercept in psoriatic arthritis?

50 mg subcutaneously twice weekly for 3 months;
then 25 mg twice weekly

what is dosing of Apremilast in psoriaitc arthritis?

10 mg once daily on DAY 1
10 mg twice daily on DAY 2
10 mg in the morning and 20 mg in the evening on DAY 3
20 mg in the morning and 20 mg in the evening on DAY 4
20 mg in the morning and 30 mg in the evening on DAY 5
30 mg twice daily thereafte

what is dosing of Abatacept in psoriatic arthritis?

Initial weight-based infusion, and then
IV at weeks 2 and 4; then every 4 weeks thereafter
125 mg subcutaneously within 24 hours of infusion; then 125 mg subcutaneously
every week thereafter

what is dosing of Ustekinumab in psoriatic arthritis?

45 mg subcutaneously at weeks 0 and 4; then every 12 weeks thereafter

what are risk factors of OA?

Risk Factors for developing disease are not always risk factors for clinical progression (e.g., a high bone
density may be a risk factor for developing osteoarthritis, but a low bone density increases the chance of
clinical progression).

what is dosing of Secukinumab in psoriaitc arthritis?

150 mg subcutaneously for the first 4 weeks; then 150 to 300 mg every 4 weeks thereafter

what is dosing of Alefacept in psoriatic arthritis?

15 mg intramuscular injection each week

what is Treatment Guidelines of OA?

1. Michigan Quality Improvement Consortium 2015
2. National Institute for Health and Care Excellence
3. American College of Rheumatology 2012

what are common sites of OA?

1. Knees
2. Hips
3. Small joints of the hand
4. Low back
5. Ankle
6. Elbow

what are Factors Associated with Developing Osteoarthritis?

fig

what are Clinical Findings in Osteoarthritis by Joint2?

what are Clinical Findings in Osteoarthritis by Joint?

what are Topical applications recommendations for tx of OA?

Topical NSAIDs
Topical NSAIDs have proven short-term efficacy, but there is insufficient information to
comment on long-term use (> 12 weeks), and they are markedly more expensive than oral
NSAIDs
Topical NSAIDs are recommended over oral NSAIDs for patients > 75 years
Consider for those patients with a history of cardiovascular disease and those who should
not use systemic NSAIDs
May not be useful for hip OA given the mass of tissue between skin and joint.
Capsaicin
Should reduce pain in about 2 weeks

what are Nonpharmacologic Interventions of OA?

1. Education about expectations for therapy, importance of nonpharmacologic management strategies, and
cognitive behavioral therapy (chronic low back pain)
2. Weight loss (at least 5%)
3. Low-impact exercise
4. Physical therapy
5. Support braces, orthotics, and assistive devices also have mixed results and are not strongly recommended
by the American Academy of Orthopedic Surgeons (AAOS).

what are APAP recommendations for tx of OA?

Recommended as the first-line pharmacologic agent (as needed or scheduled) for pain
associated with (mild) OA
(Exception: Acetaminophen is not recommended by the ACR for hand OA)
Maximal dose of 4 g daily is still acceptable, though much more likely to see transaminase
elevations with higher doses
Most research finds acetaminophen more effective than placebo for OA pain,
but only minimally effective overall and less effective than NSAIDs

what are NSAIDs recommendations for tx of OA?

Naproxen, ibuprofen as needed or scheduled
NSAIDs are more effective than acetaminophen at reducing pain, but their adverse event
profile is less favorable
No single NSAID is preferred to another, though the ACR does not recommend ibuprofen for
patients using aspirin for cardiovascular disease prevention because of FDA documentation
that ibuprofen interferes with aspirin activity
The selective COX-2 inhibitor agent celecoxib may also be considered an alternative to
nonselective NSAIDs; efficacy profile is the same as that for traditional NSAIDs, but with
fewer reports of adverse GI events, and COX-2 agents do not affect platelet function
For patients with a history of GI ulceration, a COX-2 inhibitor or an NSAID with a proton
pump inhibitor is recommended as primary therapy
For patients with a GI bleed in the past 12 months, the ACR recommends using a COX-2
inhibitor with a proton pump inhibitor

what are Glucosamine and
chondroitin recommendations for tx of OA?

Delayed onset of effects, cannot be used for immediate pain relief
Glucosamine (with or without chondroitin) has questionable benefits from clinical trials
Research is usually small and of variable quality, resulting in highly heterogeneous
conclusions in meta-analyses and systematic reviews
Chondroitin has demonstrated some benefit for knee OA in studies with high heterogeneity,
but it appears to lose efficacy when paired with glucosamine
NOT routinely recommended by the ACR

what are Controlled opioid
analgesics recommendations for tx of OA?

Opioid analgesics may be useful, but they should not be used routinely to treat pain
associated with OA
Patients may achieve response to therapy, but limit use to patients with severe pain that is
inadequately controlled with previously mentioned therapies
Likelihood of adverse event similar to that of NSAIDs
NOT routinely recommended for OA because risk and severity of adverse events outweigh
benefit potential

what is brand of Tramadol ?

(Con Zip, Rybix, Ryzolt, Ultram, Ultram ER [extended release])

what are Low-dose
corticosteroids recommendations for tx of OA?

May help with short-term pain reduction and increased mobility for patients with moderate to
severe OA of the knee

what is Safety in Tramadol STEPS?

Avoid use (Rybix, Ultram, Ultram ER) in any situation where opioids are not indicated, including
acute intoxication with alcohol, hypnotics, opioids, or psychotropic drugs
Avoid use (Con Zip, Ryzolt) in patients with severe/acute asthma, hypercapnia, or severe respiratory
depression in the absence of resuscitative equipment
Contraindicated within 14 days of monoamine oxidase inhibitor therapy
Seizures: As monotherapy or with greater risk when combined with other agents that lower the
seizure threshold
Limit immediate-release dose to 50 mg every 12 hours in patients with cirrhosis
Avoid extended-release formulations in severe hepatic impairment (Child-Pugh class C)
Cautious use in patients with mild to moderate renal impairment, and avoid extended-release
formulations in severe renal impairment (CrCl < 30 mL/minute)
Risk of serotonin syndrome in patients concurrently using agents that act on the
serotonin system

what is Simplicity in Tramadol STEPS?

May administer dose as needed up to four times daily (maximum 100 mg per dose)
Classified by the DEA as Schedule IV in August 2014

what is Tolerability in Tramadol STEPS?

CNS depression
Constipation
Dizziness
Dyspepsia
Flushing
Headache
Nausea
Postural hypotension
Pruritus
Somnolence

what is Efficacy in Tramadol STEPS?

Provides small degree of pain relief

what is Preference (Pearls) in Tramadol STEPS?

Consider as an alternative in patients who do not receive adequate pain relief from acetaminophen
and cannot tolerate it or for whom NSAID therapy is contraindicated

what is surgery tx of OA?

1. Total arthroplasty (joint replacement)
2. Arthroscopic debridement (surgical removal of "debris" within the joint)
3. Arthroscopic lavage (flushing the joint internally with water)

what are Invasive Interventions of OA?

1. Intra-articular corticosteroids may be effective for short-term pain relief (less than 4 weeks), but there is usually diminishing benefit beyond that time.
a. Joint injections should not be performed more often than every 3 months.
b. Osteoarthritis symptoms requiring regular use of corticosteroid injections (three or four a year)
should be considered for surgical intervention.
2. Intra-articular hyaluronic acid may be as effective as intra-articular corticosteroids for some patients, but with benefits observed up to 6 months.
a. Benefits over corticosteroids not observed until 4 weeks after injections
b. Much more costly alternative to intra-articular corticosteroids
c. More frequent injections because many regimens require weekly injections for 3-5 consecutive weeks

what are Patient Resources of OA?

1. Patient handouts from American Family Physician
2. Online information from the Arthritis Foundation

what are Alternative Treatments of OA?

1. S-adenosylmethionine (SAMe) may reduce NSAID need and improve functional limitations in patients with osteoarthritis.
2. Avocado/soybean unsaponifiables appear to help reduce pain in patients with osteoarthritis, but few trials with questionable supportive bias.
3. Devil's claw and willow bark have been associated with pain reduction in osteoarthritis.
4. Tai Chi may improve strength and balance, but not falls, in patients with osteoarthritis of the knee.
5. Acupuncture does not provide reliable pain relief. It is reserved for patients with moderate to severe disease who are not candidates for or refuse surgery.

what is 2016 Physician Quality Reporting System Quality Measures?

what are clinical guidelines of fibromyalgia?

1. 2016 EULAR evidence-based recommendations for the management of fibromyalgia syndrome
2. 2010 ACR preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity

what are Diagnostic tools in fibramyalgia?

fig
a. Widespread pain index (WPI): Award 1 point for each location a patient has experienced pain in
the past 7 days.
b. Symptom severity scale (SSS): Award 0-3 points for each level of severity of fatigue, waking
unrefreshed, cognitive symptoms, and somatic symptoms.
i. 0 = No problem/symptoms
ii. 1 = Slight or mild problems/few symptoms
iii. 2 = Moderate or considerable problems/moderate number of symptoms
iv. 3 = Severe, pervasive, life-disturbing problems/great deal of symptoms
c. ACR updated the diagnosis in 2010 to include the following:
i. Symptoms for more than 3 months PLUS
(a) WPI of 7 or higher and an SSS of 5 or higher OR
(b) WPI of 3-6 and an SSS of 9 or higher
ii. Absence of other disorders that could cause the same symptoms

what will pt experience in fibramyalgia?

a. Physical symptoms (weakness, fatigue, decrements in physical function, morning stiffness, heat or
cold disturbances, swelling in extremities)
b. Psychological symptoms (mood disturbances)
c. Cognitive problems (difficulty concentrating, diminished mental clarity, memory problems)
d. Photophobia, phonophobia, and/or osmophobia

what are nonconventional tx of fibramyalgia?

they may serve as complementary to conventional management, but
evidence is not yet robust enough to recommend as alternative strategies.
a. Acupuncture
b. Biofeedback
c. Chiropractic manipulation
d. Heated pool treatments (with or without exercise)
e. Hypnosis
f. Osteopathic manipulation
g. Therapeutic massage

what are Professional Treatment Recommendations?

1. Educate patients about pain management and self-management (good sleep hygiene, regular physical
activity, stress management).
2. Cognitive behavioral therapy will help reduce pain, improve function, and enhance self-efficacy.
3. Exercise programs
4. Nonconventional treatment
5. Pharmacologic treatment

what do exercise recommendations for tx of fibramyalgia include?

Exercise programs should be of moderate intensity.
a. High-intensity exercise will make symptoms of fibromyalgia worse.
b. Exercise recommendations state the patient should exercise two to three times per week to a target of 60%-75% of his or her age-adjusted maximum heart rate (210 minus patient age).
c. Patients should stretch before exercise to the point of mild resistance to reduce exercise-induced pain and injury

what are Pharmacologic treatment strategy?

a. Tricyclic antidepressants, particularly amitriptyline, are the first-line treatment for reducing pain and symptoms associated with fibromyalgia.
b. If patient has a contraindication to, cannot tolerate, or does not achieve response to therapy with a tricyclic antidepressant (at target dose), consider therapy with an alternative agent.
c. Additional classes with efficacy (vs. placebo) include the following:
i. α2δ Ligands (gabapentin, pregabalin)
ii. Dopamine D3 receptor agonists (pramipexole)
iii. Selective serotonin reuptake inhibitors (fluoxetine, paroxetine)
iv. Serotonin and norepinephrine dual reuptake inhibitors (duloxetine, milnacipran)
v. Nonopioid μ-receptor antagonist (tramadol)

what are TCA?

a. Amitriptyline
b. Cyclobenzaprine
c. Nortriptyline

what is Safety in Tricyclic Antidepressant STEPS?

FDA warns that antidepressants increase the risk of suicidal thinking and behavior in children,
adolescents, and young adults with major depressive disorder
Orthostatic hypotension
Use with caution in patients with a history of cardiovascular disease, diabetes, hepatic impairment, mania/hypomania, renal impairment, seizure disorders, or thyroid dysfunction
Patients should discontinue tricyclic antidepressants before general elective surgery that requires anesthesia

what is Efficacy in Tricyclic Antidepressant STEPS?

Tricyclic antidepressants, particularly amitriptyline, are first-line for improving the symptoms of fibromyalgia
Have been proved to decrease symptoms of pain, fatigue, sleep, and depressed mood

what is Tolerability in Tricyclic Antidepressant STEPS?

Anticholinergic effects
Anorexia
Dizziness
Hypertension/hypotension
Insomnia
Numbness
Paresthesia
Syncope
Tachycardia
Urticaria
Weight gain

What is Preference (Pearls) in Tricyclic Antidepressant STEPS?

Target dose of amitriptyline or cyclobenzaprine is 10 to 40 mg (cyclobenzaprine) or 50 mg
(amitriptyline) in the evening before sleep
Likelihood of experiencing pain relief is about the same as the likelihood of experiencing an
adverse event

what is Simplicity in Tricyclic Antidepressant STEPS?

Once-daily dosing in the evening, before sleep, to decrease adverse event severity

what is Tolerability in Selective Serotonin Reuptake Inhibitor STEPS?

Anticholinergic effects
Diarrhea
Dizziness
Dyspepsia
Headaches
Insomnia
Nausea
Sexual dysfunction

what are Selective serotonin reuptake inhibitors?

a. Fluoxetine
b. Paroxetine

what is Safety in Selective Serotonin Reuptake Inhibitor STEPS?

See Table 50 for FDA warning about suicidal ideations with antidepressants
Allergic skin reactions
May increase bleeding risk when used in conjunction with antiplatelet or anticoagulation therapy
Use with caution in patients with a history of cardiovascular disease, diabetes, mania/hypomania, hepatic effects, renal impairment, and/or seizure disorders

what is Efficacy in Selective Serotonin Reuptake Inhibitor STEPS?

Evidence is available to support use in fibromyalgia, but strength of recommendation is not as strong as with tricyclic antidepressants
The combination of a selective serotonin reuptake inhibitor and a tricyclic antidepressant is better than either class alone

what is Simplicity in Selective Serotonin Reuptake Inhibitor STEPS?

Once-daily dosing

what is Preference (Pearls) in Selective Serotonin Reuptake Inhibitor STEPS?

Fluoxetine and paroxetine are the most often studied agents to have an effect in patients with
fibromyalgia symptoms
Small clinical trial with citalopram vs. placebo did not show significantly reduced symptoms

what is Preference (Pearls) in Serotonin and Norepinephrine Dual Reuptake Inhibitor STEPS?

Both duloxetine and milnacipran are FDA approved for treating fibromyalgia syndrome
Duloxetine requires dose adjustments when creatinine clearance is < 30 mL/minute

what are Serotonin and norepinephrine dual reuptake inhibitors?

a. Duloxetine
b. Milnacipran

what is Safety in Serotonin and Norepinephrine Dual Reuptake Inhibitor STEPS?

See Table 50 for FDA warning about suicidal ideations with antidepressants
Increased risk of bleeding when used with antiplatelet or anticoagulation therapy
Severe skin reactions have been reported with duloxetine
Blood pressure and heart rate may be increased with milnacipran

what is Tolerability in Serotonin and Norepinephrine Dual Reuptake Inhibitor STEPS?

Anticholinergic effects
Dizziness
Headache
Hyperhidrosis
InsomniaNausea
Hot flashes (milnacipran)
Sexual dysfunction

what is Efficacy in Serotonin and Norepinephrine Dual Reuptake Inhibitor STEPS?

Agents equally improve pain, sleep, depressed mood, and quality of life in patients
with fibromyalgia
Duloxetine up to 60 mg daily is effective for treating fibromyalgia syndrome
NOTE: 120 mg does not have benefit beyond 60 mg, but increases likelihood of adverse events
Milnacipran's target dose is 50 mg twice daily (start with 12.5 mg twice daily and titrate every 7
days to target dose)
Class efficacy is equal to that of pregabalin, but assumed from indirect comparisons of all three
agents

what is Simplicity in Serotonin and Norepinephrine Dual Reuptake Inhibitor STEPS?

Agents are dosed once or twice daily and have a relatively quick onset of effect

what are α2δ Ligand?

a. Gabapentin
b. Pregabalin

what is Safety in α2δ Ligand STEPS?

Safety concerns are relatively rare, but still present:
Angioedema
Visual field disturbances have been reported
Use with caution in patients with cardiac disease, particularly heart failure, because of the risk of
edema

what is Tolerability in α2δ Ligand STEPS?

Dizziness
Edema (peripheral)
Somnolence
Weight gain

what is Efficacy in α2δ Ligand STEPS?

Both gabapentin and pregabalin are effective for improving pain, sleep, fatigue, and quality of life
Poor tolerability reported in clinical trials

what is Preference (Pearls) in α2δ Ligand STEPS?

Target dose:
Gabapentin 2400 mg daily
Pregabalin 300-450 mg daily
Dosage adjustments are required in patients with renal impairment
Pregabalin is registered as a schedule V substance (euphoria)

what is Simplicity in α2δ Ligand STEPS?

Pregabalin is dosed twice daily
Titration schedule for gabapentin is relatively difficult and requires thrice-daily dosing

what is additional tx of fibromyalgia?

10. Nonopioid μ-receptor antagonist (tramadol; see STEPS analysis and Osteoarthritis section)
11. Dopamine D3 receptor agonists (pramipexole): One small clinical trial (60 patients) reported at least a 50% improvement in symptoms in significantly more patients using pramipexole titrated to 4.5 mg daily than with placebo.
12. Memantine demonstrated a 2-point pain scale reduction versus placebo in patients not actively receiving other medications for fibromyalgia (dose titrated to 20 mg/day).

what is pt info forfibromyalgia?

1. Medications are effective for symptom relief, but all professional organizations advocate for education
and cognitive behavioral therapy as the root of all treatments.
2. Most clinical trials evaluate and report symptom improvement and not complete symptom resolution.
3. Patient information resources available online
a. Arthritis Foundation offers a variety of resources, including a self-help course, books, and
educational videos (www.arthritis.org/conditions-treatments/disease-center/fibromyalgia-fms/).
b. Exercise videos are available for purchase ($30 per video) through the Fibromyalgia Information
Foundation (www.myalgia.com).

what is brand of Nortriptyline ?

Pamelor

whatis brand of Amitriptyline ?

Elavil

what is dosing of Amitriptyline in fibromyalgia

25-100 mg once daily at bedtime

what is dosing of Nortriptyline ?

25-100 mg once daily at bedtime

what is brand of Cyclobenzaprine ?

Flexeril

what is brand of Paroxetine ?

Paxil

what is dosing of Cyclobenzaprine ?

5-10 mg by mouth three times daily

what is brand of Fluoxetine ?

Prozac

what is dosing of Fluoxetine ?

20-80 mg by mouth once daily

what is dosing of Paroxetine ?

20-60 mg by mouth once daily

what is brand of Duloxetine ?

Cymbalta

what is dosing of Duloxetine ?

60 mg by mouth once daily

what is brand of Milnacipran ?

Savella

what is dosing of Gabapentin ?

300-1200 mg by mouth three times daily

what is dosing of Milnacipran ?

50 mg by mouth twice daily

what is brand of Gabapentin ?

Neurontin

what is dosing of Pregabalin ?

75-150 mg twice daily

what is brand of Pregabalin ?

Lyrica

what are clinical guidelines of SYSTEMIC LUPUS ERYTHEMATOSUS?

1. 2008 EULAR recommendations on management of SLE
2. 2009 EULAR recommendation on monitoring patients with SLE in clinical practice and in observational studies

what is Active SLE ?

The patient has signs/symptoms and tests that are attributed to inflammation and are
reversible (target organ damage) with therapy

what are Stages of SLE?

Active SLE
Mild SLE
Uncontrolled SLE
Complete response
Remission

what is Uncontrolled SLE ?

The patient's signs/symptoms of SLE continue despite pharmacologic treatment

what is Mild SLE ?

The patient's condition is clinically stable without progressing organ damage or toxicity

what is Complete response ?

Clinical remission with pharmacologic treatment

what are Organ Systems Involved and Potential Complications?

table

what is Remission ?

The patient does not have signs/symptoms of SLE and is not receiving treatment

what is dx of lupus?

1. ACR criteria for classification require four positive (of possible 11) findings.
2. Findings may be present sequentially or at the same time.

what are risk factors of lupus?

Risk Factors for Disease
1. Family history of SLE or other autoimmune disorders
2. Gender and ethnicity
a. Women at greater risk than men
b. White at greater risk than African American, Asian, and Hispanic
3. Exposure to silica, mercury, and/or pesticides
4. Drug-induced disease
a. Captopril
b. Chlorpromazine
c. Hydralazine
d. Isoniazid
e. Methyldopa
f. Procainamide
g. Quinidine
h. Sulfasalazine
i. Estrogens and oral contraceptives (not causative, but may provoke and worsen flares in patients with
lupus)

what is clinical presentation of lupus?

There are several clinical findings during a patient's history and physical examination,
but some are more common than others.
1. Arthritis
2. Malar rash ("butterfly" rash)
3. Active nephropathy
4. Neurologic changes
5. Fever
6. Raynaud phenomenon
7. Serositis
8. Thrombocytopenia
9. Thrombosis

what is Eleven Criteria to Evaluate for the Diagnosis of Systemic Lupus Erythematosus?

table

what is Diagnostic Testing for Systemic Lupus Erythematosus?

what is pharmacological tx of lupus?

Antimalarial agents
a. Chloroquine
b. Hydroxychloroquine
c. corticosteroids
d. Immunosuppressive therapy (azathioprine, cyclosporine, methotrexate, mycophenolate mofetil)

what is Other Pretreatment and "Routine" Testing for Systemic Lupus Erythematosus?

what are Drug Treatment Strategies (EULAR recommendations)?

1. Antimalarial drugs are first-line therapy for all patients with newly diagnosed SLE and/or without major
organ involvement, unless otherwise contraindicated.
2. Systemic corticosteroids may be used to prevent flares and clinical relapse.
3. Steroids can be used in addition to antimalarial agents to control symptoms and prevent seromarker
elevation.
4. NSAIDs may be used for a brief period, but patients need to be aware of gastrointestinal, cardiovascular,
and/or renal complications.
5. Immunosuppressive agents (methotrexate, azathioprine, and/or mycophenolate) are reserved for patients
who:
a. Cannot achieve disease control with antimalarial drugs and corticosteroids
b. Are found to have International Society Nephrology/Renal Pathology Society (ISN/RPS) class III (foal lupus nephritis), class IV (diffuse lupus nephritis), class 5 (membranous lupus nephritis), class
6 (advanced sclerosing lupus nephritis)
i. High-dose methylprednisolone for 3 days followed by a maintenance dose for up to 6 months, PLUS
ii. Immunosuppressive therapy for up to 6 months

what is Safety in Antimalarial Agents STEPS?

Cardiomyopathy with long-term hydroxychloroquine use (rare)
May cause the following:
Agranulocytosis, aplastic anemia, and/or thrombocytopenia
Exfoliative dermatitis, Stevens-Johnson syndrome
Myopathy and muscle weakness
Exacerbation of porphyria and/or psoriasis
Loss of visual acuity and macular pigment changes (risk is highest with hydroxychloroquine
doses > 6.5 mg/kg of lean body weight)
Use with caution in patients with hepatic disease or receiving concurrent hepatotoxic agents,
G6PD deficiency, or renal insufficiency (no dosing recommendations provided)

what is Tolerability in Antimalarial Agents STEPS?

Abdominal cramping
Alopecia
Diarrhea
Emotional changes
Nightmares
Psychosis
Tinnitus
Urticaria

what is Efficacy in Antimalarial Agents STEPS?

Reduces disease activity in most patients and reduces the average dose of corticosteroids needed to control symptoms
Associated with a reduction in mortality, irreversible organ damage, and progression to active disease

what is Preference (Pearls) in Antimalarial Agents STEPS?

Recommended as first-line treatment by both EULAR (SLE without major organ involvement)
and ACR (mild SLE)
Dosing to achieve serum hydroxychloroquine concentration > 1000 ng/mL does not reduce the
likelihood of disease flare
American Academy of Ophthalmology recommends that patients have funduscopic and visual field examination within the first year of starting hydroxychloroquine; ophthalmologic screening recommendations are based on risk of drug-related disease (see Table 61)

what is Ophthalmologic Screening Recommendations for Patients Treated with Antimalarial Agents?

table

what is Simplicity in Antimalarial Agents STEPS?

Initially dosed once or twice daily until sufficient patient response
Once-daily maintenance dosing

what is corticosteroid tx of lupus?

Corticosteroids (see Rheumatoid Arthritis section for full STEPS analysis)a. Corticosteroids will delay the onset and prevent relapse or fares of SLE.b. May be dosed daily or on opposite days for patients with stable diseasec. Doses of 20 mg or higher (prednisone equivalent) may be necessary for patients with progressive end-organ damage caused by lupus

What is immunosuppressive therapy of lupus?

Immunosuppressive therapy (azathioprine, cyclosporine, methotrexate, mycophenolate mofetil)a. Agent of choice for patients when unable to prevent disease progression or induce remission with antimalarial drugsb. Recommended for patients with organ involvement (neuropsychiatric lupus, lupus nephritis, cutaneous lupus)c. Consider for use in patients who are unable to reduce their corticosteroid dose (to less than 10 mg of prednisone equivalent) per dayd. Appears that azathioprine and cyclosporine are equal with respect to effcacy and safety in patients with SLEe. Both methotrexate and mycophenolate mofetil will decrease steroid requirements for patients treated with higher-than-acceptable corticosteroid doses.f. Rituximab, belimumab, or epratuzumab (investigational), added to standard therapy, has demonstrated benefts in patients with treatment refractory disease.

What are nonpharmacologic intervention of lupus ?

Lifestyle modifcations include smoking cessation, weight control, and exercise (where applicable).a. Omega-3 fatty acid intake (1.2 g of DHA and 1.8 g of EPA each day) reduced scores on validated SLE symptom surveys.b. Cardiovascular training programs may improve SLE symptom score surveys.c. Cognitive behavioral therapy and counseling may reduce fatigue and improve patient-reported mental health.2. Recommend that patients regularly use sunscreen in all outdoor exposure.3. Do not use live vaccines in patients taking greater than 20 mg of corticosteroids (prednisone equivalents) each day.

What is pt info for lupus?

Several online resources and professional groups provide patient information.1. American College of Rheumatology (www.rheumatology.org)2. Lupus Foundation of America (www.lupus.org)3. National Institute of Arthritis and Musculoskeletal and Skin Diseases (www.niams.nih.gov)

What is dosing of plaguenil in lupus ?

400-600 mg by mouth each day

What is brand of hydroxyquine?

Plaquenil

What is Professional Treatment Recommendations and Guidelines of gout?

1.2012 ACR guidelines for the management of gout
2. 2006 EULAR evidence-based recommendations for the diagnosis and management of gout
3. 2007 British Society for Rheumatology guideline for the management of goutB.

What is prevalence of gout?

1. Peak onset is between 40 and 60 years of age.
2. Men are 3-4 times more likely to develop gout and hyperuricemia, but the gender gap is less compared with postmenopausal women (estrogen stimulates renal elimination of uric acid).

What is Characteristics of Gout?

What are Risk Factors for Developing Gout and Hyperuricemia (uric acid, serum concentration greater than 6.8 mg/dL)

What are Factors Associated with the Underexcretion or Overproduction of Uric AcidUnderexcretion of urateDehydration, hypertension?

What are Gout Complications?

1. Uric acid nephrolithiasis
2. Acute uric acid nephropathy
3. Chronic kidney disease secondary to urate crystal deposition

What is Decision to treat acute gout symptoms?

What is

...

what is management of acute gouty attack?

table

what are Treatment Options for Acute Attacks?

1. Nonpharmacologic
a. Rest and elevate the affected joint(s).
b. Ice packs
2.Pharmacologic
a. Nonsteroidal anti-inflammatory drugs
b. Colchicine
c. Corticosteroids

what are NSAIDs recommendations for gout tx?

i. Safety and tolerability discussed previously in this chapter in the Rheumatoid Arthritis section
ii. All NSAIDs appear equally effective.
iii. Recommended as a first-line option for the management of a gouty attack.
iv. May be recommended for use with colchicine for acute attacks.
v. Treatment should continue until symptoms subside (1-2 weeks).

what is Safety in Colchicine STEPS?

Doses > 4 mg may cause multiple organ failure and death
Dose adjustment not necessary when CrCl > 30 mL/minute
When CrCl < 30 mL/minute:
Do not use more than one acute treatment course every 2 weeks
Do not use > 0.3 mg daily for prophylaxis initially
Metabolized by the cytochrome P450 3A4 enzyme (elevated plasma colchicine
concentrations can lead to fatal toxicity)
Risk of adverse hematologic events includes myelosuppression, leukopenia,
thrombocytopenia, and/or pancytopenia

what is Tolerability in Colchicine STEPS?

GI discomfort
Diarrhea

what is Efficacy in Colchicine STEPS?

New(er) dosing strategy decreases the likelihood of adverse events without affecting efficacy

what is Preference (Pearls) in Colchicine STEPS?

Slower to work than NSAIDs for pain relief, but still at least a 50% reduction in pain at 24 hours

what is Safety in Colchicine STEPS?

Two tablets (0.6 mg each x 2 = 1.2 mg) within 12 hours of onset and one (0.6 mg) tablet 60
minutes later
2012 ACR recommendations suggest using 0.6 mg every 12 hours until acute symptoms resolve,
starting immediately after the second 0.6-mg treatment dose

what are corticosteroids recommendations for gout tx?

i. Safety and tolerability discussed previously in this chapter in the Rheumatoid Arthritis section
ii. Excellent option for patients with acute gout and renal insufficiency
iii. Prednisone is equal in efficacy to NSAIDs for reducing pain and discomfort.
iv. Recommended dose of 0.5 mg/kg for 5 to 10 days with or without steroid taper.
v. Intra-articular corticosteroids are especially effective with large joint involvement.
vi. Intra-articular formulations show benefits superior to oral NSAIDs at 72 hours, but equal at 1 week.

what are Prevention Options for Recurrent Attacks?

1. Nonpharmacologic
a. Adequate hydration (2 L or more of water daily)
b. Discontinue diuretic therapy whenever possible.
c. Moderate, low-impact exercise
d. Restrict dietary animal and yeast purine intake and alcohol (especially beer).
e. Avoid highly refined carbohydrates and sugars.
f. Weight reduction
2. Consideration and expectations of prevention
a. Consider preventive therapy in individuals experiencing more than one acute gouty arthritis attack
per year.
b. Therapy goal is serum uric acid concentrations less than 5 mg/dL (with tophi) or 6 mg/dL (without
tophi).
c. 2012 guidelines suggest that prophylactic therapy can be initiated during an acute gouty attack,
provided anti-inflammatory management has been started.
d. Evaluate serum uric acid concentrations every 3 months for the first year after an attack and then
annually thereafter.
e. May try to discontinue agents at any time, but most will have at least one gouty attack (90%) during
the next 10 years
3. Xanthine oxidase inhibitors
a. Allopurinol (Zyloprim)
b. Febuxostat (Uloric)
4. Uricosuric agent - Probenecid
5. other meds

what is brand of Allopurinol ?

(Zyloprim)

what is brand of Febuxostat ?

(Uloric)

what is Safety in Allopurinol STEPS?

Exfoliative dermatitis
Stevens-Johnson syndrome
Hepatotoxicity
Mucositis
Renal insufficiency
Thiazides decrease excretion of allopurinol

what is Tolerability in Allopurinol STEPS?

Elevated transaminases or alkaline phosphatase values
Transient rash

what is Efficacy in Allopurinol STEPS?

Prevents recurrent gouty arthritis attacks and reduce uric acid concentrations
Useful to reduce tophi in patients with tophaceous gout

what is Preference (Pearls) in Allopurinol STEPS?

First-line agent for prevention of recurrent gout and hyperuricemia
Evaluate renal function for possible dose adjustments
NOT for use in patients with asymptomatic hyperuricemia
Do not stop therapy during an acute attack if the patient's condition is already managed with
allopurinol
Start at 100 mg daily and titrate by 100 mg daily every 2-4 weeks (maximum 800 mg daily) to
achieve a uric acid concentration < 5-6 mg/dL
Maximal dose should be 200 mg/day with CrCl < 20 mL/minute and < 100 mg/day with CrCl <
10 mL/minute
2012 ACR guidelines suggest HALB*5801 testing for at-risk populations (patients of Korean
descent with CKD stage 3 or worse, Han Chinese descent, or Thai descent)

what is Simplicity in Allopurinol STEPS?

Daily dosing
Relatively inexpensive (< $20 a month)

what is Safety in Febuxostat STEPS?

Contraindicated in patients using azathioprine, mercaptopurine, or theophylline (Canada only)
Higher incidence of cardiovascular events observed compared with incidence in patients using
allopurinol, though no causal relationship has been proved
Hepatotoxicity

what is Tolerability in Febuxostat STEPS?

Arthralgias
Nausea
Rash

what is Efficacy in Febuxostat STEPS?

Approved to treat hyperuricemia in patients with gout

what is Preference (Pearls) in Febuxostat STEPS

Greater efficacy for reducing uric acid concentration, but no more efficacious for preventing gout
flares than allopurinol
Used to reduce tophi in patients with tophaceous gout
NOT for use in patients with asymptomatic hyperuricemia

what is Simplicity in Febuxostat STEPS?

Daily dosing
Considerably more expensive than allopurinol (about $150-$200 per month)

what is Safety in Probenecid STEPS?

Avoid use in patients with uric acid kidney stones
May worsen existing blood dyscrasias
Many drug interactions and may increase the serum concentration of target agents

what is Efficacy in Probenecid STEPS?

Increases urate excretion and decreases serum uric acid concentrations
Efficacy may be diminished when coadministered with salicylates

what is Preference (Pearls) in Probenecid STEPS?

Ineffective in patients with even mild renal insufficiency
Start with low doses to reduce the likelihood of precipitating another gouty attack

what is Tolerabilty in Probenecid STEPS?

Dyspepsia
Reflux esophagitis

what is Simplicity in Probenecid STEPS?

Co-formulated with colchicine
May cost $35-$100 per month (depending on daily dose and frequency)

what are other meds to prevent gout recurrence?

a. Colchicine
b. Pegloticase
c. Rasburicase

what are Colchicine recommendations for recurrence of gout?

i. For prophylaxis of gout induced by urate-lowering therapy
ii. Not for use as monotherapy to prevent gouty attacks
iii. Give during the first 6 months of urate-lowering therapy.

what are Rasburicase recommendations for recurrence of gout?

i. Uricolytic agent, FDA approved only for tumor lysis syndrome
ii. Seldom used for this indication
iii. Some research shows rasburicase decreases tophi and uric acid concentrations in patients with
gout.

what is Safety in Pegloticase STEPS?

Contraindicated in patients with G6PD deficiency
FDA black box warning regarding anaphylaxis and infusion reactions; patients should be closely
monitored for at least 2 hours after infusion, though delayed reactions have been reported
Risk of infusion reaction is increased when the patient's uric acid concentration is > 6 mg/dL; consider
discontinuing therapy if uric acid concentration is > 6 mg/dL, especially if it is above
this limit on two consecutive occasions
Acute gout flare within the first 3 months of therapy
Heart failure exacerbations have been reported in clinical trials
Increased risk of anaphylaxis in patients who are restarting therapy after discontinuing it for > 4
weeks

what is Tolerability in Pegloticase STEPS?

Bruising
Chest pain
Constipation
Dyspnea
Erythema
Nausea
Pruritus
Urticaria

what is Efficacy in Pegloticase STEPS?

Showed decreased uric acid concentrations and number of gout flares in clinical trials

what is Preference (Pearls) in Pegloticase STEPS?

Administer by intravenous infusion for 120 minutes
Vials must be refrigerated and stored in a carton to protect them from light
Elimination half-life is about 14 days
Recommended for patients with severe gout refractory or intolerant to conventional urate-lowering
strategies
Begin gout flare prophylaxis (NSAIDs or colchicine) 1 week before infusion,
and continue for at least 6 months

what is Simplicity in Pegloticase STEPS?

120-minute infusion (8 mg) every 2 weeks

what is pt info for gout?

a. Information from National Institute of Arthritis and Musculoskeletal and Skin Diseases
(www.niams.nih.gov/Health_Info/Gout/default.asp)
b. Gout and Uric Acid Education Society
i. Website for information and social networking
ii. http://gouteducation.org/

what is brand of Colchicine ?

Colcrys

what is dosing of Colchicine?

0.6 mg twice daily (for prophylaxis)

what is dosing of Allopurinol ?

200-300 mg by mouth each day

what is dosing of Febuxostat ?

40-80 mg by mouth each day

what is brand of Pegloticase ?

Krystexxa

what is dosing of Pegloticase ?

8 mg intravenously every 2 weeks

Sets found in the same folder

14_Cardiology kh

851 terms

5_Biostatistics

37 terms

2_Communication Strategies in Pharmacy

9 terms

2_Communication Strategies in Pharmacy 3 of

239 terms

Other sets by this creator

Dm

12 terms

25_Policy, Practice, and Regulatory Issues

236 terms

25_Policy, Practice, and Regulatory Issues 2016

73 terms

25_Policy, Practice and Regulatory Issues

42 terms

Verified questions

physics

A lead object and a quartz object each have the same initial volume. The volume of each increases by the same amount, because the temperature increases. If the temperature of the lead object increases by $$ 4.0 \mathrm { C } ^ { \circ } $$ by how much does the temperature of the quartz object increase?

Verified answer

chemistry

A gas-filled balloon having a volume of 2.50 L at 1.2 atm and 20 °C is allowed to rise to the stratosphere (about 30 km above the surface of Earth), where the temperature and pressure are -23 °C and $3.00\times10^{-3}\;\mathrm{atm}$, respectively. Calculate the final volume of the balloon.

Verified answer

chemistry

Give at least five characteristics of the elements that are periodic.

Verified answer

biology

Consider an experiment in which an aluminum soft drink can and a steel soup can are left outside for a few days. Use your knowledge of the corrosion of steel and aluminum to predict how they would look different after a week exposed to rainy weather. Explain your prediction.

Verified answer

Other Quizlet sets

final practice exam 2

100 terms

Complex Interactions Midterm

19 terms

MC-Test - Praktikum 6 Hund, Therapieplan

25 terms

LUOA US History module 7

58 terms