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What is most commonly used DMARD
methotrexate
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DMARD stands for
disease modifying antirheumatic drug
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How long is methotrexate effective in
2-6 weeks
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What is cornerstone of tx for RA
early diagnosis and aggressive treatment
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MOA of DMARDS
exact is unknown but do have antinflammatory effects that slow progression of RA and preserve the joint
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MOA of hydroxychloroquine
mimics the parent compound chloroquine.
Antiinflammatory properties by inhibiting conversion of arachidonic acid to prostaglandin F2
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Sulfonamides MOA
Unknown
Is anti-inflammatory and reaches high concentrations in serous fluids and connective tissue
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Methotrexate MOA
anti-inflammatory and immunosuppressive properties.
Impairs DNA synthesis.
Inhibitory on cytokines especially interleukin 1 and arachidonic acid
antiproliferative effect on synovial cells.
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Immunomodulators MOA
cytokines (TNF and IL) are released during inflammation. These agents have been cloned and given to immunodeficient patients for RA.
Some are given for MS
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Cytokine blockers MOA
block cytokines from stimulating cartilage degrading enzymes
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Corticosteroids MOA
inhibit production of interleukins
immunosuppressive and antiinflammatory
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JAK inhibitors
interfere with enzymes that contribute to tissue inflammation
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First line tx for RA
DMARDS- methotrexate
COX 2 selective NSAID should be used with this.
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If DMARDs do not provide pain relief then add?
acetominophen
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Low dose oral glucocorticosteroids (predinisone) should only be given _____?
short term.
May need to add calcium supplement to decrease risk of osteoporosis
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What can be used for intense flare ups of RA and OA, but can only be repeated 3 times per year
intra-articular injections
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Add opioids only if
inadequate pain relief with other drugs first
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DMARDs are only prescribed by
rheumatologist
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Hydroxychlorquine should be used in caution with patients with
These drugs can cause _______?
- renal or hepatic impairment
- or history of ETOH abuse
Irreversible retinal damage, patients should be advised to wear sunglasses due to photosensitivity
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Pts who are candidates for immunomodulator therapy should be screened for
TB risk
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What is used to monitor disease activity over time
ESR and C-reactive protein
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monitoring of methotrexate
cbc, albumin, creatinine, and LFTs at baseline and monthly for 6 months. and 1-2 months thereafter.
Also alkaline phosphatase, chest x-ray, and hepatitis b and c in high risk patients.
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Pregnancy and Lactation
B- sulfasalazine, TNF inhibitors, IL-1 receptor antagonist.
C- hydroxychloroquine (lactation prob safe), abacept
X- methotrexate, leflunomide
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Methotrexate black box warning
Drug interactions
- toxic effects, potentially serious at all dosages.
- Deaths have occurred from this medication
NSAIDS, sulfonamides, tetracycline, chloramphenicol, phenytoin, and cyclosporine may interfere with elimination of this drug.
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Vitamins containing folic acid may ______ response of methotrexate but can give to reduce toxicity without compromising therapeutic effect
decrease
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