Notesale: Turn your study into money

Document Preview

Extracts from the notes are below, to see the PDF you'll receive please use the links above

---

Rheumatoid arthritis is a chronic systemic inflammatory disease that is characterised by
joint involvement and extra-articular manifestations
...
It
also causes proliferation
...

The affected joints are the fingers, hands, wrists, knees and feet
...

The disease is characterised by flares and remissions
...
Most common:
joint pain and loss of function
...

Extra-articular features may occur in RA patients
...

Diagnosis of RA: morning stiffness, arthritis of three or more joint areas (wrists, elbows,
shoulders, knees), arthritis of hand joints, rheumatoid nodules
...

Treatment of RA: drug therapy, physical therapy, occupational therapy, weight reduction,
rest and the use of adaptive or assistive devices
...

Occupational therapy improves difficulties with any of their everyday activities or problems
with hand function
...

Drug treatment: drugs that suppress the disease process (DMARDs), NSAIDs and steroids
...
A full therapeutic response
may not be obtained before 2-6 months of therapy
...

Activated T lymphocytes are very important
...
– preferred 1st line: methotrexate and sulfasalazine
a) Drugs with affect the immune response; methotrexate, luflunomide and cytokine
modulators
...

Onset of action: within 4-6 weeks
Dosage:
- Moderate to severe: 705mg once weekly
...

- Severe: 7
...
Can be increased by 2
...

Monitoring; full blood count, renal function tests, liver function tests before starting
treatment and repeated every 1-2 weeks until therapy is stabilised
...

Blood count: as bone marrow suppression can occur abruptly
...

Liver function tests due to liver cirrhosis
...

Alcohol intake should be avoided to reduce risk of hepatic fibrosis and liver toxicity
...
Patient is to seek medical attention if dyspnoea,
cough or fever develop
...

Nausea and stomatitis can be managed by addition of folic acid dose once every
week, a day after the administration of the methotrexate dose
...

Methotrexate is teratogenic and should be discontinued 6 months before planned
conception
...

Patient advice on methotrexate:

-

-

Patient is to be advised that the dose of methotrexate is to be taken once weekly
only and that folic acid (5mg weekly) is to be taken the following day
...




Leflunomide – effective as methotrexate and sulfasalazine and may present better
quality of life to pts who cannot achieve stabilisation with these two agents
...

Dose: moderate to severe active RA: 100mg once dly for 3 days, then 10-20mg once
daily
...

Contraindicated in pts with history of TB and impaired bone marrow function
...

Side effects; GI disturbances, headache, hypertension, alopecia, rashes
...

Leflunomide has an active metabolite that has a long half-life
...




Cytokine modulators
Anti-tumour necrosis factors inhibit the activity of tumour necrosis factor alpha which is
believed to mediate inflammation in rheumatoid arthritis
...
Not used in pts where
methotrexate is contraindicated
...
Therefore before starting
treatment, the patient has to be screened for infections including tuberculosis (chest Xray, tuberculin skin test) and Hepatitis B
...
Patients should be monitored for
symptoms of heart failure and hypersensitivity reactions
...


Examples of anti-TNG alpha are:
- Adalimumab- SC
- Etanercept- SC
- Influximab- IV
Abatacept prevents full activation of T-lymphocytes
...

Not to be used in pts receiving TNF inhibitors
...

Side effects; abdominal pain, diarrhea, dyspepsia, nausea, hypertension, infection,
rashes
...

Dosage: initially 500mg once daily, increasing to 1g TDS
...

Monitoring: Full blood count and liver function tests are to be done monthly for the first
3 months and then every 3 months
...

Renal function test and electrolytes are to be monitored every 6 months
...

Given by deep IM injection and the area is massaged gently
...
Dose is reduced to a monthly dose
...


Side-effects include GI disturbances, stomatitis, diarrhoea, rashes, bone marrow
suppression, proteinuria
...
A chest X-ray should be done annually
...
Mode of action; changes in antigen presentation
...

Better tolerated than gold
...
5mg/kg fly depending on body weight
...

Side-effects include GI disturbances, headache, skin reactions, ECG changes, visual
disturbances, convulsions, blood disorders
...


2) Corticosteroids – anti-inflammatory agents- suppress cytokines and a rapid movement
in signs and symptoms of the disease (unlike DMARDs – slow response)
Side-effects associated with long-term high-dose therapy such as osteoporosis, diabetes
mellitus and hypertension have severely limited the long-term role of corticosteroids in
RA
...

When steroids are used as bridge therapy, pulse doses of steroids are used (ex
methylprednisolone up to 1g IV on three consecutive days) while long-term treatment
with DMARDs is commenced
...


In people with established RA, long-term treatment with corticosteroids is used when
the long term complications of steroid therapy have been fully discussed and all other
treatment options (including cytokine modulators) have been offered
...
Calcium
supplements and prophylactic therapy for osteoporosis should be considered
...
5mg dly
...

Usually steroids are administered as a single dose in the morning but in RA treatment is
given in divided doses
...

In rheumatoid arthritis corticosteroids are injected locally for an anti-inflammatory
effect
...

They are effective for controlling a local flare in a joint without changing the overall drug
regimen
...


NICE Guidelines for treatment of RA
1) In newly diagnosed active RA:
 combination of DMARDs (including methotrexate) are used as 1st line as soon as
possible, ideally within 3 months of the onset of persistent symptoms
...

 When sustained and satisfactory levels of disease control have been achieved, drug
doses are cautiously reduced to levels that still maintain disease control
...

2) In established RA:
 whose disease is stable, dosages of disease-modifying drugs are cautiously reduced
...







When new drugs are introduced to improve disease control into the treatment regimen
of a person with established RA, doctors might think of decreasing or stopping their preexisting rheumatological drugs once the disease is controlled
...

Short-term treatment with glucocorticoids is used for managing flares in people with
recent-onset or established disease to rapidly decrease inflammation
...

In regular full dosage NSAIDs have both a lasting analgesic and an anti-inflammatory
effect which makes them particularly useful for the treatment of continuous or regular
pain associated with inflammation
...

They inhibit the enzyme cyclo-oxygenase (COX) which is involved in the production of
prostaglandins associated with inflammation
...

NSAIDs vary in their selectivity for inhibiting different types of cyclo-oxygenase
...

Differences in anti-inflammatory activity between NSAIDs are small but there is
considerable variation in individual response and tolerance to these drugs
...

They are not to be used in combination with low-dose aspirin, which reduces the benefit
of COX-2
...

COX- 2 selective drugs include – celecoxib (Celebrex), etoricoxib (Arcoxia)

Side-effects of NSAIDs: nausea, indigestion, peptic ulceration, headache, drowsiness,
confusion, skin rashes, reversible acute renal failure
...

NSAIDs are contraindicated in pts with severe heart failure and active peptic ulceration
...

Factors to consider when choosing a specific NSAID: toxicity, concomitant drugs,
patient’s age, renal function, dosing frequency, cost
...

1) Analgesics (for example, paracetamol, codeine or compound analgesics) should be
offered to people with RA whose pain control is not adequate, to potentially reduce
their need for long-term treatment with NSAIDs
2) Oral NSAIDs should be used at the lowest effective dose for the shortest possible
period of time
...
In either case, these should be co-prescribed
with a proton pump inhibitor (PPI)
...

Therefore, when choosing the agent and dose, healthcare professionals should take
into account individual patient risk factors, including age
...

5) If a person with RA needs to take low-dose aspirin, healthcare professionals should
consider other analgesics before substituting or adding an NSAID (with a PPI) if pain
relief is ineffective or insufficient
...

___________________________________________________________________________



---