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Rheumatoid Arthritis Treatment (Non-pharmacological options (Surgery,…

- - - - 2) Infliximab
        
        chimeric antibody binds to TNF and prevents its interaction with TNF receptors on inflammatory cells.
        
        Methotrexate typically is given with it to suppress antibody production against the mouse derived portion of the molecule
        
        side effects
        
        Infusion-related reactions, may occur (rash, urticaria, flushing, headache, fever, chills, nausea, tachycardia, dyspnea).
      - **3) Golimumab
        
        human monoclonal antibody that binds to membrane-bound and soluble TNF
        
        advantage of this agent over others in the class :once-monthly SC dosing or every-othermonth IV dosing.
      - 1)Etanercept
        
        fusion protein consisting of two p75-soluble TNF receptors linked to an Fc fragment of human IgG1.
        
        MOA : The drug binds to TNF-α making it biologically inactive and preventing it from interacting with the cell surface TNF receptors that would lead to cell activation
        
        Side Effects
        
        Injection site reactions
        
        headache, infections (including TB), lymphoma, And drug induced lupus.
      - **4) Adalidumab
        
        a human IgG1 antibody to TNF
        
        no foreign protein components, it is less antigenic than infliximab
        
        The drug is provided as either premixed syringes or injection pens containing 40 mg, which is administered by subcutaneous injection every 14 days.
        
        Side effects
        
        the same as etanercept
      - 5) Certolizumab
        
        MOA : It contains PEGylated humanized anti-TNF Fab fragments leading to TNF-α inhibition
        
        Side effect : same as etanercept
        
        pegylation increase the duration of the drug inside the body
    - - Hydroxychloquine
        
        not associated with renal, hepatic, or bone marrow suppression (unlike methotrxate )
        
        but the results are delayed up to 6 weeks
        
        a therapeutic failure only when 6 months of therapy without a response has elapsed.
        
        Side Effects
        
        **Ocular toxicity :
        as benign corneal deposits
        blurred vision
        scotomas (small areas of decreased or absent vision in the visual field), and night blindness
        
        so a baseline ophthalmologic examination within 1 year of initiation of tt and annual screening examinations after 5 years of therapy.
        
        MOA : unknown
        
        can be used for tt of malaria
      - Sulfsalazine
        
        drug drug interactions
        
        Sulfasalazine’s absorption can be decreased when antibiotics are used that destroy the colonic bacteria.
        
        Sulfasalazine also binds to iron supplements
        
        potentiate warfarin’s effects by displacing it from protein-binding sites so Close monitoring of the patient’s international normalized ratio is indicated.
        
        the effect should be seen within 2 months
        
        antirheumatic MOA is unknown.
        
        side effects
        
        Gastrointestinal adverse effects could be minimized by :1):minimized by initiating therapy with low doses and titrating gradually to higher doses.
        or 2)using enteric coated tablets
        
        leukopenia, alopecia, stomatitis, and elevated hepatic enzymes.
        
        It also may cause the patient’s urine and skin to turn a yellow-orange color
        
        safe during pregnancy ( unlike methotrxate )
        
        contraindicated in
        
        patients with sulfa allergy
      - Methotrxate
        
        NOA: inhibition of dihydrofolate reductase :red_cross: folic a req for replication of cells
        
        Dose : 7.5 mg once weekly ( oral , subcutaneous , intramuscular )
        
        DMARD of choice
        
        a maximum dose of 20 mg/wk while in cancer start from 50 mg/wk IV not IM or SC
        
        onset of action : as early as 2 to 3 weeks after starting therapy.
        
        Tolerability:
        
        Abdominal cramping, Anorexia, Bone marrow suppression, MTX-induced lung disease
        
        Concomitant folic acid is given routinely to reduce the risk of folate-depleting reactions induced by methotrexate therapy.
        :eg, stomatitis, diarrhea, nausea, alopecia, myelosuppression, and elevations in liver function tests).
        
        contraindicated in
        
        patients with chronic liver disease
        
        immunodeficiency
        
        pregnant and nursing women ( HIGHLY TERATOGENIC)
        
        lung diseases , pleural or peritoneal effusions
        
        preexisting blood disorders ,leukopenia ,thrombocytopenia
        
        renal impairment.
        
        Monitoring (should be done every 12 weeks.)
        
        blood cell counts
        
        liver transaminase levels
        
        serum creatinine
        
        drug-drug interactions :
        
        MTX and trimethoprim (2 antifolate agents) are an extremely serious and life-threatening combination that should be avoided.
      - Leflunomide
        
        side effects
        
        bone marrow toxicity
        
        so complete blood count with platelets is recommended monthly for 6 months and then every 6 to 8 weeks thereafter.
        
        teratogenic
        
        liver toxicity
        
        so alanine aminotransferase should be monitored monthly initially and periodically thereafter
        
        contraindicated in
        
        preexisting liver disease
        
        pregnant woman
        
        Onset of action :4 to 8 weeks
        
        MOA : inhibits the T-lymphocyte response to various stimuli and halts the cell cycle.
        
        considerations
        
        it's teratogenic and has an exceptionally long half-life due to reabsorption via enterohepatic circulation .
        
        therapy requires abrupt discontinuation (eg, due to toxicity or pregnancy), administering cholestyramine will accelerate leflunomide removal from the body ( bile acid binder )
        
        women who have previously received leflunomide (even if therapy was years ago) should have blood levels drawn if they wish to become pregnant.
  - - - they do not prevent joint damage
      - • Selecting an NSAID depends on multiple patient-specific factors, including
        :check:cardiovascular risk, :red_cross: celecoxib :check:naproxin
        :check:potential for GI-related adverse events, :red_cross:ketolac
        :check: adherence to medication regimens & insurance coverage
      - analgesic and anti-inflammatory benefits for joint pain and swelling.
      - At equipotent doses, the analgesic and anti-inflammatory activity of all oral NSAIDs, including COX-2–selective inhibitors, are similar.
        • Topical administration of NSAIDs minimizes systemic exposure while providing pain relief comparable to that of oral NSAIDs.
    - - Low-dose glucocorticoid treatment (equivalent to prednisone 10 mg/day or less)
        
        effectively reduces inflammation through :red_cross: of cytokines and inflammatory mediators and prevents disease progression.
      - Intraarticular glucocrticoid injection:
        
        It can suppress joint inflammation for several months
        
        and can be a useful addition to DMARD therapy, especially when there is residual activity in large joints (eg, wrists, knees). لو فيه عندي جويبنت مش راضي يستجيب